Due to low reimbursement rates, many pharmacies are struggling to maintain their profit margins. Some turn to specialty medications, some convert into veterinary pharmacies, and some close their doors to retail patients and start working with long-term care facilities. And there is a category of pharmacies that step into the murky waters of adjusting patient therapies in favor of their bottom lines. Such practices, however, may cost more in the long run than any potential monetary gain derived from this activity.
To illustrate: recently several cases where filed against PharMerica throughout the nation by the federal government and individuals (qui tam actions) alleging that the pharmacy systematically altered essential elements of prescriptions to increase its profits. The most recent case against PharMerica was filed by its former employee based on intentionally incorrect data input. Sturgeon v. Pharmerica Corp., 438 F. Supp. 3d 246 (E.D. Pa. 2020).
The case explains that nursing home physicians submit prescriptions to PharMerica electronically through a “widely-used nursing home platform” called PointClickCare. PharMerica also uses its own “proprietary medicine dispensing system known as the LTC400” to fill prescriptions received through PointClickCare. Prescription data transmitted via PointClickCare is not migrated automatically to the LTC400 to create an order for filling a prescription. Instead, when a prescription is received through the PointClickCare system, a pharmacy technician or data entry clerk at PharMerica manually inputs the prescription information into the LTC400.
The problem arose when an operator of nursing homes notices that the cost of medication significantly increased after it started working with PharMerica. The investigation showed “significant discrepancies” between prescription order data received via PointClickCare and prescription fill data in the LTC400. It appeared that on some occasions PharMerica had dispensed medications different from those prescribed. These discrepancies “consistently favored PharMerica’s bottom line.”
The case alleges that PharMerica tampered with the prescriptions “so to enhance its profit margins and increase its rebates from manufacturers and suppliers” and that the use of both the PointClickCare system and the LTC400 made this possible in two ways. First, the system of manually entering prescription data received via PointClickCare allowed PharMerica to direct its clerks to alter the data intentionally. That is, in some instances, the data as originally entered in the LTC400 did not match the prescription data received via PointClickCare. Second, the LTC400 itself was programmed so that whenever an ordered drug was out of stock, the platform would prompt clerks to replace it with the most profitable alternative, even if the data was correctly transcribed. “In either case, PharMerica did not comply with applicable laws and regulations requiring that pharmacists get the prescribing physician’s consent before altering any essential element of a prescription.” Allegedly, PharMerica often altered the drug’s dosage and other times altered its form (i.e., tablet vs. capsule) or the drug itself (i.e., brand name vs. generic).
In its defense, PharMerica cited CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services (Dec. 30, 2004) that explains that a pharmacy may make adjustments to a therapy to avoid therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and drug-allergy interactions. Plus, pharmacists in long-term care also check Medicaid’s Preferred Drug Lists prior to the fill. If a prescription is dispensed for a noncovered drug, the pharmacy is at risk for the cost of the drug and the dispensing fee.
This is not the first action brought against PharMerica that stem from similar allegations. PharMerica attempted to dismiss the case due to other related and similar cases pending against it. However, the PharMerica’s motion was denied.
This case illustrates the danger of adjusting or tweaking prescriptions to increase the reimbursement. Some changes to prescriptions, however, are allowed depending on state laws.
Generally there are only a few things pharmacists are allowed to change:
- Brand name drug to a cheaper alternative (generic);
- Medication change to a therapeutic equivalent;
- changing the form or taste of the drug to make it easier for the patient to take.
Any other changes should be made only after consulting with a prescriber.
 PharMerica is the second largest institutional pharmacy in the United States. It fills prescription orders only for nursing homes and other long-term care facilities and is not open to the general public.