Fundamental Disagreement...or Fundamental Disingenuity?

It didn't take CVS very long to respond to the NYT times article with a press release of their own, nor did it take long for a letter directly from Larry Merlo to make its appearance. I've seen numerous responses across the many other pharmacy pages that I frequent, countering almost every point in the press release and letter. My colleagues have been quick to point out that these documents must have either been written by someone who is so incredibly disconnected from the truth of their company's operations as to have no effective grasp of reality, or simply by a shameless liar or "architect of alternate truths." My only other suggestion is that perhaps the author(s) live on another planet or in an alternate reality. Pharmacists have been calling out these exact issues for years - it's far from a "new" problem.


I feel my job is to create an organized, point-by-point deconstruction of the false narrative created by this CVS press release so that we have a clear and easy way to explain to the public the "bad faith" that is represented by its claims.


Let's start at the beginning.


The release begins, "We fundamentally disagree with the recent assertion in The New York Times that patient safety is at risk in America’s pharmacies."

Fair enough. Everyone is entitled to their own opinion, though one could argue that a person wearing a blindfold may not have the most accurate appreciation of a glorious sunrise...or a disastrous train wreck. The people writing this press release would obviously not be those front-line pharmacists managing pharmacy locations from day to day, and clearly don't have an accurate perception of that environment based on recent revelations. Or worse, they do, and are simply lying about it. Surprisingly, the remainder of that paragraph was perfectly accurate. But surrounding one lie with 3 truths doesn't make the lie any more truthful.


The second paragraph begins with the claim that "Patient safety is our highest priority."

My favorite comment I've seen so far about this claim was, "I'd really hate to see what priorities 2 through 10 look like." And then once more, the less-than-truthful first sentence is followed by two mostly-true sentences about the hard work and dedication of CVS employees, which no one that I've heard of is arguing against, at least when it comes the referenced "30,000 pharmacists" and their associated pharmacy technicians. It's the suits we're worried about.


The next claim is, "Despite our excellent safety record, we are committed to continually improving."

However, absolutely no data or solid informational claims are given to support this "excellent safety record." In fact, numerous pharmacists have commented that large numbers of errors go entirely unreported due to lack of resources at the store level to complete the reporting process.


Under incredible pressure to take care of impossible numbers of patients, I would hazard a guess that all but the most egregious errors often go unreported. Not due to negligence on the pharmacists' part, but because a large number likely go completely undetected, are forgotten by the end of the day, or time simply runs out. Fourteen hour days are long enough even for jobs with lower stress levels. But after standing for 14 continuous hours without so much as a bathroom break, pressed to work at breakneck speed, surrounded by utter an cacophony from all directions, all while expected to make zero mistakes on pain of someone else's potential death, an extensive error reporting process is far from top priority, especially for "minor" errors, and even more especially when reporting an error on oneself can be an endangerment to one's employment in a cutthroat work environment.


The rest of the paragraph highlights CVS's supposed continuous quality improvement efforts via technology, measuring quality (cover word for metrics), and "listening" to their pharmacists. Unfortunately, their technological improvements seem to be resulting in a lot of unintentional harm and/or waste, their metrics are the exact issue highlighted by the recent reporting, and their employees sing a very different story about whether they are ever listened to.


On to paragraph three: This time we begin with three truths.

1) Pharmacy practice is rapidly evolving. Check.

2) It's not just about Rxs, patients expect more. Check.

3) Pharmacists can help with immunizations, adherence, and interventions. Check.

ALL TRUE!


Then it goes all sideways again.


"That is why we are fierce advocates for expanding the number and role of pharmacy technicians at our stores. Qualified and trained pharmacy technicians allow pharmacists to have more time to provide patient care, answer questions about medications and serve as true health care counselors."

This is technically correct, yet skirts the truth in a multitude of ways. First, CVS is well known to staff absolute bare-bones levels of both pharmacist and technician labor. They are required by law to have at least one pharmacist on duty in the pharmacy during operational hours. Technicians support those pharmacists by performing delegated tasks that do not require clinical licensing, allowing the pharmacists to process more prescriptions in a shift than they could process alone. Most states limit pharmacists to a certain number of technicians they can supervise at any given time. But CVS regularly staffs as few support hours as possible, leaving their pharmacists scrambling to do their own share, as well as what they previously relied on technician labor to accomplish.


Next, the press release moves on to highlight what it claims are CVS's contributions to advancing the level and precision of pharmacy care. The first point given is "Advocacy for Additional Pharmacy Resources".

