Why small pharmacies matter

On the role that I play when I don my white coat in a small business pharmacy

In a time of scams everywhere, having a local person you can trust who is not constrained in what they say and do by a distant corporate master is incredibly valuable. Local businesses matter. Small business pharmacies are, yes, for profit businesses trying to earn a living by selling pharmaceutical care. Pharmaceutical care is the framework of the practice of pharmacy I was trained in. It encompasses both the actual provision of medications that is the entirety of pharmacy in the minds of a large part of the public, as well as the care provided by a pharmacist to ensure that the process of and use of medications are safe and rational. Identification of and solutions to medication-related problems are part and parcel of the independent pharmacist’s daily work.

As a recent example from my practice, I had a prescription come in for Mounjaro. The patient’s Obamacare plan includes coverage for Mounjaro, but applies a $1500 deductible, and then applies 30% coinsurance after that until they reach their $10,000 maximum out of pocket. The patient had apparently been receiving compounded Tirzepatide from a medical spa for a few months for $200/month. I was able to reference their list of covered medications, their plan benefit design, and the reimbursements we receive to help her decide the best course of action from a cost and quality standpoint. On a cost basis, she was faced with a $1056 price for the first month of Mounjaro, which I was able to reduce by $150/month by helping her identify a coupon from the manufacturer. Her initial response was to decide that that made no sense compared to the $200/month at the medical spa. After looking at it further, we did decide that the cost to her for the year was less at the medical spa, even though the brand name would be cheaper once her deductible is met ($170/month). We also discussed the pros and cons of the compounded product vs. the branded product. Working in a small business gave me the freedom to take ~5 minutes of my time to give her the peace of mind that she was making a financially optimal choice, and to know what circumstances would cause that to change.

Another example was at the intersection of clinical and insurance issues. I have a patient who has a G-tube and is unable to take many medications for that reason. She needs a medication for acid reflux. Most of the medications available for that problem cannot be given by G-tube, or can only be given with extreme difficulty. She has limited financial resources and coverage through medicaid, and Pepcid and similar medications did not work for her. This meant that the only appropriate medication that was covered through her plan was an orally disintegrating tablet form of lansoprazole, which required a prior authorization from her medicaid plan. I was able to identify a second option for her – we could compound an omeprazole formulation for her. Unfortunately, that would not be covered by her plan, and her financial resources would not support the cost for more than a month. We decided to pursue the prior authorization, which was processed and approved, and she started therapy with the lansoprazole ODTs. Because I had no corporate mandated quotas to meet, I was able to take the time to discuss alternatives and identify the best option for this client.

A third example was a woman newly prescribed a teriparatide injection. She had heard that medications designed to strengthen the bones can make the bones more brittle and can result in very strange fractures. This medication was also quite expensive due to her plan’s deductible. In this case I was able to reassure her that teriparatide is not in the same category of medicines as alendronate, which can cause the strange fractures and brittle bones. I was also able to help her understand and enroll into the new Medicare Prescription Payment Plan that was created last year by the Inflation Reduction Act, allowing her to spread out the financial impact of her deductible across the entire plan year, instead of having to pay her $795.06 copay lumped in January. While our primary job is to get people the best medication accurately, a pharmacist’s clinical knowledge does not matter if their patients cannot afford their medication, as shown in the tragic death of a 22 year old of asthma after NOT getting adequate pharmaceutical care from a corporate-owned pharmacy.

A fourth example was a father of a 1 year old who was sick with an ear infection. I was able to explain in detail to this nervous young father how to use the medication and pass along some tips about how to get his little boy to take his medication. In the course of that conversation, I learned that they chose to come to my family’s pharmacy after having a very poor experience waiting for nearly an hour at the local Walgreens.

What do these stories have in common? Unlike corporate pharmacies which are able to use their scale to force customers of certain insurance plans to use their pharmacy, and who have extremely well-known national brands, small business pharmacies have to compete through offering better care and service. We spend the money to have enough staff to process the prescriptions quickly AND allow the pharmacist to be a trusted professional with adequate time to use their position to solve medication related problems for our patients, rather than simply to provide the legal checkbox of having a licensed pharmacist present and able to accept liability for inevitable failures. To be clear, my pharmacist colleagues employed by chain pharmacies are, as a rule, well-meaning and competent pharmacists. They, and the technicians that support them, are, unfortunately, too often treated by management as a cost to be minimized rather than as professionals deserving respect.

As a local professional whose practice is owned by a local businessman who has to answer to his customers if he gets greedy and cuts staff, without the scale to arrange coercive exclusive deals with insurers, I am able to give my customers meaningful reassurance that they are not being scammed by “the system,” an disturbingly common occurrence in our overwhelmingly corporatized healthcare system. This trust that I am able to build with my patients is, in no small measure, due to the local control of our pharmacy. This is why, despite prominent liberal voices questioning the value of local pharmacies, I care so deeply about the local ownership and control of healthcare practices from pharmacies to physician practices and hospitals. I believe that local ownership and control results in practices that are more responsive to community needs, while distant financial masters cause myriad harms to both medical professionals and the public. I believe that the increasing consolidation of control in large health systems and in large insurers is a major threat to the health of the American populace. I say it is time to Break Up Big Medicine.