Ten Things Your Pharmacist Won't Tell You

1. "My prices will make you sick."
The pharmacy business should be all about uniformity. Go from drugstore to drugstore and your prescription should have the same name, dosage and instructions for use. Hey, the pharmacists even have the same white coats. So you might expect different pharmacies to charge the same prices. Think again.

Random phone calls made in early July 2000 to pharmacies in New York's Greenwich Village actually found little consistency in price: 30 tablets of Claritin sell for $72.99 at the chain store Value Drugs; at nearby competitor Duane Reade (DRD), the same exact order costs $82.49, a difference of 13%.

What gives? There are, of course, differences in the cost of doing business. Rents vary, as do other fixed expenses. But there's another factor at work, explains Larry Sassich, a pharmacist and researcher with the Public Citizens Health Research Group: "The pharmacist has to figure out his break-even point." Among the variables is the percentage of prescriptions filled that are covered by insurance. In pharmacies with a lot of covered customers, the break-even cost is shifted heavily to patients who are paying full price -- generally the elderly on Medicare or the working poor. "Pharmacists can't push around a big HMO," says Sassich, "but they can push around a little old lady."

In Florida, the attorney general's office recently took the state's Rite Aid (RAD) stores to court for jacking up prices in just that way. The charges? The drugstore chain raised prices for uninsured customers. While the judge dismissed the charges, Mary Leontakianakos, the attorney general's chief of economic crimes, thinks the practice is indefensible. "People would think that if you went to a medical professional with a prescription, that you would not have to haggle over the price like you would with a used-car salesman," she told the Legal Intelligencer. "We are very pleased with the judge's decision," says a Rite Aid spokesman. "It confirms what the company believed all along, that our pricing practices were and continue to be well within the law and consistent with pricing practices in many other industries."

The state of Florida does not agree, and has filed for a rehearing.

2. "I'm overworked..."
Have you noticed that your doctor is more likely than ever to prescribe medication? That is indeed the case. In 1998 pharmacists filled 2.5 billion prescriptions. That number is expected to clear 4 billion by 2005. Explains Frederick Mayer, a veteran pharmacist and president and chief executive of the Pharmacists Planning Service in California, "Managed care tells doctors to give patients medicine in order to get them in and out of the office quickly."

The upshot is that your pharmacist is probably working way harder than he should be. While the California Pharmacists Association recommends that its members fill a maximum of 15 prescriptions per hour, Mayer says he regularly works twice that fast. "Pharmacists are stressed out," adds Mayer. "And it's getting worse."

Not surprisingly, then, most pharmacists don't have the time to offer the counseling that federal and state law require with each prescription. In fact, in a recent undercover operation, Mark S. Herr, director of the New Jersey Division of Consumer Affairs, found that nearly a third of Garden State pharmacists were not complying with that law.

3. "...so accidents will happen."
Back in 2000, a 20-year-old Danville, Calif., man named Daniel Hawkins had a prescription filled for penicillin. Hawkins took his medication and got violently ill. Days later, it was discovered that he had mistakenly been given Zoloft, an antidepressant. Such incidents are not isolated: In California alone, there were 359 complaints of prescription error filed with the state Pharmacy Board in 1999.

Those inside the industry blame such mix-ups on long hours, tough working conditions and a shortage of qualified personnel. And surely, the rapid pace of the work has much to do with the problem. "Things get so busy," says Mayer, "that I have no time to look at the computer screen or even to look inside the bottle and make sure that the pills I'm giving out are the right ones."

4. "I don't understand my merchandise."
These days, with many customers taking an interest in alternative medicine, most pharmacies sell profitable herbal remedies right at their prescription counter. This leads people to make impulsive herbal purchases while picking up their prescriptions. The problem, notes Brett Kay of the National Consumers League in Washington, D.C., is one of potentially harmful interactions. "While a lot of pharmacy computer systems have good drug-interaction software, herbal medicine is (usually) not kept in the database," he says. (The CVS (CVS) chain, to its credit, now has software that can incorporate any nonprescription supplements you are taking into your patient profile.)

And many pharmacists are woefully uninformed about the complications that can transpire when various drugs and herbs get taken in tandem. Even if your druggist sees you purchasing, say, the memory enhancer ginkgo as you pick up a prescription for the blood thinner Coumadin, studies have shown that he may fail to recognize that the two taken together increase your risk of internal bleeding and stroke. "It is a problem," says Varro E. Tyler, professor emeritus at the pharmacy school of Purdue University. "Herbs get sold in this country as dietary supplements and foods. But they are drugs. And all drugs have interactions."

5. "I count on kickbacks."
You might assume that pharmacists earn enough money by marking up medication. Apparently not. In fact, it is common practice for druggists to receive financial incentives for time spent trying to switch customers to medicines that cut costs for HMOs.

Some pharmacists are so hungry for the payments that they devote portions of each workday to calling physicians and pressing them to make prescription modifications. Dr. Martin D. Trichtinger, an internist in Jenkintown, Pa., says his practice receives as many as 15 such requests a day. And sometimes they make little medical sense. Once he got a call from a druggist who wanted to switch a patient with a heart condition from one beta blocker, Coreg, to another, Inderal.

"The change would have worsened this person's underlying condition, and there is a good chance that it could have been fatal," says Trichtinger, adding that he's never told whether the purpose of the switch is to save money for the patient or to make money for the pharmacist.

