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Thousands Of US Pharmacy Workers Mount 3-day "pharmageddon" Wildcat Strike
"Behind closed doors with the top brass of any chain pharmacy, their ultimate truth would sound something akin to, 'Patient safety is the primary focus if and when it doesn't affect our profitability.'"—Shane Jerominski, independent pharmacist and labor organizer
On Monday, Tuesday and Wednesday this week, October 30 through November 1, thousands of pharmacists at Walgreens, CVS, Rite Aid and other drugstores across the United States will take part in a wildcat strike action against the conglomerates that control the vast majority of US pharmacies.
Shane Jerominski, formerly a pharmacist at Walgreens and now an independent pharmacist and labor organizer, told the World Socialist Web Site that he and other pharmacists are planning the three-day walkout to protest unsafe working conditions that put pharmacists, techs and their patients across the country at risk on a daily basis.
Jerominski, a licensed pharmacist with more than 15 years of experience in the field who is leading the walkout, has dubbed the event "pharmageddon." This will be the third such work action by non-unionized pharmacy laborers on the heels of the Kansas City CVS walkouts in mid-September and the Walgreens three-day walkout in early October. Jerominski said he expects about 4,500 employees to take part and possibly tens of thousands more if they did not fear retaliation by their employers.
The pharmacy workers are using the social media platforms Reddit and Facebook to organize and conduct their labor action, recently posting that "Organization for pharmageddon is underway." In their call to action, they cited the lessons learned from the October Walgreens walkout, dubbed "Operation Spotlight," writing:
The public and our patients support us. The media reports were huge and were followed by millions. The overwhelming majority of comments were positive. Reddit trolls, corporate shills, and Walgreens lied. The support center number for participating stores [in Operation Spotlight] was over 600. Due to Walgreens' quick crackdown on team members talking to the media and our lack of rallying, Walgreens got away with some of those lies.
The organizers are planning to hold rallies outside select locations across the country to put a visible face to their strike action and demands. In their statement, they note that "Walgreens has cut raises. The new 4 C's rating scale makes it nearly impossible to get good reviews. Walgreens says bonuses aren't looking good. And at the same time, they announced they won't be changing the dividend strategy."
Jerominski made the media rounds over the weekend, speaking with Bloomberg and CNBC and explaining that many of the pharmacy workers have told him they are reaching their breaking point. Understaffing has become a severely chronic issue for the pharmacists, while insufficient pay and cutbacks in hours for pharmacy techs means the growing workload is being carried out by fewer staff working shorter hours.
Jerominski noted that the Kansas City CVS walkouts were effective because they were able to provide the pharmacy technicians "strike pay." The organization he runs had raised about $25,000 with the aim of forming a union for pharmacists, the vast majority of whom are not unionized. When he heard about the Kansas City strike action, he offered a "living wage" assistance of $20 per hour for an eight-hour workday, far more than the workers' daily earnings of $16.60 an hour at a reduced six-hour day. They were able to provide wage assistance to 175 technicians across the country. Once workers caught wind of this, Jerominski said, "donations began to pour in." Since that time, they have raised over $60,000.
During the COVID-19 pandemic, the chain pharmacy retailers have become characterized as "fast-food" vaccination centers by the pharmacists, as they now prioritize immunization due to their high profitability of $70 for each flu shot administered.
The vast increase in vaccination rates at the pharmacy chains places greater demands on the pharmacists' limited time, as they are now required to ensure that labels are printed correctly, drug interaction alerts are checked and insurance and co-pays are addressed. With the cutback in the number of hours pharmacy techs work, the entire smooth operation of the pharmacy rests on the shoulders of the pharmacists, whose license is on the line if any medication errors lead to a serious health consequence.
Jerominski said that turnover rates are high for pharmacy technicians, who on average are earning far less than $20 per hour and work under incredible amounts of stress. Meanwhile, pharmacists, who also work on an hourly wage, oftentimes come in several hours before their shift and stay late to ensure prescriptions are filled out and ready for the patients. They often have to skip lunch to finish their ever-growing mountain of work, leading to significant mental and physical health consequences that include even deaths among pharmacists.
Jerominski explained that internal documentation has revealed that many pharmacies are backed up on their work logs, stretching the limits of the 14-day window they have to ensure prescriptions are ready for patients. A pharmacist working solo may at times have to fill out 3,000–4,000 prescriptions per week to ensure corporate meets its requirements. This translates to about 10 to 15 seconds of time to fill a prescription, said Jerominski, including oftentimes having to address prompts that the computer flags on possible drug interactions or health concerns.
In other words, pharmacists, out of an obligation to their patients and fear of losing their license if they make a mistake, are providing corporate pharmacies their labor for free to get through the backlog of prescriptions needed to get to patients depending on them for their well-being.
Jerominski explained that most pharmacists are not asking for higher pay, but rather for more support staff to ensure the smooth operation of their pharmacies. Despite claims by the corporations that they do not have funding to support such staffing, acquisition costs and prices they charge on medications clearly demonstrate there are ample funds available to provide an adequate staff with living wages.
