In our last bit of ‘blog time’ together, we discussed the January 31st New York Times article written by Ellen Gabler entitled, “How Chaos at Chain Pharmacies is Putting Patients at Risk.” And, there was simply too much to ‘unpack’ in this article with one posting. In the last blog, we discussed the idea of “professional self-regulation” that the article openly critiqued. It hinted, not so subtly, that health professions have allowed the fox to guard the henhouse, so to speak, jeopardizing medication safety. But the article delves much deeper than our regulatory structure. It also pointed a finger at the financial metrics with which retail pharmacists are being directed to integrate into practice.
The article alleges that that two of the leading chain pharmacies, CVS and Walgreens, tie bonuses to achieving defined metrics. Nearly everything is tracked and scrutinized, the article reports, from phone calls to patients, the time it takes to fill a prescription, the number of immunizations given, and the number of customers signing up for 90-day supplies of medication, just to name a few.
So, what is the problem here? Why is this concept featured in an article devoted to medication safety in the pharmacy? One could easily argue that this is no different than any other metric that corporations routinely measure in other industries. Delivery companies, for example, use metrics to evaluate drivers on everything from adherence to the speed limit, hard braking, and the amount of time spent at each delivery site. Fast food industries use metrics to determine how long customers are waiting at the drive-through and how many apple pies are added onto the order after the suggestion has been made by the cashier. I once had a surgical nurse friend who shared that a metric for operating room staffs was how quickly the room could be cleaned between procedures. This is a disturbing idea, is it not, to be going into surgery behind the employee with the “best metrics” on this one?
The point here is that a narrow focus on financial metrics can quickly lose sight of the ‘bigger picture’. In the case of the operating room, the ‘bigger picture’ is obviously the quality of the sanitation… and the risks of associated secondary nosocomial infections. And, I think that too often health care managers and administrators lose sight of what the metric is actually measuring. For a more personal example, I will revert back to my days as a retail pharmacist. At that time, one of the coveted corporate metrics was the ‘generic to brand’ ratio. Essentially, the more generic drugs dispensed, the better the ranking within the company. Spreadsheets went out on a regular basis ranking pharmacies from ‘best’ to ‘worst’. Our store blew this metric out of the water! Week to week, we are at the top of the list. We were even awarded a trophy for having the most favorable ratio in the district. What this narrow metric, however, did not reveal was the ‘back story’ behind the success. In this case, my partner (who has long since retired) would absolutely refuse to fill a brand name prescription when a generic was available. He would claim that he was unable to get it from the warehouse or whatever… and the patient either accepted the generic alternative or took the prescription to one of our competitors. I seriously doubt that any of our neighboring competitors had a trophy on top of the refrigerator, but they had our customers! This was an outcome that the corporate team closely monitoring that metric clearly never envisioned!
Likewise, the fear that the article alludes to is the idea that pharmacists are being measured against metrics that could have disproportionate disastrous consequences among the “best metric performing” pharmacies. In the highlighted Missouri Board of Pharmacy survey, 60% of pharmacists went as far as saying that they ‘agree’ or ‘strongly agree’ that they feel pressured or intimidated to meet standards or metrics that may interfere with safe patient care. Proponents of the metrics argue that the metrics are meant to provide better patient care, not to penalize pharmacists. Once again, as we surmised in our last blog, we see completely opposing views… with both arguments using drug safety as the central pillar.
The New York Times article put many health care conversations on the table, with the idea of metrics for pharmacists being only one of them. It has garnered the attention of the public and, by default perhaps, the attention of the regulators. The South Carolina board of pharmacy, as one example, recently published a statement “discouraging the use of quotas and encouraging employers to value patient safety over operational efficiency and financial targets.” The real challenge, I believe, will be in identifying which metrics truly improve patient safety and underscore the role of health care professionals… and which metrics place that goal in jeopardy.
At the end of the day, pharmacists do not go home to relish in the fact that they have the best generic to brand ratio in the district. Pharmacists do not celebrate the fact that they hold the record for the fastest turn around on telephone calls with patients. As pharmacists, we celebrate the successes that the metrics fail to capture: the averted tragedy, the genuine connection with a patient struggling to afford an essential medication, the timely guidance provided to an exasperated mother of a sick infant, and so on.
Does that mean, then, that metrics are inherently bad for pharmacy? Not necessarily. I believe that the true danger of metrics comes when the potential ‘adverse events’ of the metric are not properly weighed against the benefit of measurement. The true danger of metrics lies not in the metric itself, but in those who fail to understand what information the metric is conveying and what impact a focus on that single element has on the broader system. We can, after all, have excellent metrics and poor outcomes, as our pharmacy’s trophy from years past highlights so well. In the case of pharmacy, the stakes of poor outcomes may be catastrophic. We must ask, then: Are our pharmacy metrics moving the profession toward positive patient outcomes, or are they pushing the profession toward catastrophe?
[Author’s note: The article being referenced appeared in the New York Times on January 31, 2020. There are many points to unpack in ‘the’ article. Future postings will evaluate other aspects of this article. The original article, in its entirety, may be viewed here.]