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Mail-order dispensers are costing community pharmacists time and money, and independent and chain store pharmacists alike expect to lose more of both in the coming year.



Community pharmacists are counseling, catching serious medication errors, and dispensing "tide-over" supplies for a growing number of customers who regularly receive their prescription medications by mail from another state hundreds or more miles away.

Not enough regulation: Jolted by these new competitive and professional pressures, most pharmacists don't think their state boards or national pharmacy organizations are doing enough to ensure that community and mail-order pharmacy practice under the same regulations. Almost all pharmacists believe interstate mail-order pharmacy should be regulated by federal law, and a clear majority favor an outright ban.

These are just some of the major findings from an exclusive Drug Topics poll of more than 900 independent and community pharmacists nationwide on the Drug Topics Council of Pharmacists. Of that number, 647 answered -- for a 68% response rate. Their opinions present a rare, detailed look at mail-order pharmacy's impact at the retail level.

According to the Drug Topics survey, the average community pharmacy is losing 15 prescriptions a week to mail order. Fully 61% of the independents and 31% of the chain pharmacists responding to the survey said the impact of mail-order pharmacy on their business was moderate or severe. A majority of pharmacists expect to lose even more prescriptions to mail order this year (see table, page 43).

A Tennessee chain store pharmacy manager maintained that "you can't really know the number of prescriptions you miss." But a store manager in central Illinois asserted: "If anyone believes that mail order isn't hurting them at all, they aren't talking to their customers." This R.Ph. estimated his store was losing 21 to 30 Rxs a week and added that the number "could be much higher."

A New Yorker, whose store fills 75 to 100 Rxs daily and who judged mail order's impact as slight, admitted it was difficult to determine how many scripts he was losing. "I am aware of maybe a dozen or so people who do me the 'honor' of filling emergency prescriptions," he noted.

The poll found 8% of all community pharmacists indicating that mail order is severely hurting their pharmacy's business. Another 40% described the impact as moderate, while 45% think mail order is only slightly diminishing business. Six percent believe it has no effect at all.

Independent pharmacists bear more of the brunt of mail-order business than chain pharmacists do, both told Drug Topics. Twelve percent of the independents stated mail order is severely hurting their business, versus only 5% of the chain pharmacists.

In the past year, almost half the pharmacists discovered they were losing more Rxs to mail order. Only 1% said mail-order competition was getting less of their Rx business, and 53% said losses were about the same.

Again, more independent pharmacists than their chain colleagues see an erosion of their Rx volume due to mail-order drugs. Fifty five percent of the independents said mail order is costing them Rx volume, versus 38% of the chains. Further, a majority of pharmacists believe they will lose more in 1991.

Those polled named the American Association of Retired Persons (Retired Persons Services Inc.) as the single biggest mail-order competitor. Also cited was the Department of Veterans Affairs (see table, page 45).

Price a factor: One reason for mail order's growing popularity, especially from the patient's point of view, may be price. The majority of pharmacists polled believe mailer-order drug prices are lower than those at their place of employment. Five percent believe mail-order prices are higher, 11% think they are the same, and 23% said they didn't know how prices compared.

More chain pharmacists than independents believe mail order offers substantially lower Rx prices than community stores do. The most frequently cited reason was that mail order gets better prices from manufacturers, a belief more strongly held by independents.

A majority of R.Ph.s also believe the use of nonpharmacists keeps mail-order costs low. A Massachusetts R.Ph. attributed mail order's lower prices to "buying any and all generics, having formularies, more technicians, and cheaper prices from manufacturers." A Mississippi store owner offered no explanation of why mail-order prices are lower but noted that after a $5 co-pay for a three-month Rx supply, "the insurance company picks up the difference."

Dispensing larger quantities was also cited as a cost-saver. "Some of my customers tell me they can buy three months' worth of drug from a mail-order pharmacy through their insurance, while we can give only a 30-day supply (by state regulation)," a Southern pharmacist said. An Illinois R.Ph. reported that he "recently lost a good customer" to an insurance plan that charged the patient $8 for a three-month Rx.

