Exhaustive Refill Requests

Many of us grew up hearing the story of “The Little Boy Who Cried Wolf.”  In the story, a young boy was tasked with guarding the town’s sheep and to yell for help when necessary. The boy, however, had a habit of screaming ‘wolf’ at the slightest hint of a problem. Any slight rustling of the leaves or a scampering squirrel triggered a full response and cry for help. After the townspeople responded repeatedly to find that there was truly no threat, they grew tired of the repeated cries and stopped responding over time. Of course, when the real threat came, no townspeople responded, and the consequences were disastrous. 

As we continue our evaluation of the January 31st New York Times article by Ellen Gabler entitled, “How Chaos at Chain Pharmacies is Putting Patients at Risk,” the story seems rather fitting to a corner that we have painted ourselves into professionally. I am speaking to the author’s allegation that prescribers are complaining about being bombarded with unnecessary and inappropriate refill requests by the pharmacy. These are refill requests that have not been requested by the patient and, in many cases, are automatically generated by the pharmacy’s computer system. This is not necessarily our first thought when looking at the profession from a ‘medication safety’ lens. Certainly, there are bigger health system issues that typically grab the attention of those looking at drug safety and patient care. This, however, was not a thought that Gabler ignored in her critique of the system. She tackles it head-on.

The implication in the article, of course, is that the financial incentive for pharmacies to fill more prescriptions outweighs the push toward effective patient care. Such refills, the article maintains, are sometimes tracked by pharmacy chains, factoring into employee bonuses. As quoted by an anonymous Missouri pharmacist, “We are forced to harass patients at check out to fill unnecessary meds, request unnecessary refills, and to enroll in automatic fill programs that result in dangerous duplications and meds to be filled that were intended for single time use.

Dr. Mark Lopatin, a Pennsylvania rheumatologist, estimates that about half of the pharmacy generated refill requests are not warranted and that the patient is often unaware that the refill has been requested. A North Carolina psychiatrist places that estimate at 90%!  Clearly, professionally, we have “cried wolf.” Some prescribers, like the townspeople in the fable, are beginning to ignore ALL requests from the pharmacy, taking only refill requests made directly by the patient seriously. 

The true dilemma here, I believe, lies in evaluating who is at fault when the “wolf shows up” and no one responds. Would the prescriber be at fault for ignoring the repeated pleas by the pharmacy for a refill? Would the pharmacy be at fault for “crying wolf” too often? Would the patient be at fault for failing to contact the prescriber directly? There are no easy answers, as there are no easy answers to the dilemma of who is responsible for the sheep in the fable. It would be difficult to argue, though, that the pharmacy does not have some corresponding responsibility here for its “sheep.”

Although not entirely transferrable in scope, I am reminded of Dr. David Brushwood’s live program with FreeCE entitled, “Pharmacist Assistance to Patients Regarding Third Party Coverage Matters” in which he highlights a case in which a patient died while communications were going back and forth between the prescriber’s office and the pharmacy regarding a prior authorization for an expensive seizure medication. In that case, the courts ultimately ruled that “[the pharmacy] owed a limited duty to take reasonable steps to notify both [the patient] and [the physician] of the need for prior authorization each time [the patient] tried to fill her prescription.”

Transposing this position, then, into diligent documentation of communication with the patient’s prescriber when warranted is paramount. There must be a balance, however, as to when communication is appropriate and warranted… otherwise, our communications become meaningless. Just as the little boy in the fable pleaded for help that never came, we are ultimately placing patients at risk with each mindless and improper automated communication that leaves the pharmacy.

[Author’s note: The article being referenced appeared in the New York Times on January 31, 2020. There are many points to unpack in ‘the’ article. Future postings will evaluate other aspects of this article. The original article, in its entirety, may be viewed here.]