Wednesday, October 26, 2011

Walgreen's Bold Vision Of The Future As It Actually Works In The Real World, Including Tips On How Addicts Can Use The POWER Program To Get A Fix

Like I said in my last post that wasn't inspired by the violent crackdown on peaceful protesters that happened in Oakland yesterday, Walgreen's, the country's largest drug store chain, has decided that big changes are in order for the profession. For the last couple years their emphasis has been on what they call the POWER program, which to recap for those of you just now tuning in, is a radical transformation of how pharmacy is practiced at the community level. POWER turns the act of filling a prescription into an exercise in industrial-type efficiency management, moving as much work as possible away from the store. Routine refills are done at a central location, phone calls are taken at a remote call center, and prescriptions themselves are scanned into a computer and verified by pharmacists working at home."The goal" a Walgreen's Vice President told Drug Topics in 2009, "is to relieve in-store pharmacists of certain tasks in order to give them more time to offer medication therapy management services"

Great. What could possibly go wrong?

"Let me start off by saying that not everything that Walgreens has done with POWER is negatively impacting our profession." says the source I've developed, who for no other reason than my love of all things Watergate I'm calling "Deep Pill." "The central fill concept is actually a good idea. Having all the next day refills filled at a separate location and then shipped to the pharmacy saves the pharmacy staff in the store a lot of time to focus on the patients who are in the store."

To do lots of Medication Therapy Management I bet, and totally not to do things like ring up potato chips and Walgreen's brand beer. 

"If POWER stopped there," Deep Pill went on,  "any of the few problems with central fill could be easily mitigated, and, even if not, the benefits would far exceed the liabilities"

Well there you go, can I just stop posting now?

"However, POWER, as you are well aware, does not stop there."

Oh crap. Although you knew that was coming, didn't you?

At this point I think I'm just gonna let Deep Pill take over, as his and/or her experience speaks for itself. Read on to see where the big thinkers in the biggest player in the profession are taking us, and our patients:


I worked in what is called the Pharmacy Care Center (PCC), which is a call center. The way it works is that, when someone calls a Walgreens store in Florida or Arizona, the call goes into a call bank where it first goes through a voice recognition automated system, then to a non-pharmacist staff member (called specialists) when the automated system does not suffice. Normally, that would be fine. That is what would happen in stores where technicians answer the phones. However, the people whom Walgreens hires for these jobs almost never have any pharmacy experience whatsoever. Walgreens is literally hiring people off the street. They do not understand, and, in many cases, lack the ability to understand how a pharmacy functions. The customers and doctors' offices can quickly ascertain this incompetence. The calls that the specialists could not resolve were transferred to the pharmacists at POWER (on the other side of the room from the specialists). Usually, we were able to resolve the calls fairly easily. One example of that early on in my career there was that the specialist was unable to clarify for the customer the meaning of the phrase "1 refill remaining before 6/19/09" printed on a prescription label. For the calls we were unable to handle for whatever reason, we pharmacists transferred the calls to the store pharmacy directly. 
Now that you understand the workflow of the call center aspect of POWER, let me break down the problems that occur at each step. While the specialists are told that they are not to answer any questions the callers may have about their drugs, they frequently did anyway. If you click on the name of the drug, you can see its common uses; however, as is the case with several drugs (e.g. gabapentin, cholestyramine, amitriptyline), the FDA-approved use is in many cases not why the drug has been prescribed. Giving the callers misleading information results in panicked callers being transferred to the pharmacist queue where we had to calm them down and correctly educate them about their medications or panicked callers hanging up and calling their doctors. This problem is exacerbated by the fact Walgreens has these specialists answer the phone as follows: "Hello. This is the registered pharmacy technician (insert first name). How can I help you?" While that statement is true about their position, most people hear the word "registered" and think that the following word is always "pharmacist". Some people do not listen closely and miss the part about technician. Others cannot discern the words after "registered" because the specialists slur them together so much (a product of answering hundreds of calls per day). This problem is annoying and troublesome, but there is a more serious issue at this step.

