In September, about 32 pharmacists employed by CVS pharmacies in the Kansas City area refused to show up for work, saying they were overworked and understaffed.
Days later, Gov. Glenn Youngkin signed emergency regulations designed to prevent pharmacies in Virginia from coming to a screeching halt.
The regulations require a minimum number of employees, discourage drugstore chains from dictating productivity quotas and give protections to whistleblowers.
But pharmacists are still hesitant to make complaints and put their own names on the line, said Karen Winslow, interim executive director of the Virginia Pharmacy Association.
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Across the country, pharmacies have been beset by understaffing, leading to crowds of patients and stressed out employees. Pharmacists have taken on more responsibilities since the pandemic, but resources for them have not kept pace.
The walkouts were a sign of desperation from pharmacists who needed to take a stand, the Virginia association said last month.
The association has been working on employee burnout since 2019. Last year, the Virginia Board of Pharmacy started a workgroup to study the issue. The state has more than 5,000 pharmacists, Winslow estimated.
In 2021, a CVS in Virginia Beach was fined $427,000 for understaffing that led to repeated mistakes. One patient received 100 extra doses of Percocet, the Virginia Mercury reported. Another went to the emergency room after staff neglected the patient’s history, which noted an intolerance to the prescribed drug.
The new regulations require drugstores to schedule enough employees that workers do not become victims of fatigue and distraction. Drugstore chains are also directed to avoid productivity quotas or any other program that interferes with a pharmacist’s ability to spend time with a patient.
The pharmacist on duty can decide if the location should close while he or she is on a break. If the pharmacy stays open, the pharmacist has to remain on the premises.
The regulations also provide a safeguard for whistleblowers. Pharmacists can report staffing issues to the state board, and drugstore chains cannot discipline him or her for doing so.
The whistleblower protection is important, Winslow said, because a primary way of enforcing the regulations is by an employee making a complaint to the board. Complaints cannot be made anonymously, and some employees still worry they will get in trouble. Infractions can also be found on routine inspections.
At the root of the problem is that many pharmacies are being asked to do more with fewer resources, said K.C. Ogbonna, dean of the Virginia Commonwealth University School of Pharmacy.
Pharmacists administered millions of COVID tests and vaccines during the pandemic, and now pharmacists in Virginia have the latitude to conduct tests for flu, strep throat and UTIs and direct the patient on his or her next step for treatment.
But what a patient’s insurer pays a pharmacy for a drug can be dangerously low. In some instances, pharmacies lose money on the drugs they distribute.
Pharmacies buy drugs through middlemen, called pharmacy benefit managers, who negotiate prices on behalf of the manufacturers that build the drugs. Then the insurance company — or Medicare or Medicaid — reimburses the pharmacy for the cost of the drug. Sometimes, that reimbursement is less than what the pharmacy paid to get the medicine.
Pharmacies also lose money on fees, known as DIR, or direct and indirect remuneration, in which payers claw back money based on a pharmacy’s performance on certain quality measures. These measures often are not transparent or consistent, Ogbonna said.
This leaves pharmacies stuck between a rock and a hard place, doing more work while their income lags behind.
Large drugstore chains have responded to complaints that they are not adequately staffing their sites. Walgreens said it spent $265 million last year to retain and recruit pharmacy staff, The Wall Street Journal reported. CVS is trying different ways to ease the burden on staffers, including directing them not to answer the phone and instead call patients back when they have time.
It’s unclear what kind of effect the new regulations will have in Virginia, but leaders are hopeful. Other states are looking to Virginia as a model for requiring minimum working standards, Winslow said.