In this section, CVS claims to be "on the forefront of advocating for states to increase pharmacy technician to pharmacist ratios," which I don't doubt at all. However, while CVS claims that their motivation for this advocacy is to "ensure that we are safely and effectively filling prescriptions, and most importantly, that pharmacists are able to provide more effective patient care and counseling," that's only one overly myopic perspective on the issue.


One would think that having a higher number of technicians to support a pharmacist would always be a good thing. But there is a point beyond which additional technician labor is not enough to handle additional prescription volume. One pharmacist alone cannot adequately supervise every interaction in a pharmacy filled with numerous technicians at various work stations and also concentrate on carefully checking prescriptions and drug interactions at breakneck speed.


CVS's idea of expanding the role of technicians is less about helping pharmacists, and more about minimizing the number of pharmacists they have to pay in order to accomplish the same amount of work. Technicians will never be allowed to perform the clinical reviews and patient counseling that are the core basis of a pharmacist's job. These pharmacist-only duties are vital to patient care and are the main bottleneck in pharmacy workflows since typically there is only one pharmacist on duty at a given time who must review every order and counsel every patient personally. The time required to fulfill these duties cannot be decreased past a certain point, and furthermore, should not. In order to alleviate this particular burden, the pharmacy would HAVE to employ additional pharmacists, thus legally also allowing them to also utilize more technicians in the same space, without need for any regulatory changes. The problem (from CVS's perspective) is that pharmacist labor is far more costly than that of their grossly underpaid and undervalued technicians.


Innovation and Technology

This is the one section of the press release in which the author(s) cite actual figures, claiming a 500% increase in e-prescribing since 2015 and reduction in errors through automation of prescription data entry. I have no qualms with any of these claims. It's true that automated data entry and e-prescribing are generally helpful. However, that doesn't mean that every automated, e-prescribed Rx doesn't still have to be reviewed carefully by human eyes before completion. Automated data entry systems don't have the human or clinical capacity to recognize many types of errors. There are whole pharmacy page galleries of funny or clinically impossible e-prescribed prescriptions. I'll insert some below.


One example of an electronically prescribed medication with all fields technically filled in - but in need of clinical clarification. The instructions do not match the prescribed medication, strength, or quantity authorized..
Ouch.
This prescriber said to heck with it and just manually sent instructions and information that will not autopopulate. It will be helpful to the pharmacist, but means the data entry will have to be corrected by a human.
In the scariest image so far, we have instructions that could be easily deadly. Unfortunately this medication WAS dispensed to the patient before being caught on a refill. So the patient received a prescription labeled with these deadly instructions at least once.

The next words out of their mouth though, are "the automation of electronic prescriptions has resulted in a reduction of some pharmacy labor hours."


OK...so...you automated some work to free up your employees' time to do other "more patient-centric" work

...but then you cut their labor hours so that they are back to square one?

Does anyone else see that this is a losing battle? That they are "talking out of both sides of their mouth" here?


Unfortunately I can't comment on the system upgrades mentioned surrounding a change from an alphabetical filing system to a numeric one as I am not familiar with that process. I do remember CVS fairly recently changing their workflow process from a unified verification system to a "split-verification" system, in which the pharmacist verifies prescription data entry in a separate step or screen and then later verifies the packaged product against a another screen. Both systems have their advantages, but I know the change was a significant added stressor for many pharmacists when it took place. However, I also think that this particular comment may refer to a different change with which I am not personally familiar.


Measurement = Improvement

Instead of accepting criticism for their overuse (and arguably misuse) of metrics, here CVS attempts to re-label and double down on their practices, claiming "we measure the quality of services our pharmacies provide. Accountability for our pharmacists is important, and our use of metrics mirrors what’s commonly used throughout the health care industry."


Must be one of those fun house mirrors - the kind that grotesquely distort the original until it's only partially recognizable. They then claim to have reduced the number of metrics by half over the past 18 months. I cannot speak to this, but it doesn't seem to have reduced any of the burdens on their staff in any meaningful way.


Finally, they claim to "monitor...and make changes to [their] staffing levels as volume changes." But that seems to be a one-way only street. I would implore ANY CVS pharmacist that has been allotted an increase in technician hour allotments to chime in in the blog comments below. I suppose it is possible, but I have only ever heard of labor hour cuts, even operational hour cuts, continuing even as prescription volume actually increases.


Encouraging Employee Feedback

Here, CVS claims to highly value employee feedback, saying, "We value the feedback of our pharmacists and take individual, legitimate concerns seriously. We have a firm non-retaliation policy in place for any employee, including our pharmacists, who want to voice a concern."