Here is where all you addicts should start paying attention:

When the caller wants a refill and cannot figure out how to request it online or on the automated phone system, they will speak with one of these specialists. They also tend to speak with one of the specialists if they know there is going to be an issue with the prescription (e.g. want to change from insurance to cash, pick up at different store, change quantity). The following scenario played out quite frequently. The caller wants to pick up his Lortab or Xanax refill but wants to pick it up at a different store in the area. The specialist, without looking at the last time the prescription was filled, processes the refill at a different store. The patient is then able to refill whatever prescription he wants extra early without anyone noticing because he is paying cash price. I saw many examples where this problem happened. The worst one was a customer who filled the same prescription (for Lortab 10/500 quantity of 240) 5 times in 5 days at 5 different Walgreens stores. (Yes, you can transfer a controlled substance prescription more than once if all the pharmacies have a shared database.) What made that example so much worse was that the authorized refills on that prescription were authorized by a specialist, and the "original" prescription was a bogus verbal prescription (I called the doctor to check on it) taken by one of the pharmacists at the call center.

Got that? It's way easier to phone in a fake prescription when the pharmacist isn't familiar with the community, and way easier to get early refills when the person processing them isn't even a pharmacist.

It becomes really hard for the call center pharmacists to even investigate prescriptions we believe might be fraudulent because that means not taking incoming calls for a few minutes in order to call the doctors' offices and the local Walgreens pharmacy. Everytime we stopped taking calls for any reason, the non-pharmacist managers would start getting on our case. The senior group manager of our department publicly called such time shrinkage. Having worked in retail, I know the term "shrinkage" means stealing the company's resources, either by the customers or employees. These non-pharmacist managers just wanted us to take calls and get the callers off the phone within the target time of 1 minute and 55 seconds. Therefore, many pharmacists at the call center did not even investigate the validity of any prescription so as to avoid trouble.

Seriously, you addicts should go back and read those last couple paragraphs again. And thank the God of controlled substances a Walgreen's manager invented the concept of "time shrinkage"


The other problem at the call center pharmacist step came with taking new verbal prescriptions (legitimate ones). At first, we just wrote them up by hand. Then a specialist would walk around, pick up these paper prescriptions, and scan them into the patient's profile. Then the prescription would go through the Central Utility Department. This department types and verifies new prescriptions. Therefore, these new prescriptions that we had taken would be typed up by a specialist and then verified by a pharmacist in that department. About a year after I started working at POWER, they stopped having us write the prescriptions by hand, and instead we just inputted them ourselves directly into the computer. The next step after we inputted the prescription was clinical review, or, in some cases where clinical review did not apply to the prescription, it went directly to the store to be filled. This change most definitely saved time, but it removed that additional safeguard of having a couple of different people look at the prescription to prevent careless errors (e.g. it would be easy to acidentally pick Abilify 20 mg instead of Abilify 2 mg because they are right next to each other on the scroll down tab). 
As for the store pharmacy staff, the final step in the call center chain, there are a couple of major problems. The first problem is that, due to the implementation of POWER, staffing levels in the store (pharmacy and non-pharmacy) were drastically reduced.

Wait.....I'm a little confused. Walgreens said the goal was to give store pharmacists time to do medication therapy management. How can they do this with drastically reduced staff? I don't understand. Maybe because I didn't go to business school. Or because I'm not a liar.

When a call is transferred to the pharmacy, very often there is only 1 pharmacist with 1 or 0 technicians working. That pharmacist is handling all the problems of the customers in the store and cannot pick up the phone. After a specified number of rings, the call will be terminated. If someone in the pharmacy miraculously picks up the phone, typically the pharmacy staff member will ask the caller to hold. After a specified number of minutes of holding, the call is terminated. When the call becomes disconnected by one of the previously described processes, the caller becomes irate and has to actually go to the store for service.

Sweet. So basically an integral part of POWER would seem to be hanging up on customers when you can't get to the phone.

The other larger problem comes in the prescription filling process. When there is a technician working, the technician does all the filling, and the pharmacist just stands at the cash register to sell prescriptions. Supposedly, the pharmacist is to verify prescriptions by comparing the image of the dosage form printed on the leaflet to what is actually in the prescription bottle. In many cases though, that does not happen. One reason is that the prescription is for a liquid. There is no way that can be verified because there is no image and the technicians are told to never put the stock bottle next to the bag. All the pharmacist ever receives is the plastic Ziploc bag with the labeled prescription bottle and the leaflet. Another reason is that the store pharmacy staff is so rushed due to under-staffing that they do not have time for this visual verification. The store pharmacist feels that the NDC number matched up or the label would not have been printed or however he or she rationalizes not visually verifying the prescription. I know Walgreens will state that this error is on the individual pharmacist, but the company created that environment due to its own staffing levels.

