OVER THE COUNTER 1994-09-19

Janice Zoeller

Health care reform was put on the back burner in mid-August as Congress ajourned to catch the last few waning days of summer. The marketplace, though, is taking no vacation. If anything, the changes have accelerated and they are unsettling.

In the last month, Ivax Corp., Miami, agreed to buy Zenith Laboratories, Northvale, N.J., in a deal that would create the world's largest maker of generic drugs. American Cyanamid Corp., Wayne, N.J., is being purchased by American Home Products Corp., New York, and SmithKline Beecham, Philadelphia, is buying Sterling Winthrop Inc., after having purchased Diversified Pharmaceutical Services.

The turmoil afflicting the industry was evident on the exhibit floor of the National Association of Chain Drug Stores' recent Pharmacy Conference in Orlando, Fla. The most often repeated comment by pharmaceutical manufacturers and chain executives alike was, "Who knows what's going to happen next?"

Supermarket pharmacists pondering the future should reflect on pharmacy's strengths: relationships with patients, scientific knowledge and public trust.

This month's cover story, profiling a Dillon pharmacy manager in Olathe, Kan., demonstrates that providing meaningful customer service is not incompatible with working for a large chain. Dillon, which operates 43 pharmacies and is a division of Kroger Co., Cincinnati, in fact, encourages such efforts with its corporate policies. After all, the measure of success of any business is not its size, but the relationships it builds with customers.

It remains to be seen, though, whether the pharmacy profession can maintain its independence in the face of the growing influence of managed care and the continued consolidation and vertical integration of the industry. While the threat posed by closed provider networks has faded, pharmacy is now being threatened on two other fronts as formularies undermine the ability of pharmacists to make independent judgments concerning medications and rebates entice pharmacists to jeopardize their standing as the most trusted professionals.

What are people to think when they read articles in The New York Times, USA Today and The Wall Street Journal that say pharmacists are being paid to change peoples' drug therapy?

There's probably nothing wrong with having an informed patient agree to have a drug changed to a similar one that will mean a 10% savings on a monthly drug bill. But what about when customers are not informed? Having the pharmacist change a customer's drug therapy in order to return money to the pharmacy and third-party payer begins to sound different. Who then is the pharmacist looking out for?

Disturbing, too, is the response to The New York Times article by Tim Vordenbaumen, president of the American Pharmaceutical Association. Vordenbaumen made no distinction between programs that pay pharmacists to counsel patients and those that pay pharmacists to move market share.

The distinction is important. Are pharmacists primarily advocates for their customers or for third-party plans and/or pharmaceutical companies? What are the standards for deciding that it's safe -- and ethical -- to convince a patient's physician to switch his or her medication? Are customers involved or even aware that such decisions are being made on their behalf? For so long, the pharmaceutical industry argued in favor of physicians being able to choose the right drug for the right patient, to be able to take into account individual reactions and sensitivities. We even hear some talk about the need for drug therapy to be customized for patients to minimize side effects.

The reality is that a type of mass prescribing is taking hold, with pharmacists being recruited as the agents to carry it out. Is this the future for the pharmacy profession? If so, someone should warn those idealistic pharmacy students who are busy sharpening their counseling skills.

If pharmacists allow themselves to become the agents of managed care organizations rather than customers, the cost will be high, in terms of loss of trust and confidence in the profession. Supermarket pharmacies have the most to lose in a marketplace that ceases to be primarily customer-driven.

While big is not necessarily better, it's not necessarily worse, unless the changes taking place lead to pharmacists abdicating their role as advocates for patients.