Local Pharmacies Struggle to Stay at the Front Line of Health

Bella Feinberg juggles life, work, family and a host of chronic illnesses. Asthma. Blood pressure. A heart condition. She heartily chuckles, trying to remember her list of daily medications.

“I think I have 13 prescriptions,” Feinberg, 69, said. “Maybe that’s without my asthma medicine. Maybe it’s more with my asthma.”

For the past thirty years, Feinberg has filled her prescriptions at Waldinger’s Pharmacy, a 5th Avenue mainstay in the heart of the Bay Ridge shopping district in Brooklyn. She depends on pharmacist Frank DeRosa to help keep her medications on track.

But beginning next month, Feinberg will no longer be able to rely on DeRosa. Her insurance company switched to mandatory mail order through CVS and won’t pay for medications dispensed at places like Waldinger’s.

Feinberg isn’t the only patient DeRosa has lost to mandatory mail order. Waldinger’s prescription drug business has dropped 60 percent over the past few years, said the pharmacist. Other pharmacies along Bay Ridge’s 3rd and 5th Avenues report declines in prescription drug sales from 20 to 60 percent. Such sales represent a large portion of a pharmacy’s income and are a main incentive driving customers into the store.

“We’re a pharmacy, [prescriptions] is where all of our business comes from,” said Igor Grabov of Bay Ridge Specialty Pharmacy. When it comes to mail order, “they take their share, but we have to compete with them.”

At a time when more employers are opting for savings through mandatory mail order prescriptions, DeRosa believes he still provides a vital community service—personalized care from a pharmacist who understands the individual needs of each patient.

“Patients look to us to answer their questions, to explain to them things they don’t understand with their medication and their treatments,” DeRosa said.

But insurance companies and drug managers believe that mail order prescriptions are more efficient, cut costs and serve patients well. The increase of mandatory mail order prescriptions threatens not only the survival of those hard hit pharmacies, but the community service they provide to patients in need of constant guidance.

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Listen: Waldinger’s turns to creative methods to attract customers and compete with mail order prescriptions.

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As President Barack Obama and lawmakers on Capitol Hill debate how to expand coverage and control spiraling health care costs, prescription drugs comprise one of many conundrums. In 2008, prescription drugs sales reached $291.5 billion, a 1.4 percent increase from the year before, according to Forbes magazine. According to the Centers for Disease Control, chronic conditions account for 96 percent of drug costs in the country.

Within the pharmaceutical industry, drug managers—also known as pharmacy benefit managers—advocate mail order prescriptions for patients with chronic illness. They say mail order is the best option to streamline the price, the sale and the distribution of prescription drugs. These managers take in large rebates and discounts by purchasing drugs in bulk and thus have considerable discretion over which drugs are used.

Although mail order prescriptions date back to the 1940s, the business boomed in the 90s and quickly became the fastest-growing distribution channel for the industry. It is estimated that today, one in three households nationwide use a mail order pharmacy to fill prescriptions. Thirty-six percent of those households are required to do so by their health plans, according to the 2007 Pharmacy Satisfaction Digest from WilsonRx and Boehringer Ingelheim, two health care research firms.

In New York City, health insurance plans for all city employees and several major unions require mandatory mail order for all maintenance drugs—prescriptions taken regularly over an extended period of time.

Mail order is convenient, saves money for employers and patients, and is designed specifically for people with chronic conditions, said Jennifer Leone Luddy, a spokesperson for Medco Health Solutions, one of the country’s largest pharmacy benefit managers and mail order pharmacy operators. Medco offers phone consultations with pharmacists 24 hours a day, and also with specialists in several common chronic conditions. Luddy said these services help patients manage chronic illnesses.

“These specialist pharmacists can tell if a patient is not refilling their prescription on time, and [is] therefore not compliant, or not getting testing for things,” Luddy said.

Many users swear by mail order’s convenience and savings. John Morlano, 75, a life-long Park Slope resident and diabetic had bypass surgery 12 years ago. Since then, he has taken a cocktail of 13 prescription pills a day.

“I take four pills a day for diabetes,” Morlano said. “And four water pills, four pills for blood pressure, one pill for my heart, plus vitamins.”

Morlano, a veteran of the Korean War, orders his medication through Veterans Affairs. He prefers mail order because “it’s good and cheap,” he said. “I pay $8 per prescription. You can’t beat that, and all I gotta do is call up.”

But managing a complicated regimen isn’t so easy for everyone. Pharmacist DeRosa said some patients are confused and devastated when new conditions arise and need a great deal of personal attention to walk them through major life changes.

For instance, 12 years ago, an elderly man began seeking DeRosa’s help after he’d been diagnosed and prescribed medication for gout—a form of arthritis that causes pain and swelling of the joints, mainly on toes and fingers.

“In the beginning, we thought he was a cranky old man,” DeRosa said. “But it was because he didn’t feel good.”

The man, now 69, continued to develop new illnesses—following the gout was asthma, then vision problems, and most recently, diabetes. He now takes more than 30 medications a day, said DeRosa.

“He’s got a lot of questions,” DeRosa said. “He doesn’t understand what’s going on with his health, what his doctor’s trying to tell him. But he’ll come here, and we go over everything together.”

Despite a major language barrier—Arabic is the man’s native language—DeRosa said he and the patient have developed a common understanding based on gestures and simple phrases. DeRosa is skeptical that over-the-phone pharmacists would be able to serve this man’s needs—or develop relationships that serve patients in the long term.

“We are the front lines for people’s health,” DeRosa said. “We are the ones they come to help them when they don’t feel good. You need to be able to have that access to a pharmacist who can recognize if it is a simple cold or rash or sprain, or is it something more serious.”

Devon Stone of the Washington, D.C.-based organization, National Community Pharmacists Association, says that despite industrywide financial stability in 2008, local pharmacies continue to face several pressures: mandatory mail order, big chain drug stores and lower reimbursement rates from insurance providers and Medicare.

“You can’t go head to head, mano y mano, against the mail orders and the big chains,” Stone said.

The solution, according to Stone, is for community pharmacists like DeRosa to continue what they have been doing for years: offering personalized care and a diverse set of services. DeRosa is hoping that industry decision makers will recognize the preventative role pharmacists play in health care: helping cut costs by preventing conditions from getting worse. That, said DeRosa, is often missing from policy talk.

Feinberg said she would continue coming to Waldinger’s with her questions and for the occasional cold medicine. But without constant communication, DeRosa cannot provide the same quality of care as he has for the past thirty years.

Each patient DeRosa loses to mail order only reminds him of a changing industry where employers, insurance providers, and drug managers decide which patients stay and go.

“Before, simply being here was enough,” DeRosa said. “People needed pharmacies, and they needed pharmacists. It’s not the case anymore. Still, I don’t think any of them are a good substitute for what we provide in the pharmacy, and I hope people realize that.”