"My main gripe," said a Midwestern pharmacist, "is that customers who won't take a generic from me automatically get generics from mail-order houses because they have no choice. Then they come in and tell me how much money they've saved when my price is as good as or better than the mail-order company's."

Prices aren't the only topic of conversation between mail-order customers and community pharmacists. Only a handful of pharmacists have never had to answer a question about a mail-order drug. While 40% experience this situation less than once a week, 56% have had consumers with questions more frequently. The average pharmacy, be it chain or independent, fields two questions a week.

"Retail R.Ph.s carry the load for mail order," said a Pennsylvania pharmacist. "People are more likely to call the local drugstore with questions (than the mail-order firm)," she continued. When mail order is delayed, "I have to advance the patient a certain number or call the doctor for an Rx of five or so." An Alabama pharmacist said he won't "give information concerning mail-order Rxs, as I have no way of knowing if they were filled correctly."

Errors found: But answering questions has led to the discovery of serious medication errors, according to the pharmacists polled by Drug Topics (see boxes, page 44). In fact, one out of three said that was the case. A New York R.Ph. even found her mother receiving the wrong drug by mail: "My mother was sent Vasotec by mistake. (It) should have been Glucotrol. She took it for a week before the mistake was caught." A Texas R.Ph; found an amitriptyline Rx filled with something else. "I was unable to determine with what," he said. "It was an unmarked tablet that was too large to be that drug."

A New York independent recalled a patient who was prescribed 90 tablets of benzodiazepine but actually received 300. "I am not aware of any injuries," said an Ohio store owner, "but there have been several misfills of brand products. The big problem is when they use a 'white pill' on one filling and a 'yellow pill' or 'blue pill' the next time. The patients come in to me to identify the medication, but I can't identify some generics, and the patient can't get through by phone to the mail-order firm." A Colorado R.Ph. reported that after a similar experience, "I gained a customer. That was his last mail-order Rx."

A Louisiana independent found a patient "afraid to take the medication" because of different color and shaped tablets appearing without explanation in a refill. And a Tennesseean recounted this mixup: "A prescription was mailed to a patient with her name on it, but she didn't order it, nor was it her medicine, although she was a mail-order customer. She called them three times trying to return the medicine, with no success."

Wrong medication: Among pharmacists who have seen a serious mistake or problem regarding a mail-order drug, the most frequently mentioned mistake/problem was that of the wrong medication (cited by 42%). An incorrect strength and lateness in receiving the Rx were noted about half as frequently. Among other problems reported was this: "The VA has sent as many as nine bottles of the same medication in three days," maintained an Oklahoma independent.

When it comes to regulating mail-order pharmacy, three out of four pharmacists surveyed expressed dissatisfaction with the way their state boards of pharmacy are performing (see table, page 44). For pharmacists who have caught a serious medication error, the dissatisfaction runs even deeper. State boards "(should) not allow it. Period," wrote an Indiana chain R.Ph. "You don't get counseled by a doctor by mail, so why should you buy prescriptions like that?"

Not surprisingly, as reported losses of Rxs to mail order rise, the level of satisfaction with state boards decreases. For pharmacists with low claims of losses, 40% said they approve of the way their board is regulating mail order. But for pharmacists reporting losses of more than 20 Rxs a week, only one in five are satisfied. "There is not much any state board can do against big business' being backed by large insurance companies," said a Maine pharmacy manager. A California store owner wrote: "Our state does not inspect out-of-state pharmacies. In fact, they can't even inspect the pharmacies within the state properly."

This suggestion came from an Alabama chain R.Ph.: "Mail-order houses should be required to pay state licensing fees for all states they mail Rxs to. Also, every pharmacist working at a mail-order house should be required to have a valid license for every state the company services. Finally, any nonpharmacist personnel should be governed by the strictest state laws concerning ancillary personnel in pharmacies." A Tennessee independent said, "I do not understand how a prescription written in one state where the doctor is licensed can be filled in another state where he is not licensed. Why not pursue this aspect?"