Jerominski highlighted the nasal spray fluticasone, which used to alleviate nonallergic runny stuffy noses. Although the cost runs less than $2.50 per bottle to acquire, CVS and Walgreens retail it at $57, or a markup of more than 20-fold.
As for medication errors, Jerominski said that if the pharmacy discovers it, they are under no obligation to report it to the Board of Pharmacy. However, if a patient reports it, the major consequence befalls the pharmacist, who may be placed on probation and lose their job, while the corporation would only incur a minuscule fine.
In an attempt to short-circuit the grievances raised by pharmacy workers for the last several years that have culminated in the current courageous strike actions, Michael Hogue, the executive vice president and chief executive officer of the American Pharmacists Association (APhA), published an open letter on September 8, 2023, in which he wrote:
Pharmacists, let's also speak candidly about the undercurrent issue that is at play here. Understaffing of pharmacies is a major problem. Negative stories in the media don't help the issue—it becomes harder to recruit the best and brightest into our great profession. Truthfully, the work environment in most community pharmacies is not ideal or supportive of optimal patient care.
APhA is fully aware of this, and we are working very hard on these issues. Our board of trustees are practicing pharmacists across the span of health care settings, including community and hospital pharmacy, and including frontline pharmacists.
This problem is not new, and the solutions are complex. We know that it feels to many of you like nothing is happening, but something is happening. APhA is driving change. APhA's workplace and well-being issues task force has issued recommendations and resources for the profession. Commitments have been made by large employers to make changes, and while change can't happen fast enough, incremental change is happening.
In response, Jerominski replied,
[Mr. Hogue,] the examples you cited like shortened shifts are nothing more than corporate cost cutting measures. When a chain pharmacy makes the decision to decrease hours of operation this doesn't magically correlate to a lower prescription volume. If anything, this has the potential to further burden a staff already struggling to keep pace with demand. As for the improved compensation for pharmacists and technicians this was a consequence of the abysmal working conditions, not the efforts of APhA. Many markets experienced frequent store closures. Not due to a shortage of available pharmacists but merely the lack of pharmacists willing to work in an environment so unsafe it would put their patients and license at risk.
Jerominski noted that the current reimbursement structure and costs of pharmaceuticals, tightly controlled by Pharmacy Benefit Manager (PBM) systems, have contributed to both the exorbitant prices paid on prescriptions and the current state of working conditions for pharmacists.
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Despite claims by PBMs that out-of-pocket expenses on prescription drugs have been falling for decades, pharmacy advocate groups have found that between 1987 and 2019, patient out-of-pocket costs have increased 222 percent (from $16.7 billion to $53.7 billion). Prescription drug benefit costs have risen 1,279 percent in the same period from $26.8 billion to $369.7 billion. Meanwhile, price inflation had grown only 126 percent in the 30 years.
As the report explains, PBMs set reimbursements to pharmacies at rates far below actual costs of medications, leaving the pharmacies "on the hook to pay the differences and later appeal their losses." However, these regulatory bodies also have the power to deny these appeals or take months to reimburse pharmacies for the claims.
According to the report, 630 rural communities lost all local pharmacy services by March 2018 and another 302 fell to having just one pharmacy open. Meanwhile, independently owned pharmacies are at higher risk of closing due to preferentially being denied reimbursements. In short, this is leading to a form of acquisition and merger of these resources in which corporate pharmacies who also own these PBMs can acquire the lion's share of the distribution networks that include how these drugs are priced.
Jerominski concluded his letter to Hogue by writing:
The current PBM structure is decimating independent pharmacies to the point of extinction. Fines and predatory audits that unfairly target small businesses are serving their intended purpose. Chain pharmacies will slowly absorb that market share, then when they've done so turn attention towards fixing the issue of fair reimbursement.
He added,
Let's be honest though, if chain pharmacies were suddenly more profitable as a result of better reinsurance reimbursement their first priority wouldn't be to make stores safer. The financial boon that was COVID for both Walgreens and CVS sent them on a merger and acquisition spree, not a billion dollar investment in improved safety standards.
The "pharmageddon" strike action this week is an important development which must be supported by workers in all industries. To carry this struggle forward, however, requires not a turn to the AFL-CIO union bureaucracy, but the building of a network of independent rank-and-file committees, democratically controlled by workers themselves, and aimed at uniting with all other sections of the working class, both in the US and internationally.
The WSWS will assist pharmacists and all other healthcare workers entering into struggle in their efforts to build such committees of workers' power, as part of the expanding network of committees affiliated with the International Workers Alliance of Rank-and-File Committees (IWA-RFC).
Get information about building or joining a health workers rank-and-file committee
Pharmacy Staff From CVS, Walgreens Stores In US Plan 3-day Walkout
By Leroy Leo
(Reuters) -Some employees at CVS Health Corp and Walgreens Boots Alliance's U.S. Pharmacies launched a three-day walkout starting Monday to push the companies to improve working conditions and add more staff to their stores.
