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The Spokesman-Review Newspaper
Spokane, Washington  Est. May 19, 1883

Pandemic pivots: Pharmacy closes and dog food’s out of stock – what now?

With supply chain disruptions and some empty shelves these days, plan ahead before that last pill, drop of over-the-counter medicine or cup of pet food.

There’s no need to hoard, regional health experts say. It’s more about taking stock of what’s at home, such as those last dog kibbles (see pet sidebar).

Also, pharmacies are hit hard nationwide with staffing shortages. Issues that started before the pandemic have worsened, causing shortening of hours and temporary or permanent closures, said Julie Akers, a Washington State University pharmacy law expert.

Prescriptions have refill limits, “but you never want to wait until that last day,” she said. “In addition to having access to pharmacy issues, we often see patients who run out of refills and don’t realize they need a new prescription.

“Whether it’s for pandemic reasons or worried about temporary closures and access, or just in general, it’s a good idea to have a minimum three- to four-day supply.”

After a recent temporary closure of the CVS pharmacy inside the Target on South Regal Street, Spokane resident Don Cutler tried to call a number listed on a sign. But that got him nowhere, Cutler said, so he later contacted his doctor to move his prescriptions to another pharmacy.

“We first learned it closed on Oct. 27,” Cutler said. “I called a number for CVS and held for nearly an hour, then got someone who had no idea what was going on.”

He said he didn’t get a promised call back. “We can deal with this; we know our doctor, so we can navigate. We know someone who has serious prescriptions for blood-thinning medication, and they ran into a real hassle.”

A Target employee told The Spokesman-Review that the temporary CVS pharmacy closure beginning late October was caused by staffing issues. Messages requesting information from CVS weren’t returned, but the pharmacy site reopened Nov. 8.

Generally, Akers said two issues are affecting the industry: pre-pandemic shortages of pharmacy technicians that got worse and pharmacies impacted by fees and low insurance reimbursements.

“We have the added burden right now in pharmacies where they’re doing much of the COVID testing as well as now immunizations,” Akers said. And it’s flu season. “Most people in our state get an influenza vaccination from a pharmacist or a pharmacy technician who is trained. With the staffing issues, we went into the pandemic with pharmacies being overly stressed due to the shortage of technicians already, and it’s just amplified.

“A lot of issues we’re seeing in community pharmacies historically revolve around reimbursement for prescriptions through pharmacy benefit managers or PBMs that are kind of the middle man between a pharmacy and an actual insurance carrier.”

A pharmacy files a claim per a patient prescription to the PBM, which responds with what payment the pharmacy will get for that prescription, Akers added.

“Many pharmacies are at a point where they have little revenue to oftentimes a loss on the cost of the drug,” she said. “Coupled with that is something called direct and indirect remuneration fees.

“They’re called DIR fees implemented by PBMs where months after the prescription is filled, they’ll review aggregate data from the pharmacy related to any of the prescriptions filled through them, and they’ll do what’s called a clawback fee.”

Such fees began for quality measures, and if met, meant smaller clawback fees or potentially none. Transparency around measures is a concern, Akers said. Five-year trends show more independent pharmacies impacted by revenue loss that closed or sold to larger organizations.

“Some of these DIR fees are in the millions of dollars,” she said. “Even the larger companies are being hit by this.”

Akers said those issues impact staffing because salaries dollars come from sales and revenue. In the past five years, another trend is lessened staffing hours. Then, staff get sick, must quarantine or care for family, along with COVID-19 tests and immunizations.

“Where you used to have two pharmacists working at a pharmacy in a day for their volume, you might have one and a half pharmacists that day or only one pharmacist doing a 12-hour shift.

“Same with technicians, where you might have had three technicians to assist with the volume, you see stores going down to two or one. It’s really overwhelming to have the pressures of getting all that volume of work done and ensuring safety for patients.”

Nationwide, drug shortages occurred long before the pandemic, said Danial Baker, WSU pharmacotherapy professor. Ingredients or supplies might be overseas. “It’s obviously gotten worse under COVID-19, and for a lot of different reasons, but it’s not a new problem,” he said.

Factors include fewer manufacturers making widely used drugs, contaminants taking a drug off shelves and unpredictable increased demands. If people do encounter shortages, Baker said it’s best to work with a pharmacist to locate a supply or offer an alternative.

“Sometimes, it’s just as easy to switch to another drug that’s similar. The other problem we’ve got is there is no one computer network to identify where products are sitting.”

There also are some supply chain issues. “The worst problem we’ve got right now is that it’s a shipping problem from the manufacturer. It might be sitting on a truck or on a train somewhere in the United States.”

However, Baker said around most products, “There should be no issue for the majority of people.”

Akers said Washington state has requirements for permanent closures to notify the pharmacy commission at least 30 days prior and say where records and products will go. Patients must have a posting 30 days prior with pharmacy signage and either a direct mailing or newspaper public notice. Little is required for temporary closures.

“If they’re changing hours temporarily, there’s really not any statutes or rules,” Akers said. “Pharmacies are expected to have signage of hours, but they do have flexibility if there are emergencies and they must temporarily shut down.”

Patients can try contacting another pharmacy in the same chain, ask about delivery or seek a prescription transfer, she said. A health care provider might cover the gap. “Oftentimes, the provider would give you a one-week supply or one-month supply depending on the medication.”

Some newly developed drugs are slower getting to market under pandemic travel restrictions for federal workers who do the approvals, Baker said. They couldn’t go to the manufacturing plants, and now there are backlogs.

“We’ve had a number of recent drugs that missed their potential approval date.”