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.
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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
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
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