But wait.....there's more.......

My understanding of pharmacy law as it pertains to the pharmacist-technician relationship is that the technicians are to be under the supervision of a pharmacist. At the call center, there are technicians (or specialists as I call them) and pharmacists working in the room. However, the pharmacists are busy with their own calls and are not supervising the technicians. There are quality analysts listening in on the calls. However, they do not listen to all the calls, and, even if they did, these quality analysts are not pharmacists. I submit that these technicians are working without pharmacist supervision, a violation of the Florida Pharmacy Act (and probably of the pharmacy laws of any other state). Walgreens has its own representative at the Florida Board of Pharmacy. That situation seems like a conflict of interest to me and enables the company to get away with such violations. However, even still, when POWER management learns that the Board is coming to inspect, they move some of the pharmacists over to where the specialists work in order to give the illusion of supervision. Even if that enabled pharmacist supervision (which it does not because we all wear headsets and have too many of our own calls to monitor anyone else's performance), that is not how POWER typically operates. With the exception of visits from the Board or from corporate, the specialists and pharmacists do not sit together.

"Well at least Walgreen's never tried to have technicians do the type of work that the law says can only be done by a pharmacist" you may be saying.

And you would be wrong:

Another legality issue that arose during my time there was the issue of transfers. Each day, management would designate 1 or 2 pharmacists to do incoming transfers. Those pharmacists would not take incoming phone calls during their shifts. They would just call competitors for prescription transfers. Even still, there were so many transfer requests that they were always behind. To remedy this situation, management came up with the idea of having technicians call to get transfers, recording the phone call, and then having a pharmacist listen to the call and compare it to what was written up for accuracy. This program was eventually scrapped because there were not many of the call center pharmacists who were willing to participate. Also, many of the pharmacists for the competitors called the Board to complain about it. Much like the other legal issue, the reason that this issue even arose was a result of non-pharmacist management's desperate attempts to save money any way possible. They did not want to pay pharmacists to be monitoring the specialists' phone calls (because then those pharmacists would not be taking incoming phone calls themselves), and they did not want to use more pharmacists to do the prescription transfers (because then that would take too many pharmacists away from answering calls). They did not care what laws they broke in their quest to save money.

I'll repeat that last line again, in case you were just skimming that last paragraph:

"They did not care what laws they broke in their quest to save money."

Except I'm sure Deep Pill really meant "In their quest to give pharmacists more time to do medication therapy management"

And finally, this is who is deciding the future of your profession:

There are some pharmacists in upper management at POWER; however, the vast majority of management are not pharmacists, and, in fact, they have never even worked in a pharmacy. For example, the senior group manager to whom I alluded earlier was a call center manager at Sprint.

So they can't even sell out the future of pharmacy to managers of GOOD businesses. I'm sure it's not news to most of you that Sprint sucks.

Generally speaking, the non-pharmacist management there treated the business as if we were selling aluminum siding rather than drugs. I have seen other companies start to emulate Walgreens' POWER model, and I would like to see POWER have its plug pulled by the Board of Pharmacy so that this disease does not infect the entire pharmacy world.

So would I Deep Pill.....so would I.

And so should you. If you give a crap about the potential poisons you put in your body.

I am not hopeful however. God help us all.

32 comments:

Anonymous said...

Just in time for Halloween - this is scary.

Two Grumpy Pharmacists said...

I love the future of my profession, it is so up-lifting.

Do they still have on-line M-CAT training, time to go back to school methinks.

Anonymous said...

