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Safety Questions Arise on Pharmacy Staffing Bill

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

The Florida House has passed a bill that makes a lot of pharmacists nervous. Patients might be, too, if they were aware of it.

The bill sharply raises the number of technicians who can be assigned to a single pharmacist for supervision, from a maximum of three to six.  And it takes away the Florida Board of Pharmacy’s power to keep the ratio below the limit in cases where it sees a risk.

HB 671 has split the pharmacy community. Its supporters are chain drugstores and mail-order facilities. Opponents include independent pharmacists and those employed outside the commercial arena, such as in a hospital or a university.

Those who are supposed to protect the public are also split. Members of the Board of Pharmacy first voted to support the bill, when most of the pharmacists who made it to the phone meeting had ties to regional or national chains. But the vote was overturned at the next meeting, when community and hospital pharmacists were able to attend. It was a squeaker: 5 to 4.

Members who had missed the first vote said they had been given no warning that the board would be weighing in on the tech bill. They said they were astounded when they found out. And concerned.

“How many scripts can one pharmacist be responsible for?” asked community pharmacist DeAnn Mullins of Lynn Haven. “I think we’re putting the public at great risk.”

The bill that passed the House on Wednesday has a companion in the Senate, SB 818. It passed one committee, stalled in a second. If Senate leaders want to, they can take up the House bill or pull the companion to the floor for consideration.

“It’s a toss of the dice,” said the Florida Pharmacy Association’s executive director Michael Jackson. “No one knows.”

There isn’t much time to decide; the session is scheduled to adjourn on May 3.

The chains say that giving pharmacists more techs would let them shed some of their routine duties to concentrate on higher-level work, such as studying the patients’ chart to make sure the appropriate drug has been ordered and doesn’t conflict with another one, and counseling patients on how to use medications correctly.

Pharmacy board member Jeffrey Mesaros of Tampa said  those duties are important: “A pharmacist is more than a pill-counter,” he said.

But associations representing Florida’s 29,000 licensed pharmacists say they  aren’t always the ones who get to decide how many technicians they can safely handle. Many work in companies where decisions are made in another state.

Among those opposed to increasing the tech-to-pharmacist ratio is Cleveland father Christopher Jerry. His 2-year-old daughter Emily died in 2006 from a sodium chloride overdose caused by a tech’s error on a prescription that was never checked by a pharmacist. Jerry, now a full-time patient safety advocate, traveled to Tallahassee to testify against the legislation.

“If Walgreens and the other retail pharmacies can turn prescriptions more into an assembly line type of business, errors are only going to go up. When pharmacy technicians make mistakes, people can be harmed and even die,” Jerry said.

CVS, Walgreens and the Florida Retail Federation have their lobbyists in the Capitol, pushing for the bill.  The companies tell legislators that pharmacists spend more than 40 percent of their time doing routine work that technicians could do, and will not be burdened by additional supervision if they can delegate some of those duties.

“The technicians can take over some of the administrative duties to free up the time of the pharmacists to do their professional duties,” said CVS spokesman Mike DeAngelis.

Most of the more than 700 CVS stores in Florida have three technicians per pharmacist, the current maximum in Florida, DeAngelis said. If the bill passes, he said, Florida stores would likely resemble the CVS average national ratio of about four techs, although some stores could have higher ratios for all or parts of the day.

Walgreens, the state’s largest drug chain with 850 stores, believes the bill would give pharmacists “more time to be with patients, to counsel and advise, and to provide additional health care services,” Walgreen Co. spokesman Jim Cohn said in a statement. That would benefit consumers, supporters say.

Florida is like half of the states in the nation, allowing no more than three techs per pharmacist, according to the National Association of Chain Drug Stores. Florida pharmacies can go above a one-to-one ratio only if approved specifically by the Florida Board of Pharmacy, which oversees and disciplines the pharmacy profession. The three other states that fill as many scripts as Florida – California, New York and Texas – allow only two techs.

Proponents say the trend nationally is toward expanding the number of techs. Seventeen states have no limits on how many techs a pharmacist can supervise, they say, and there is no evidence of patient harm.

But members of the Pharmacy Board who oppose the bills say the states that have no limit on techs require them to have a higher level of training. Board member Michele Weizer of Boca Raton rattled off several studies that showed the error rate rose with the number of techs per pharmacist.

“We need to be careful about what we’re supporting,” she said.

The drugstore chains’ push to expand the tech-to-pharmacist ratio is nationwide; they’ve persuaded two states to raise the limit to six. Seven allow four techs.

Proponents say the higher tech ratio is voluntary; pharmacists don’t have to take advantage.

But the Florida Pharmacy Association and several other groups representing druggists said professionals would have no choice if their employer insisted on more techs. They contend the push for more techs is strictly about money.

Pharmacists who are graduating today have doctoral-level degrees and make $80,000 to $110,000 a year. Techs, who complete a training program but do not need a college degree, make $25,000 to $35,000, said Goar Alvarez, president of the pharmacy association and pharmacy director at Nova Southeastern University in Davie.

Supervising prescriptions filled by six techs will leave less time for scrutinizing each patient’s case, Alvarez said. A pharmacist’s most important duty, he said, is catching prescriptions that could conflict with other drugs the patient is taking, that are contraindicated for the patient’s medical problems, or that are at a wrong dosage. Alvarez said he finds such mistakes every day.

“If you have six technicians, I can tell you the pharmacist is just making sure they put the right pill in the bottle. It’s just going to be verifying the drug, not doing all the background work,” Alvarez said. “That’s a very scary and dangerous thing.”

The chair of the Senate Health Policy Committee, state Sen. Aaron Bean, R-Fernandina Beach, took the unusual step of voting against the bill in his committee. He said he initially thought the bill was okay when he set it for a hearing, but was persuaded against it after talking to his sister, brother and a friend who are all pharmacists.

“They said speed is not the key in a pharmacy, being careful is the key,” Bean said. “It’s about making sure somebody’s eyeballs are on that prescription and on that patient’s needs.”

Even so, the Senate bill passed in his committee on a 5-4 vote April 9. 

With just two weeks left in the session, the bill could get lost in the cracks. 

“If time runs out,” Bean said, “CVS and Walgreen are not going anywhere. They will be back next year.”