Friday, June 12, 2009

Phasing Out Pharmacies

There was a time, or so I was told, when pharmacies and pharmacists played an important role in our health care system. If those days existed at all, they are now long gone. It is high time that we begin to phase out the pharmacy. We should do so by progressively making more and more medications available without a prescription. At the same time, we should ban advertisements for any medication.

Pharmacies add a significant layer of expense to our health care system. While I can buy aspirin or ibuprofen at the 7-11 store, I can only get meloxicam (an anti-inflammatory that serves the same purpose as ibuprofen and is no more dangerous) at a pharmacy. That creates two different kinds of expense. First, it adds to the cost of the medication. A pharmacy must have a highly trained -- and highly paid -- pharmacist on duty at all times. In addition to the pharmacist, there is almost always a second employee who hands out the prescription medications and often rings them up on a separate cash register. Furthermore, the pharmacy incurs expenses in complying with various regulations. Compare that to the cost of selling aspirin. A store simply stocks the shelves with bottles, and the customers help themselves.

The pharmacy also imposes a non-monetary cost, one which I find particularly vexing. I can get an aspirin at the 7-11 or Trader Joes at any hour, without a prescription and without an appointment. Getting propanolol (a common beta blocker) requires a prescription, which must be presented at a licensed pharmacy. I must then wait until the pharmacist fills the prescription, and stand in a special line to receive that one item. That process is a waste of time, in addition to a waste of money.

I suspect that the prescription system imposes yet another cost, which may be even more important than the two costs described above. The prescription system discourages patients from being good consumers and paying attention to the choices they are making. Prescription drugs are treated as holy: only the doctor decides which ones we take, when and in what doses. The insurance companies have their secret formularies, which try to impose on the doctor's choice. Then, only the pharmacist can actually deliver the goods. Even a patient who wants to get involved in choosing a medication will have a hard time doing so in the face of those three forces.

Compare the purchase of pain killers, where the patient can select from a variety of over-the-counter medications, in various doses, brand name and generic. These medications quickly lose their magic aura, and patients learn to make intelligent choices. Consumers feel free to think for themselves and experiment appropriately with the available products. They learn to avoid overpriced brand names, and they learn which medications work best for them. I suspect that eliminating the prescription requirement on a medication would quickly create more savy consumers and thus reduce the price the market would bear in many instances. I bet the big pharmaceutical companies would hate the idea of phasing out the pharmacy.

We do not get anything worthwhile from pharmacies. Few, if any, patients actually seek the advice of the pharmacist. If a few patients want to pay for such advice, they should of course be free to do so, but there is no reason to require everyone to pay for advice which very few of us want or even receive. Pharmacists do not tell us how and when to take medication; doctors do that. The pharmacist simply copies what the doctor wrote down and, in my case, often makes mistakes in doing so. Theoretically, a pharmacist could alert a patient to conflicts between medicines. That only works, however, if the patient always uses the same pharmacy. The only time I have been alerted to a conflict was by my doctor, and one of the conflicting medications was non-prescription, so a pharmacy could not catch it, even if it knew all of the prescription drugs I was taking.

The prescription system most certainly does not protect those who would abuse drugs from getting what they want. Even making a drug completely illegal does not prevent determined buyers from getting ahold of it. The prescription system provides even less protection than an outright ban. One who is determined to get his hands on a prescription drug can always find a crooked doctor, forge a prescription, fake a symptom and/or send the same prescription to ten different online pharmacies. Pharmacies are not in the business of preventing the improper sale of medications.

Far more importantly, only a small minority of prescription medications are drugs of abuse, i.e., fun. No one is going to pop Lipitor at a party. Sudafed, on the other hand, can be turned into a drug of abuse.

Most prescription medications are no more dangerous than over the counter medications. It is easy enough to kill oneself with all sorts of household items, beginning with alcohol. I doubt that taking an entire bottle of Crestor is any worse than taking an entire bottle of ibuprofen.

In the end, pharmacies are just another entrenched special interest. We take it for granted that they are necessary, but they are not. It is time to start phasing them out.

Friday, June 5, 2009


Most of us have heard the saying: "Give a man a fish, and you have fed him for today. Teach a man to fish, and you have fed him for a lifetime." It seems to me that the old saying may not go far enough. Giving a man a fish may provide a lesson along with the meal: the way to get a fish is to wait until someone gives you one. Simply handing out free food may, in the long run, do more harm than good.

It seems that most charity focuses on eliminating an immediate need without addressing the underlying problem. In fact, Mother Teresa herself, that icon of giving, has been criticized for perpetuating poverty, rather than trying to alleviate it. She is alleged to have said: "I think it is very beautiful for the poor to accept their lot, to share it with the passion of Christ. I think the world is being much helped by the suffering of the poor people." That, in my view, is not kindness.

Government charity is often in that vein: food stamps, unemployment payments, medicare, welfare and Section 8 housing vouchers address the need of the moment without doing anything about the underlying problem of poverty. The unintended result of this kind of charity is poverty that is passed down from generation to generation. Similarly, food kitchens and homeless shelters do nothing to address the underlying problems of poverty, addiction and mental illness that lead to homelessness in the first place.

I realize that there is a place for simply giving support to the needy. Victims of one-time disasters such as hurricanes need help now. Similarly, there are those who simply will never be able to take care of themselves for whatever reason. There is no point in trying to teach them to fish, because they simply cannot learn for whatever reason. In these instances, it is makes sense to provide what is needed. In my view, however, the more important task is addressing the underlying problems that leave people sick, uneducated and poor.

Recently, I have become a fan of, a micro lending organization that allows people to make no-interest loans to small businesses in the third world. The borrowers include taxi drivers in Moldova, small farms in Peru and grocery stores in Nigeria. The borrowers do pay interest to Kiva's local partners, but at lower rates than would otherwise be available to them, assuming that they could get a loan at all. One of the biggest problems in the third world is the lack of access to capital. Hopefully, these small loans help people grow their own businesses and move them up just a little bit towards economic Independence.