The steady creeppp of non-professional staff making professional decisions. Remember when it was going to be all about health insurance companies staffed with medically trained folks who could legally evaluate drug substitutions? When generic drugs were initially promulgated by the industry, the Wyoming Pharmacy Act (and I daresay most other State Boards of Pharmacy were in on it, too) was interpreted to mean that ALL the following were in concordance a. the patient authorized the substitution, b. the physician authorized the substitution, and c. the pharmacist in their authority authorized the substitution. Little by little the individual pharmacist authority has been usurped by the corporate world, as we recall that our Supreme Court has ruled that corporations can be considered as having rights as individuals. So, like 1984 (oh that was SSSSOOOO long ago) we are all in the business of redefining words with different meanings.

pharmaciststeve said...

They have to make up for the Express Script and Obamacare lost business/profits that are coming... they are just being pro-active ;-) Maybe their new mission statement is
"..fill them until we kill them .."

dr lasermed said...

This is really scary. It explains a lot about Walgreens. One recently opened up in our town. I hate calling the pharmacy. Now I know why.

bcmigal said...

Excellent post. This is the disturbingly sad and imminent future of pharmacy. It breaks my heart.

Anonymous said...

Posting anonymously, but I can concur with this from the brick-and-mortar side of things in Florida Walgreens'. We hate picking up the phone because most times the patient has already talked to at least two people that couldn't figure out their problem. When we talk to them, it's usually just to take some verbal abuse on things we had no clue about. A good day is when a patient walks up demanding to talk to the female they talked to on the phone. This is a day when only two males were present in the pharmacy all day.

Most prescriptions are entered and billed wrong (days supply is a big culprit), however when we're audited, who takes the blame for it? If someone gets the wrong medication that was called in at a call center, verified in a different city, and filled at central, who is held accountable? Pharmacists in the store are told to never verify anything that comes in from central fill.

POWER is a great system in theory and on paper. However, Walgreen's implemented it with only money in mind, and it's only a matter of time before a high-profile person dies and hopefully gets everything scrapped.

Anonymous said...

What is happening in pharmacy is depressing. With the over abundance of pharmacists, chains are in the drivers seat and headed straight into the ground :(

Anonymous said...

I've never worked in a pharmacy, but I depend on a number of medications, and I moved my scripts from Walgreens to another chain pharmacy (where they are also not real reliable when it comes to details) -- my only other real choice, as I'm homebound -- a few years back, and none of this surprises me in the least.

I really wish it did. And I wish I didn't suspect that in a few years you'd be able to write exactly the same thing about the other chain.

Anonymous said...

Held out on my "certified Immunizer" bullshit. Was told "we take your lack of certification as your resignation" 20 years as a RADrone. Looks like I'll try Walgreens; at least I can sit down all day!

Từ Thanh Giác said...

Coming soon: Your RX will be filled in China and air shipped to your local Walgreen's.

Frantic Pharmacist said...

This is so totally illuminating and explains why my call to an Arizona Walgreens today for transfers was a complete clusterf&*ck. NOW I understand.

Carys said...

WTF, Walgreens. WHY?

Anonymous said...

Because Walgreens CEO doesn't care. His #1 goal is to keep the profits hight for 12 more months collect his super huge bonus and then catch his golden parachute once this whole thing falls apart and wagreen's stock hits riteaid levels. The people making the big decisions do not know nor care about pharmacy. They are about getting huge bonuses.

Anonymous said...

Dear Monkey (and readers), each month Wisconsin Public Radio asks what their listening audience would like to have as a program topic during the following month. I’ve seriously been contemplating asking them to address the issue of retail pharmacy workload as it relates to public health and safety (including increased Rx volume, time constraints, constant distractions, reduced technician hours, flu shots, MTM, 12-14 hour shifts with no help or breaks, BP/cholesterol/A1C testing, etc.) It seems to me the state boards of pharmacy have been deliberately silent on this important issue. If they are charged with protecting public safety in regards to the profession of pharmacy, one would think they might have a say in the dangerous staffing practices of the large chains. Instead, these corporations are allowed to push their employees to the brink, creating a threat to the safety of the general public in the name of profitability, recording record sales and profits as they go. Meanwhile, the general public remains mostly oblivious to the plights of the fine people who are working feverishly every day behind these pharmacy counters to serve them to the best of their abilities despite having one hand tied behind their backs. Unfortunately, Big Business will never listen to the common-sense pleas of their minions, but only to their customers and shareholders. I truly believe this subject needs to be brought into the public light before someone is tragically injured or killed as a result of these corporate “standards”. It’s obvious that we as pharmacists are too weak to stand up for ourselves and need someone to help us “put their feet to the fire.” I believe public radio can do just that. SO I ASK ALL OF YOU: WHO WOULD BE THE BEST PEOPLE TO SUGGEST AS GUESTS ON WISCONSIN PUBLIC RADIO TO SPEAK ON OUR BEHALF AS PHARMACISTS? In addition, I urge all of you to contact your respective state’s public radio association to address this issue. We need to take a stand against these unsafe practices and get the public on our side if we ever hope to improve this dire situation.

