Medication reviews may miss patients who need them

Medication reviews, which are publicly funded safeguards designed to make sure people are taking prescription drugs correctly, are not always performed properly or reaching the people who need them most, an ongoing investigation on Canadian pharmacies by CBC News and Marketplace reveals.

Some pharmacists are speaking out about increasing business pressures to perform extra services that can be billed to provincial governments.

They say that pressure to perform medication reviews with patients means that younger or less complicated patients are attractive targets because they can be done quickly, instead of the elderly or people on a high number of medications who would benefit more but take longer.

A Marketplace investigation in January revealed how some pharmacists feel that pressure to meet business quotas increases the likelihood that they could make mistakes. With no mandatory national tracking of pharmacy errors, there is little data on why and how often mistakes happen.

“I think the quotas just need to be banned,” Derek Jorgenson, a pharmacist and professor at the University of Saskatchewan’s College of Pharmacy and Nutrition, told Marketplace co-host Erica Johnson.

“These quotas are really forcing pharmacists into a really difficult position where they’re needing to cherry-pick the lowest risk and the simplest patients who qualify for the service so they can meet their quota each day.”

Major pharmacy chains contacted by Marketplace say that patient care is the top priority.

Most provinces have adopted medication review programs to help make sure patients on multiple prescriptions are taking medication properly and that they have a complete list of all medications they take.

The programs are free for the patient, but the province pays for the service. Fees for medication consultations range from $52.50 to more than $150 for an initial assessment, depending on the type of review and province. There’s another lower fee for a follow-up review.

Medication reviews and other professional services are an increasingly important source of revenue for pharmacies.

In Ontario alone, the provincial government paid out nearly $100 million for MedsCheck consultations last year.

Many provinces added the additional services after establishing caps for what pharmacies can charge for generic drugs and eliminating drug rebate programs, both of which contributed substantially to pharmacies’ revenue.

‘It’s not long enough’

Some pharmacists contacted Marketplace with concerns about the quality of care they are able to deliver while being asked to perform medication reviews as often as possible.

Marketplace agreed to protect the identity of the pharmacists who spoke out because they fear retribution in the industry.   

“The computer was set up to monitor when people were due for a MedsCheck, and head office wanted us or required us to do every single one,” one former Rexall pharmacist said.

"There's no way you could realistically do that when you've got people waiting for antibiotics. The last thing you're going to do is spend 15 minutes with a senior diabetic patient who needs a lengthy MedsCheck."

Several insiders said that to meet quotas, they would choose low-risk patients, including younger patients on fewer medications.

“The people that need the meds checks are the seniors with 10 medications, [who] can't always remember the whole list of medications. They're the ones you haven't got time to do properly,” said the pharmacist.

One pharmacist said she received constant emails from head office reminding staff to conduct medication reviews.

“In reality, you pick and choose and do the easier ones. You'll do the ones where the person's taking maybe just three medications,” the pharmacist said.

Medication reviews are supposed to take anywhere from 20 to 45 minutes, according to provincial websites.

But the pharmacists who spoke out said it was impossible to take that much time and fill quotas.

“Sometimes it would just be two or three minutes. It's not long enough,” one pharmacist said.

“It's just a very quick — you take this, you take this. Do you smoke, do you drink? Sign this. Go home.”

Pharmacies respond

Marketplace reached out to the pharmacies about the concerns raised by pharmacists. Both Shoppers Drug Mart and Rexall declined to speak about these issues on camera.

In a statement, Rexall wrote that: "In order to deliver on our commitment to patient care and improving health outcomes, we expect our pharmacists to engage and speak with patients about their overall health or the medications they are taking.

“Our pharmacists use their professional judgment when a patient-focused service should be provided and we expect our pharmacists to practise to the highest professional standard and in accordance with provincial regulations and regulatory standards of practice and bylaws.”

Rexall denied that head office issues specific quotas for these services.

Shoppers Drug Mart responded that it does not set quotas and that pharmacists are not punished for failing to perform a set number of billable services.

“We do not exercise punitive measures to pressure our pharmacies to provide services that would be counter to optimal patient care. Working with our pharmacist-owners, we measure the delivery of pharmacy services so that we can plan appropriately for the labour needs required to deliver those services. This planning is based on industry-wide standards set for each type of pharmacy service.”

The College of Pharmacists of BC recently surveyed its members and found more than half of respondents from chain pharmacies reported they were under pressure to perform medication reviews.

The college is set to become the first regulatory body in Canada to take measures to restrict pressures on pharmacists from head offices. The college has proposed new regulations that would ensure that if quotas are in place they do not compromise patient safety.

Patients feel pressure

Tom and Rosette May, who live in Smiths Falls, Ont., say that they don’t feel that their medication reviews have been valuable because of the way they have been conducted.

Tom May said he’s had two consultations at the same pharmacy and was under the impression that the service was mandatory.

He said that the first meeting lasted only a few minutes and the second only lasted 30 seconds.

“They said, ‘Oh, can we do a MedsCheck while you're here?’ I said, ‘Do I have to really do one? I just did one not very long ago with you.’ And the pharmacist said, ‘Oh, not with me.’ ”

Rosette May said she was called repeatedly at home to tell her to come into the pharmacy.

When she was there, she was embarrassed when the pharmacist read out a complete list of her medications, which other customers could easily overhear.

“I didn't think it was anybody else's business what medication I had to take, except my business.”

She said the pharmacist quickly ran through things and was done in minutes.

Medication reviews are supposed to be done in an area where the patient and pharmacist can have some privacy, according to provincial guidelines.

Jorgenson said that the pressure to bill for this extra service is taking a toll on many pharmacists, too.

"It makes pharmacists feel horrible,” said Jorgenson. “They know it’s unprofessional. They know based on their professional judgment that some patients don’t need that service even though they’re technically eligible to bill for that service."

• Based on a Marketplace investigation by Lynn Burgess and Lindsay Sample.