The Enemy is Us

Illinois Collaborative Pharmaceutical Task Force
Postmortem Dissection

Recent Illinois pharmacy regulations, or lack thereof, precipitating from a 2016 Chicago Tribune investigation might best illustrate how retail dominance can bias development of pharmacy regulation and preserve drug chain competitive advantage. The investigation found significant counseling issues in 52% of chain drug pharmacies. In response, legislators recommended changes aimed at eliminating, or at least reducing, this clear risk to the public.

The Collaborative Pharmaceutical Task Force, convened to review public risk and proposed legislation, concluded a 30-minute meal period would solve the failure to counsel issue. It sidestepped the investigation’s issue of workload in focusing the discussion solely on the length of a workday. The Task Force may have rejected key legislative changes aimed at regulating chain drug store workload using logic fallacies and questionable statistics.

The mandate of the Task Force was to ‘protect the public and provide quality pharmaceutical care’ by, at a minimum, examining legislative provisions provided to the Task Force. One might imagine the mandate required the Task Force to resolve workload issues the Chicago Tribune investigation cited for chain drug stores.

A postmortem dissection of the Task Force published minutes and recommendations suggests drug chain operation risks remained intact despite the public mandate and many recent articles citing concern for workload and error risk. Moreover, the recommended solution may have increased the risk to patients by allowing pharmacies to close during meal periods.

Below are some questions raised by the Task Force organization, discussion, and product. All observations are posed as questions for you to decide their credibility.

Should Task Force membership have balanced ownership and drug chain management with knowledgeable public proxies?

    • Did the fact that a significant majority of members were current or former drug chain executives, employees, or representatives from organizations directly affiliated with a drug chain affect the outcome of the public hearing?
    • Would the addition of hospital outpatient and independent pharmacy representatives offer a different operations perspective and result in a different outcome?
    • Should the Task Force have cited without representation, regulatory, hospital, and independent pharmacy limitations for rejecting proposed legislation aimed at drug chains?

Was the Task Force disingenuous in defining the problem and selecting a discovery path? 

    • The Chicago Tribune investigation clearly described the problem as workload and drug chain
    • A workload discovery path might have revealed:
        1. A link between high workload and potential for errors
        2. Workload error potential exists regardless of hours worked
        3. Impact of process interrupt frequency and significance of disruption
        4. Recent articles citing workload as patient and staff risk
    • The discovery path chosen by the Task Force would, in contrast:
        1. Equate all pharmacies regardless of market or operations
        2. Ignore workload and other differences for non-drug chain pharmacies
        3. Re-affirm error potential is not (solely) related to hours worked

Was it reasonable for the Task Force to benchmark regulatory criteria to hospital and independent pharmacy risk and capabilities? 

    • The investigation and ensuing proposed legislation differentiated drug chains
        1. Did the Task Force have an obligation under the mandate to ascertain if the results of the investigation extended to hospital outpatient and independent pharmacies before citing them as cause for rejecting proposed legislation?
        2. Did the Task Force have an obligation to apply regulations to the entities posing the cited risks?
        3. In benchmarking regulations to dissimilar operations, did the Task Force allow a potential risk to the public to exist by overgeneralizing the industry?
    • Should Task Force members have addressed operation and market differences between different types of pharmacies?
        1. Do hospitals staff to meet higher patient demands for prescription resolution, fulfillment, and counseling for wait-time averse insured patients?
        2. Do chain pharmacies have the ability to pass burdens for prescription resolution, fulfillment, and counseling on to patients (evidenced by denials and extended wait/delivery time)?
    • Should members have acknowledged advantages of drug chain resilient demand queues and absence of outcome risks?
        1. Risk-free, resilient demand queues will allow pharmacies to operate at lower labor cost and potentially pass this cost on to patients in the form of delivery
        2. Hospital outpatient and independents do not have resilient demand queues, and the former carries the risks for unsuccessful therapeutic outcome and adverse drug
    • Did the Task Force make an error equating drug chain entity risk with independent and hospital outpatient pharmacy entity risk?
        1. Did the Task Force have an obligation to determine what, if any, impact minimum technician hours would have on independents and hospital outpatient pharmacies before citing this as a reason for rejecting the minimum hour legislation?
        2. Is it fair to conclude that drug chains should not bear the cost for minimum technician hours, despite significantly different operations, because smaller pharmacies could not bear the potential burden?
        3. Would wrongly equating entity risk to reject minimum technician hours and script per hour limit help preserve competitive advantage, if one exists, by continuing to allow chain drug to avoid minimum technician hours?

Was the Task Force correct in citing an ISMP ambulatory pharmacy self-check questionnaire to support the belief that error risk is the same regardless of hours worked?

    • Was the self-assessment based on a study of hospital healthcare workers, specifically nurses, and more broadly included other healthcare workers?
    • Did a drug chain pharmaceutical distributor for major drug chains, with interests in their own pharmacies, fund the ISMP study?
    • Are drug chain and hospital pharmacy staffing and workload really the same?
    • Did the Task Force factually establish the ISMP as consistent and industry-wide guidance before citing it as incontestable evidence against limiting the length of a workday?
    • Did the Task Force fulfill its obligation to engage public discussion on readily available articles and citations for the health and error risks posed by extended work hours?

Did the Task Force exceed its mandate and authority for public hearings?

    • Was there evidence of a vote or timely notice to end public input prior to the Chair denying the floor to a member of the public to make a comment?
    • Did a Task Force member speak for and by-pass regulators to close action on a key point to differentiate drug chains from independents and hospital outpatient pharmacies, and was this contravention of the mandate to focus on drug chains?

The postmortem dissection of the Task Force year-long review of proposed legislation may not have addressed and resolved the true cause for the Chicago Tribune findings. It should, however, raise awareness for the need to discriminate between drug chain, independent, and hospital outpatient pharmacy regulations.

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