Anonymous said...

The stores in non-POWER states have had their pharmacy hours cut drastically as well. It's very typical that the pharmacist is working with only 1 technician at a time. There is very little overlap in technicians, and when they start getting behind, a manager is called to filled the prescriptions so the tech can answer phones, enter scripts, and run the registers. Generally speaking, that member of management has little to no training. I should know, I'm that manager, and beyond counting pills and changing manufacturer for medications (when necessary), I'm totally useless. I'm not certified, I have no idea how to enter a prescription, and lord help us all if a patient has an insurance question.

Anonymous said...

My Walgreens lost 80 technician hours a week over the last year, that's two full time people. The funny thing is that our numbers haven't gone down at all. So basically we are all a lot more stressed and working our asses off.

Anonymous said...

I'm waiting for the day that Walgreens decides to replace pharmacists with robots, would love to see the sh*tstorm that's going to cause. "Error 4321234, your Viread requires prior authorization. Please check back in 2 weeks."

Vagabond Rx said...

I'm a pharmacist in Northern Canada (Yukon). Some of the stuff you American pharmacists have to deal with just boggles the mind. Some of the problems are very similar. I know some pharmacy chains have been talking about central fill and some long-term care facilities too. Based on what I'm reading here, it seems that one of the big problems for pharmacists to stand up for what they know to be good practice is an over-abundance of pharmacists, so that an individual is reluctant to say anything as there's always another pharmacist out there willing to do what the company says.

In Canada, I have found the freedom (relative, as all things are) by working in a remote area. There aren't too many pharmacists who want to live in a smaller, more remote place, even though I get paid about $15/hour more than I would down south. But I do have the ability to say no, and I know I can find other work if I have to.

For all of you stuck in the US Megaconglomocorp Pharmacies, my sympathies, and I hope you can find a way to be true to what you know to be right.

Pop said...

You might want to look at this article
http://www.usatoday.com/money/industries/health/2008-12-30-pharmacies-boards-mistakes-prescriptions_N.htm
It might shed some light on why the boards act like they do...

It is also reported that 100,000 people are killed annually by medical errors and 1.5 million people are harmed annually by medication errors..

you might also might want to read this
http://healthblog.steveariens.com/?p=138

Barry said...

The only time companies centralize operations is to reduce costs. There are only 2 costs in a pharmacy that matter to the bottom line, Labor and drugs. Centralizing reduces both, but will not work unless the labor that was formally utilized at the store level is reduced. So, anytime you hear management saying they are going to centralize an operation (like refills), expect layoffs at the store level.

doggiedude said...

The companies can only continue to do this sort of thing as long as there are pharmacists willing to work in the environment created. I've worked retail, hospital & nuclear over the years. Would never even consider going back to retail the way things are set up now. I even quit my favorite job (in nuclear) because the working conditions made by new management were not safe for the employees. It will take a mass movement of pharmacists to stop putting up with this kind of shit before any improvements will be seen. If you're willing to walk in everyday & allow someone to force you to work at an unreasonable pace than you are just as much to blame.

Anonymous said...

POWER is old news for us at Walgreens. No one in the company even talks about POWER anymore. In fact, it was such a failure that it was never instituted beyond the 2 pilot states of Florida and Arizona. But, the company refuses to go back to the " old way" in those 2 states. Now, that doesn't mean that it won't resurface in a new form somewhere down the road under a new name and with a few tweaks to the process. I would like to point out, however, that many of the problems with POWER that surfaced at the beginning have been addressed. It's still not a perfect system, just like everything involved with retail pharmacy.

