Adverse drug reactions caused by unknowingly taking the wrong combination of drugs can range from drug ineffectiveness to death.
The prevention of those situations is the essence of the pharmacy profession and, perhaps, the most important reason Hawai‘i’s independent pharmacists successfully compete with health-maintenance organizations, hospitals, large retailers, mail-order and online pharmacies.
“Education is one of our primary tasks,” says Phyllis Robinson, president of the Hawaii Independent Pharmacists. “We encourage our clients to use local pharmacists’ professional expertise” to answer everything from how much of a medication to take, to which walker is best.
“Over the last two decades, we’ve seen independents losing ground to mass marketers like Wal-Mart and Rite Aid,” says Robinson. “And because we can’t price things the way we want, our profits get smaller. We end up having to find niche markets.”
According to Robinson, independent pharmacies use four basic strategies to compete: offer greater convenience and consultation; provide durable medical equipment such as walkers; create and compound special drugs on site; and know patients’ medical histories.
There are now nearly 800 pharmacists registered in Hawai‘i, up from 729 in 1996 and 548 in 1990. Some are associated with large retail pharmacies like Longs Drug Stores. But many work for the 55 independent pharmacies around the state, comprising a community of independent businesspeople who, for all their modern knowledge, employ a time-tested method of survival: herding.
Competition starts from the point of purchase for independents, most of whom associate themselves with distributors Value Rite and Good Neighbor, who in turn purchase their stock from wholesalers like McKesson Corp. and Bergen Brunswig Corp. These wholesalers purchase directly from pharmaceutical companies.
This system gives independents the economy of scale necessary to buy in bulk and sell at a profit, which is hard to come by because drug prices are frozen by third-party payers or insurers.
“We can’t possibly compete with online and large retailers without associating with them,” says Robinson.
This buying scheme has resulted in a relatively constant number of independents over the last decade, according to former Hawaii Pharmacy Association President Jim McElhaney.
Hawai‘i’s independent pharmacies have a rather friendly relationship with the other pharmacy associations, such as HMOs, hospitals and Hawai‘i’s biggest retail pharmacy, Longs Drug Stores.
The Hawaii Society of Health Systems Pharmacists recently merged with the Hawaii Pharmacist’s Association, which includes members of Hawaii Independent Pharmacists. They combine their efforts to lobby on behalf of all pharmacists in the state, often uniting against common competitors.
“Online and mail-order pharmacies are the scourge of the industry,” says McElhaney. “They pose a very serious problem in the distribution of medicine because there’s a total separation between the providers of acute medications and the client.
“The risk of bad drug interactions goes up, especially with online providers, which could lead to more emergency-room visits, hospital visits, and a lower quality of life,” he says.
“Right now, the average pharmacist fills about 15 to 18 prescriptions per hour. But with mail order and online pharmacies, that number is about 90 to 95 — and the error rate goes up, too,” McElhaney says. “These are numbers I wouldn’t be comfortable with.”
To be fair, online and mail-order pharmacies are not all the same. Most require qualified physician or pharmacist approval before ordering, and are tied into insurance medical databases. But others allow prescription orders after completing a simple online questionnaire.
“Sometimes people can buy a three-month supply for one copayment,” says Robinson. “This is pretty hard to compete with, because by law we can only supply a one-month supply for the same co-payment.”
It’s not just cheaper prices that drive people to online and mail-order pharmacies. As the population ages, take-charge baby boomers are looking for information and products to help manage their own health, often going online.
And their probable purchases, according to registered nurse Carolyn Burgess, will be standard medications for the maintenance of self-monitored diseases like diabetes, blood pressure and antibiotics — all typically self-administered.
Now, the Hawaii Medical Service Association might be getting into the game. HMSA officials are studying a possible partnership with online pharmacy Planet Rx of Memphis, Tenn. A partnership would mean HMSA’s 610,000 clients — nearly half of Hawai‘i’s insured — would have what HMSA officials say is a safe and economical place to purchase drugs online.
The key difference between the use of Planet Rx and other online pharmacies, according to HMSA chief pharmacist Roy Yamauchi, is that Planet Rx will be tied to HMSA’s database, giving the online pharmacy the same information as a retail or independent pharmacist in Hawai‘i. This should, according to Yamauchi, prevent prescription interaction problems and other errors, and eliminate co-payment problems that come with doing business from a nonparticipating site.
However, HMSA Senior Vice President Cliff Cisco says, HMSA clients have not shown much interest in online pharmacies.
Only about 3 percent of Hawai‘i’s pharmaceutical orders are online, says McElhaney, compared to 14 percent nationally.
Reasons for such reluctance include Hawai‘i’s distance from Mainland warehouses, possible mail delays, and technophobia, says Robinson.
But there may also be a simpler reason: Hawai‘i’s people like that their pharmacists know them personally, are intimately familiar with their medical histories, and are willing to take time to counsel them.
Phil Hayworth, business editor, may be reached at 245-3681 (ext. 251) or mailto:phayworth@pulitzer.net.