As for national pharmacy organizations, 60% of the pharmacists polled by Drug Topics feel they are not doing enough to minimize or eliminate mail order's impact on retail pharmacy (see table page 44). "I think they're trying," said one Pennsylvania pharmacist, "but it's hard to convince people when they need to pay only $5 as opposed to full price." Pharmacists in stores reporting losses of more than 20 Rxs a week to mail-order drugs are least satisfied with their national organizations (Those polled were not asked if they belonged to any national associations.)

As for what the associations should be doing, the most frequent suggestions were pushing for federal legislation, lobbying Congress, and telling the public, through promotion, about the problems community pharmacists see with mail order. "Cut down the politics in national organizations and worry more about the practice of pharmacy and professionalization," advised a Texas store owner. Another Texan maintained the associations should be "buying Senators and Representatives."

Counterads: A more legal approach was offered by a Colorado store owner: "We should allocate money to counter the advertising of mail-order pharmacy -- design our own "salespeople." Added a Pennsylvania store owner, "More pressure should be put on employers to stop this from occurring. It's hurting quality of care for their employees." And a New Jersey R.Ph. suggested, "Take on AARP to stop those fairy tales."

Almost nine out of 10 pharmacists believe a federal law is needed to regulate interstate mail-order pharmacy. In fact, more than two-thirds of pharmacists believe Congress should outlaw the practice altogether. A North Carolina R.Ph. said "in-state competition is OK" but drew the line at interstate.

A clear majority of pharmacists said flatly there is no place for mail order in pharmacy at all. About one-third disagreed, and 12% responded that they just didn't know. A Missouri pharmacy manager said, "I believe in a free-enterprise system. A business will either stand or fall on its own. It's not up to us to decide." Many commented that they were not afraid to compete with mail order "on a level playing field" --most often meaning the same pharmacy board regulations.

Only one in 10 pharmacists be lieve retail pharmacy should get into the mail-order business. About twice as many chain as independent pharmacists hold this view. But those views were tempered somewhat by what sort of mail service the retail pharmacists thought should be provided. About 20% said they would enter it by offering to mail Rxs to a customer on vacation, during bad weather, or for emergencies. Another 14% said they would mail Rxs to housebound patients.

But clearly some chains have bigger plans. "Our chain is considering it," reported a Washington pharmacy manager. "We have lots of customers who want their Rxs mailed. (It) would be ideal for maintenance meds. I think every Rx would have to be followed by a phone call between R.Ph. and patient to be in compliance with our counseling laws."

The jury is still very much out, though, on whether chains will get into mail order in a big way. Rite Aid Corp., for example, sold its three-year-old mail-dispensing operation last year.

One factor chains and mail order are both watching closely is the greater emphasis now being placed on pharmacist-to-patient counseling. Making counseling mandatory, as more in and out of pharmacy are demanding, would at the very least make business more difficult for mail-order pharmacy.

What's more, many pharmacists view counseling as a vivid way of demonstrating to the patient the difference between mail order and community pharmacy. "Person-to-person contact is the most important part of pharmacy," said an Indiana independent. "Dialogue and communications (both verbal and visual), along with background information (experience, patient knowledge, and profiles) -- give the total package. R.Ph.s are selling much more than 'pills.'"

POLL DATA

A 20-question survey was mailed on Nov. 19, 1990, to 950 pharmacists on the Drug Topics Council of Pharmacists. There were 647 usable questionnaires -- a response rate of 68%.

MAIL-ORDER Rx ERRORS DISCOVERED BY COMMUNITY R.Ph.s

For one out of three of the pharmacists polled by Drug Topics, customers' questions about mail-order drugs led to the discovery of serious dispensing errors. Here are some:

* Orinase instead of Ornade.

* Coumadin 5 mg instead of Lasix 20 mg.

* Coumadin instead of Aldomet.

* Clonidine 0.2 mg instead of Klonopin 0.5 mg.