Anonymous said...

I keep hearing that pharmacists are just pill pushers anyway and that the big PBMs are going to push out the community pharmacies.Everything will be mail order and if anyone wants their questions answered, about prescriptions, they will have to talk to their doctor. This next year will be very interesting. Power may be the least of your worries.

Red_No_4 said...

I am a floater pharmacist at Walgreens in Florida, and I have a deep love/hate relationship with Power. Some stores I work in are what we call full Power -- the prescriptions are typed and verified off site; the leaflets print themselves out and all you do at the store is fill and verify what the leaflet says (scary). Some stores are under-Powered -- prescriptions are typed off site, but the in-store pharmacist must verify what was typed before filling and verifying the fill in store. This gives you a chance, even as a floater, to look at the patient's profile and catch some interesting mistakes (i.e. why is a 4-year old been prescribed cyclobenzaprine? Oh, someone at Power chose the wrong profile...).
Full Power stores tend to be those with the highest volume. The staff pharmacists there are scared witless about dropping their volume because then they might become under-Powered. My pharmacy trainer was one of those, insisting that we scan every piece of paper that was given to us -- OTCs, x-rays, blood work -- just to maintain the volume. And for the record, no, I can't do an MRI at the store. Not enough duct-tape :)
In general, I like Power (except when I hate it). For maintenance medications, it makes a lot of sense. The only drawback is when people insist that they need their lisinopril coming in tomorrow's central fill box NOW, and now you have to trick the computer into letting you fill it.
The call center for Power is apparently staffed by untrained baboons (trained ones would do infinitely better). It is the true reason why Power is awful. The call center can't activate a stored prescription but will tell patients it will be ready in 15 minutes. When in doubt, Power will run everything as cash, to make the prescriptions go through quicker (which makes you look like an ass when you ask the patient if they have insurance). Or, even better, they will delete any insurance information that doesn't work, forcing the store to re-enter the info into the patient's profile. Call center techs also tend to promise the impossible and -- my favorite -- tell anyone who calls that yes, we have that C2 in stock. 180 oxycodone 30mg? No problems, we can fill that.
This is why I begin every shift with a prayer and 800 mg ibuprofen. Be prepared.

Anonymous said...

Walgreens may have instituted the technology allowing the "Hunger Games" of greed to finally accomplish the actual devaluation human life in favor of complacency with "Operator Error" Obviously, the toxicity of the vital systems measuring their integrity and temerity in the arena of healthcare have plunged to the undeniably lowest level pharmaceuticals has ever witnessed.

Anonymous said...

Yep, I've learned whenever calling the Walgreen's near me that is "full" power ( to verify they have my Adderall on hand ) I IMMEDIATELY ask to be be transferred to the store. I've totally called them before and they put me on hold for less than 60 seconds and came back w/ a "yep! We have it" When I go to fill it.... of course, they did not. Lesson learned! -CPhT

Anonymous said...

How ironic... I graduated from pharmacy school in 1984.... I should have known ...!!

Anonymous said...

The pharmacy business is just that a business controlled by government.as such there is a blind eye turned on any wrongdoing.wake up the corporate machine can buy and sell politicians,just like the bank bailout fiasco who pays? Taxpayers pay taxes the government /(Congress +Senate)make laws not to help the taxpayers,but the corporations that pay them to enact laws for the corporate Americas benefit

Illya Kurynov said...

I graduated from pharmacy school in 2000. I laid in the sun for 2 months afterwards and while I soaked up the rays, I thought corporate--retail, retail-- corporate, back and forth everyday. I got stressed out. I realized that if I'm stressed over choosing which way I was going, then how would I deal with working in retail? As I read this article today, I'm sure glad I chose to work in R&D. Because what is going here in this article is a mess. A travesty. Yuch!

Anonymous said...

What is the law in Illinois if you want a controlled substnce transferred from Walgreens to CVS? Wagreens sid i had 2refills..one was filled on3-17. See I asked for the last one to be transferred..Walgreens said its too soon to fill. I said i dont want a refill!! Im still waiting for a response from Walgreens. What should i do?

Anonymous said...

You have to have CVS call your walgreens for the transfer and tell them to "store" it for you for when you want to fill it