Unfortunately, this claim does not harmonize with the unified outcry from numerous CVS employees who claim that any act of dissidence results in an immediate "target upon one's back," and can only result in unfavorable assignments and even falsification of metrics in order to create a pattern of constructive dismissals. I'd also like to point out the qualifier in that quote, specifying they care about "legitimate" concerns. My question is, who makes the call on what's a legitimate concern? Someone who has worked in direct patient care any time in the last decade? Likely not.


The author(s) then turn to the "overwhelming majority" of positive responses to a recent employee survey and an extremely low employee turnover rate. What they conveniently leave out of both of these points are certain qualifying factors that change the connotation of the truth.


The survey they reference claims to be confidential, yet requires the employee taking it to be logged into a computer system using their unique employee identifier in order to complete it. I've also been informed that any negative responses to the survey are considered to reflect badly upon the individual store management of the location in question, thus creating incentive for respondents not to cause undue consequences to their colleagues in store management who have no control over pharmacy staffing.


Additionally, the touted low turnover rate is debatable, and if it does hold true, they managed to leave out that one tiiiiiiiiiiiny pesky little detail about how pharmacists likely cannot leave their jobs in the current environment due to extreme market oversaturation with newly qualified pharmacists, which is driving down pharmacist wages at a staggering rate.


New graduate pharmacists, massively indebted and desperate for ANY job, can easily be hired to replace a seasoned pharmacist at perhaps 2/3 the cost of the older pharmacist. Due to consolidation and closing off of other avenues of practice to community pharmacists (arguably due to the very practices of CVS and their associated PBM), there is nowhere else for them to go. So, naturally turnover would have decreased over the past 3 years as the job market has become increasingly competitive. Numerous lawsuits have claimed that large pharmacy chains have actively discriminated against older pharmacists in attempts to replace them with younger, cheaper, and less troublesome (read: more pliant) laborers.


90-Day Supply: Options and Benefits

In the funniest (to me) section yet, CVS attempts to defend their actions surrounding the provision of 90-day supplies. They state some benefits of 90-day supply provision, which are true in theory. However, in reality, any pharmacist knows that the true intention of heavily pushing 90-day supplies and automatic refills is to improve "adherence ratings" in order to rate better pay from insurers, while at the same time increasing sales. It does not matter if the ratings reflect actual patient adherence, as long as the computer says the medication was filled. This may result in patients with massive oversupplies of medication sitting at home and is a form of pharmaceutical waste.


They do mention that only certain medications are eligible for 90-day supplies and that they don't "switch 30-day prescriptions that have no refills to a 90-day supply without contacting the prescribing physician for approval." This is good, but the main complaint voiced by physicians is that they are being inundated with those requests, even when not clinically appropriate.


The other question this leaves me with is that they don't address prescriptions which are written for 30-day supplies but which DO also have additional refills. In some states, pharmacists are permitted to "convert" those refills into 90-day supplies without contacting the prescriber if certain criteria are met. One specific exclusion is that this may not be done for psychiatric medications. Based on numerous prescriber complaints, it seems that this is being done anyway.



That concludes my point-by-point response to the press release, but likely still leaves a great deal out. I have heard from so many pharmacists that this company actively cultivates a culture of fear in its employees. Some have said that after making "anonymous" complaints, they were contacted at their store by corporate for further detail, revealing that the anonymous reporting system is in fact, not anonymous at all. I've also been told that in the short time that has elapsed since the publication of the NYT article that already corporate is handing down reminders and further training on policies against employees speaking with the press.


Below I would like to attach links to several public discussion threads in which pharmacy employees discussed and responded to both the NYT article and the responses. And I'll add in a few more e-scribing failure examples as well - some dangerous, and some simply funny.


My final closing point that I want to draw yet again into the light is that this response is shameless in its "dance around the truth". The question for me is simply - is this a fundamental disagreement? Or simply an attempt at fundamental and intentional disingenuousness, intended to cover the tracks of something far more sinister than a lack of insight into the issue?


Further reading:

E-script gallery

NYT article discussion on The Cynical Pharmacist's Facebook page.

CVS press release discussion on The Accidental Pharmacist's Facebook page.

NYT article discussion and CVS press release discussion on "Excuse me! This is a PHARMACY not a fast food restaurant!" Facebook page. Three Reddit threads:

How Chaos at Chain Pharmacies Is Putting Patients at Risk

CVS’s Response to Being Exposed by Recent NYT Article

Merlo's response is even better to the NYT article 📷

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