* Dilantin instead of Dyazide.

* Ibuprofen 400 mg instead of Tagamet.

* KCI elixir instead of theophylline elixir.

* Tegretol 200 mg instead of Tagamet 300 mg.

* Valium instead of Cardizem.

* Antihistamines instead of Lanoxin.

* Fiorinal instead of Bactrim.

* Chlorpropamide instead of clorazepate.

* Lanoxin instead of Lasix.

* Dilantin instead of Coumadin.

* Furosemide instead of dipyridamole.

* Vasotec instead of Glucotrol.

MORE Rx ERRORS?

Anytime you or another pharmacist in your store catches a serious error involving a mail-order prescription, tell Drug Topics. We'd at least like to know the name and strength of the drug the patient received and what was supposed to have been dispensed. If you can determine what state the mail-order facility is sited in, please include it.

Also include your name (which will be kept confidential) and the city and state your store is in. Any other pertinent details about the incident would be welcome.

Please sent the information to: Editor, Drug Topics, 680 Kinderkamack Rd., Oradell, N.J. 07649.

THE VIEW FROM THE MAIL-ORDER SIDE

The impact of mail-order dispensing on community pharmacy has been "nominal," and the whole issue is one of "smoke and mirrors," asserted Delbert D. Konnor, Pharm. M.S. and director of the American Managed Care Pharmacy Association. The AMCPA represents nine "home-delivered pharmacy service" companies with 25 facilities in 11 states. They did about $2.5 billion worth of business last year, dispensing 50 million prescriptions. (The Department of Veterans Affairs dispensed 30 million Rxs, and the American Association of Retired Persons, a founder of AMCPA but no longer a member, 10 million.)

Konnor told Drug Topics that the pharmacy trade press and some pharmacy associations have been "instrumental in playing up the so-called mail-order issue." As a result, many community pharmacists now believe that mail-order pharmacy must be taking prescription customers away. "I don't believe we've had any impact on the business," he declared.

Turning to the poll question on catching "serious prescription errors," Konnor defended the record of the mail-order industry. "If you put our pharmacies up against any inndependent or any chain, you would find that the rate of errors of ours would be infinitesimal," he said. This is due to "the high technology in robotics and the kinds of systems using bar coding and others that almost eliminate any error that might be coming out of a pharmacy."

What about free advice and counseling from community pharmacists on mail-order drugs? "I'm not so sure consumers feel they have their personal family pharmacist," responded Konner. "Consequently, the consumer has always had the right to go to any pahrmacy at any time to get free advice from all pharmacists for anything, be it an OTC or a prescription drug." Furthermore, community pharmacists shouldn't look at that free advice and counseling as a burden but rather as an opportunity to convince the patient to come to their store to buy other kinds of medications.

Lower prices? "Our members, because they are operating under economies of scale, are in fact able to offer prescription medication at a lower cost," Konnor said. Other cost factors are that mail-order firms act as claims processors and provide regular management data reports to clients, all built into the single price. "So it's not just the fact that the cost of the individual prescription is lower, it's that the lower price includes a lot of value-added services the retail pharmacist does not provide."

Most critics of mail order "have never been in a mail-service facility that I know of," Konnor continued. "They are using anecdotal data from the trade and professional literature to perpetuate (these data), and they use them, in some instances, as scare tactics before legislative bodies." He said state boards of pharmacy do a good job of regulating mail-order facilities. Those facilities must abide by the practice regulations of the state in which they're sited and not those of the state to which the Rxs are mailed. That situation does not make the case for any federal law to regulate interstate mail-order pharmacy, he observed.

As for the future, Konnor indicated mail order probably wouldn't continue to grow at the 50%-a-year pace it has maintained since 1985. That rate has given 6% of the total nonhospital Rx market. He figured that if the industry grows by 30% a year and predictions that by 1995 about 75% of Rxs will be for maintenance or chronic drugs hold up, "we will probably have a market penetration of about 15% doing about $6 billion worth of business -- that's conservatively. It could grow to about $9 billion."

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