Mail service and community pharmacies must work in tandem
From the November 17, 2005
With the advent of Medicare Part D and the wide variety of insurers and prescription drug plans, it's likely that more patients will be relying in part on mail service pharmacies for fulfillment of their prescription drugs. Last week, we received a media release about a newly published study that touts the dispensing accuracy of mail service pharmacy practice (click on Latest News at www.medco.com). Conducted by Medco Health Solutions, the 2003 study uncovered a 0.075% dispensing error rate (less than 1 error/1,000 prescriptions) (1). All errors discovered were associated with the initial stages of prescription processing, such as order entry. Among more than 21,000 prescriptions involved in the study, no errors were associated with actual product dispensing-an impressive accomplishment that the authors attributed to a high degree of automation used in the dispensing process.
Citing similarities in the definition and interpretation of a dispensing error, the authors also compared their findings to a 2000-2001 study of 50 community pharmacies, which revealed a 1.7% dispensing error rate (less than 2 errors/100 prescriptions) (2).
The recent media release about the study seemed to highlight the difference in dispensing accuracy between mail service and community pharmacy, rather than the positive impact that dispensing automation has had on patient safety. This comparison of dispensing error rates could influence the public's perception about the safety of community pharmacies, especially if the public is unaware of the increased use of automation in community pharmacies since the above-cited study was conducted. While mail service pharmacies have been leading the way in dispensing automation, technologies such as bar coding, robotic dispensing, and electronic scanning of prescriptions are becoming commonplace in community pharmacies. Perhaps lagging behind at first, community pharmacies are now positioning themselves to achieve similarly impressive dispensing accuracy rates through automation and other improvements.
Without diminishing the achievement of substantially lower dispensing error rates in highly automated pharmacies, a comparison of dispensing error rates alone does not tell the whole story about the contribution that community pharmacies make to patient care. In fact, community pharmacies play an essential role in helping patients who use mail service pharmacies to achieve the best outcomes; they periodically compensate for some inherent weaknesses in mail service pharmacies that were not examined in the recently published study (e.g., unrecognized prescribing errors, mail delivery errors, unprocessed prescriptions).
Emergency and interim prescriptions. Patients with prescription drug plans that encourage mail service pharmacy must turn to community pharmacy for emergency prescriptions and medications prescribed for acute illnesses. Understandably, mail service cannot fulfill this critical need. Community pharmacies also serve patients that need help when their medications run out before mail service deliveries arrive. The medications may be in transit, "lost" in the mail, or never sent if, for example, a faxed prescription was never processed. Regardless of the cause of the delay, patients have often relied on community pharmacists to help them obtain an interim supply of medications.
This can be time-consuming for the community pharmacist, but well worth the effort to ensure continuity of patient care. Typically, the pharmacist receives a rejection from the patient's insurance company if the mail service pharmacy has already processed the prescription or refill. Sometimes the pharmacist is able to call the insurer and secure approval for a short-term supply of the medication to hold the patient over until the medication arrives.
The patient's physician might also need to be contacted for a new prescription, as in the following example: A patient went to his community pharmacy because he had not yet received his prescription for ACCUPRIL (quinapril) from a mail service pharmacy. The pharmacist first needed to call the physician's office to obtain a new prescription for a 10-day supply. He then attempted to get approval from the patient's insurer, but the prescription was rejected because it had been filled one week earlier by a mail service pharmacy. Since the patient had run out of Accupril, the pharmacist called the insurer and was finally given approval to dispense a 10-day supply.
If the insurer does not cover interim supplies, some patients have resorted to paying for the medication themselves, especially if the community pharmacist has taken the time to discuss any significant health risks of missed doses. However, other patients have placed themselves at risk when faced with unanticipated out-of-pocket expenses by electing to wait for their medications. Reports of drug therapy omissions under these circumstances include potentially harmful situations involving medications such as warfarin, thyroid medications, antiarrhythmics, and antihypertensives.
Patients who are unaware of the insurer's policy requiring higher co-payments when filling prescriptions for chronic medications in community pharmacies may also experience an interruption in therapy. To cite one example, an elderly patient had filled a new prescription for DIOVAN (valsartan), paying a $5 co-pay. When she went to the pharmacy to pick up a refill, the co-pay was $49. Unknown to the patient, subsequent refills of this medication required a higher co-pay if it was not refilled via mail service pharmacies. At first, the patient told the pharmacist, "My blood pressure has been fine; maybe I'll just wait until I can get the medication." After the pharmacist described the risks associated with omitting this medication, the patient reluctantly purchased the refill. Unfortunately, not all patients can bear the burden of higher co-pays. Community pharmacists have been able to direct some of these patients to local assistance programs to help cover the costs; they have also provided interim medications without reimbursement.
Face-to-face counseling. Dispensing errors have often been averted when counseling patients about the medication, reason for use, dose, route, and directions for taking the drug. This offers patients an opportunity to speak up if any information does not match their expectation. Unfortunately, mail service pharmacies, at best, can provide counseling over the phone if the patient calls with questions. Some patients have opted instead to ask a pharmacist in their community for advice. One reported example involved a patient who received DUONEB (ipratropium and albuterol) from a mail service pharmacy but was confused about proper timing of the medication. He had been using DuoNeb via nebulizer four times a day as prescribed, but just 2 hours apart for the first three doses after waking, and then once before bed. When he continued to experience afternoon and evening breathing difficulties, he visited his local pharmacist, who prepared a written time schedule to facilitate more consistent relief for the patient. Similar reports have been received, some-times due to patients' difficulties in communicating with mail service pharmacists.
Conclusions. Community and mail service pharmacies share a common goal of ensuring that patients have access to the most appropriate, effective, cost-efficient, and safe pharmaceutical products. Together, they should explore more seamless medication dispensing services to reduce fragmented care, improve handoffs when necessary, and promote continuity of pharmaceutical care. As such, we hope the study and recent media release do not spark yet another round of potentially damaging competition (particularly to community pharmacy) between these two practice settings. If truth be told, whether by choice or need, mail service pharmacies need to work in tandem with community pharmacies to provide the best service possible to patients. Community pharmacies excel at offering a personalized means of providing medications and clinical services via a widespread network of providers-a network that mail service pharmacies also need to be successful.
(1) Teagarden JR, Nagle B, Aubert RE. et al. Dispensing error rate in a highly automated mail-service pharmacy practice. Pharmacotherapy 2005; 25(11):1,629-1,635.
(2) Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc 2003;43(2):191-200.