6. "Your private records are an open book."
In 1997, a Long Island, N.Y., woman in the midst of a nasty divorce and custody battle was prescribed an array of medications to treat her emotional problems -- problems that she had hoped to keep to herself. Then one day a letter came to her house on behalf of a pharmaceutical firm that was trying to get her to switch to a new antipsychotic drug. Her husband got his hands on that letter, explains Jeffrey R. Krinsk, a partner with the San Diego law firm Finkelstein & Krinsk, and used it as fodder in their divorce battle. Armed with this proof that his soon-to-be-ex-wife was unstable, the husband got custody of their child.

Krinsk, who maintains that the woman's address and medical history came from her pharmacist without her authorization, views this as a case of privacy being invaded through leaked pharmaceutical records. And as he knows, this is not a rare occurrence. In 1999, the attorney launched a class action suit against CVS Pharmacies, among others, for allowing patients to become the targets of such mailings. "We are vigorously contesting what they say in court," says a CVS spokesman. "We believe that their case has no merit."

While the results of such privacy violations are not always as devastating as a loss of custody, they can surely be embarrassing. (The classic case, says Krinsk, is that of an unknowing wife discovering her husband's Viagra habit.) In either case, such breeches are surely unsuspected. "When you go to a pharmacist," notes former U.S. Justice Department attorney John Bentivoglio, who focuses on health-care fraud and privacy issues, "you don't expect that your personal information will be used for anything other than for you to get the right drug."

7. "I'm sneaky."
The rise of managed care has certainly made prescription drugs more affordable for many consumers. But it's also brought out the worst in pharmacists, who often resort to underhanded tricks in order to beef up their profit margins.

Jim Sheehan, an assistant U.S. attorney based in Philadelphia, found this out firsthand when he was on vacation in Florida and came down with strep throat. A pharmacist inspected Sheehan's prescription for antibiotics from a nearby urgent-care center and offered the following choice: "You can pay cash for the medicine and I will give it to you right now. Or else, if I need to run this through your insurance company, well, it'll take about 30 minutes since you're from out of state." Sheehan, who specializes in prosecuting health-care fraud cases, had heard of this scam. "The pharmacist figured that I had no idea of the retail price and he would have charged me whatever he wanted," he surmises. So he opted to wait. The process of checking with the insurance company, of course, ended up taking only a few minutes.

Other tricks Sheehan has come across are equally dodgy. He's seen pharmacists who buy deeply discounted drug samples from doctors and turn around and sell them at retail prices. He's also seen unethical druggists who will charge you your insurance plan's $10 co-payment even if the retail price for the drug is less than that.

8. "Your medication is stale."
Most people don't think that underworld crime figures can come between them and their Celebrex. Well, they haven't heard of Anthony "Tony Ripe" Civella. In 1991, Civella was convicted of buying $1 million worth of discounted drugs that were supposed to go to nursing homes -- where large quantities of medication are purchased at bulk prices and used quickly -- but instead found their way to retail pharmacies (at a tidy profit for Tony Ripe). The problem is called "drug diversion." In a typical case, crooked druggists buy diverted medication at reduced prices and in quantities way bigger than they're legally allowed to handle. By the time the last of the shipment reaches consumers, the pills are way out of date.

The big losers in all this are consumers who end up with stale medications that haven't been properly stored, explains Chris Whitley of the U.S. attorney's office in Kansas City, Mo., where a case of drug diversion is pending trial. Secondly, he points out, there is a price paid even by the people who do not get stuck with any of these unintentional placebos: In the long run, he says, "it raises the cost to the consumer. Somewhere the drug manufacturers and wholesalers have to recoup their losses -- from having discounted drugs going to retail pharmacists."

9. "I don't just sell drugs. I make them."
Say your five-year-old needs a medication that comes only in pill form. If you think he'll do better with a liquid, you can ask your pharmacist to make the conversion himself -- right there at the store. It's called "compounding," and when done right, it's perfectly safe.

But some pharmacists compound drugs that already exist -- such as injectible morphine, for example -- because it's cheaper. "They do that so they can make more money," says Larry Sassich, explaining that greedy pharmacists purchase raw ingredients and whip up their own versions -- sometimes inadvertently weaker or more powerful than they ought to be. "Only the dangers get passed on; none of the savings," Sassich notes.

The bottom line is that if the product is available commercially, you're better off getting it that way. "Pharmacists don't do this under good manufacturing guidelines; they do it in the back of their shops," adds Sassich, advising that "if you can buy the FDA product, you should." Indeed, Cesar Arias, an investigator with the Florida Department of Health, saw a compounded drug for lung disease stored in the same refrigerator that pharmacy employees used for their lunch.

10. "I'll give you any drug you desire."
Go on the Internet to buy medicine and you'll probably save time and money. But you might also lose your good health. While there are many legitimate Web sites that sell prescriptions, such as PlanetRx.com, there are also countless dubious operations in cyberspace, which tend to specialize in "lifestyle drugs" like Viagra and Propecia. (Look for an insignia bearing the initials VIPPS, which stand for Verified Internet Pharmacy Practice Site, to tell the difference.) And in lieu of requiring a doctor's prescription, such rogue sites offer e-physicals in which you answer questions to determine whether or not you should be taking the medication in question.

Not only is this illegal, it's dangerous. "Viagra can kill a man with a heart condition," warns New Jersey's Mark Herr. "You should not be buying Viagra online if you do not have a doctor prescribing it. You can be certain that if the only checkout is a layperson filling out a questionnaire online, well, sooner or later you will have a disaster."