The walkout, which has been dubbed "Pharmageddon" on social media platforms such as Meta's Facebook where it was largely planned, started on Monday and led to the closing of some stores in New York City, two organizers told Reuters.
Shane Jerominski, a former Walgreens pharmacist and one of the organizers of the walkout, told Reuters that as many as 5,000 pharmacy workers would walk out across the three days, but said that the exact number of affected stores and participating staff was not clear due to the lack of a union.
He pointed to "grossly understaffed" stores where employees have to fill not only prescriptions but also look at appointments and walk-ins for immunization as one of the triggers for the action.
In September, some staff from CVS stores in Kansas City went on a two-day strike, while there was another by Walgreens store employees earlier this month.
Pharmacy staff in New York and Pennsylvania were planning to participate, including workers at some of Walgreens' Duane Reade stores in New York, he said.
Some pharmacists were also planning to conduct rallies outside CVS' headquarters at Woonsocket, Rhode Island and at Walgreens at Deerfield, Illinois, according to social media posts.
Jerominski said the organizers were also seeking better pay and more consistent hours for technicians, who locate, dispense, pack, and label prescribed medication for patients under the supervision of pharmacists.
In a bid to cut costs post a consolidation in the pharmacy industry, large companies have not employed enough pharmacists and technicians at the stores, leaving the staff overburdened, said John August, director of healthcare labor relations at Cornell University.
"The pandemic just caused so much additional work and stress that the turnover rates (of staff), which were already very high, just became extremely epidemic," he said.
The walkout is a sign of a new labor movement where people are organizing on their own without a union, August said, adding that such walkouts, even though legal, are risky because the staff "don't really have a traditional union to back them up in their strike."
A spokesperson for CVS said its leaders were connected with their pharmacists to directly address concerns and engaged in a "continuous two-way dialogue," while Walgreens said it has taken steps to help its pharmacy teams "concentrate on providing optimal patient care".
"Our ongoing efforts are focused on how we recruit, retain, and reward our pharmacy staff," a spokesperson for Walgreens told Reuters, adding that they have also centralized some operations to reduce pharmacists' workload.
The company earlier this month said it opened its 11th micro fulfillment center, which are centralized units that fill prescriptions, allowing its "staff to spend more time with customers" to offer other health-related products and services.
The walkouts are part of the larger trend of labor unrest in several industries, including strikes by autoworkers, writers and actors, as well as the largest recorded medical worker walkout by employees of Kaiser Permanente earlier this month.
(Reporting by Leroy Leo in Bengaluru; Editing by Shinjini Ganguli and Anil D'Silva)
Assessing Sponsor Attitudes Toward Retail Pharmacy Involvement In Clinical Trial Recruitment And Execution
Retail pharmacies have slowly established their positioning within the clinical research enterprise, proposing that the ubiquity of their locations and membership can fill existing gaps in participant diversity and clinical trial efficiency. While there has been interest in the industry around these ideas, the proposition is new and untested, with little publicly available data on what these clinical trials models will look like in practice or the ways in which pharmacy chain involvement can benefit or hinder the clinical research process. CVS' unexpected and ambiguously explained exit from the clinical research enterprise in May 2023 elevates uncertainty around the viability of success for other retail pharmacies.1
To begin to address this uncertainty and inform understanding about the potential role of pharmacy chains in supporting clinical trial planning and execution, in summer 2023, the Tufts Center for the Study of Drug Development (Tufts CSDD) conducted 10 45-minute interviews among clinical development executives of medium to large biotechnology and pharmaceutical companies to investigate industry awareness, attitudes, and concerns around retail pharmacy chain participation in clinical trials. Interviewees included vice presidents, directors, and managers in clinical operations, innovation, and patient engagement functions. The aim of the study was to assess reactions to CVS' departure and gather insights into how the market perceives proposed models, as well as identify the challenges that other pharmacy chains may need to address.
The interviews focused on both the benefits of pharmacy chain involvement as well as concerns and barriers to adoption. Primary benefits to retail pharmacy involvement were identified as:
Major barriers and concerns raised were:
The interviewees—clinical research executives—were excited about the potential of increasing awareness among the public about clinical trials. This was seen as the "lowest hanging fruit" because it would involve the least investment and minimal regulatory oversight. According to interviewees, materials have already been created by various sponsors to increase awareness, and retail pharmacies would merely be involved in the distribution of them. This would be simple to operationalize and could have a far-reaching impact.
Long-term follow-upClinical research executives highlighted long-term follow-up (LTFU) as a major opportunity for retail pharmacies to provide their services. Typically, once LTFU is reached, no major procedures are being conducted; in most cases the treatment is no longer being administered; and most data collection has already been completed. Much of LTFU in current clinical trials is already done remotely or with the incorporation of select decentralized trial (DCT) elements, making this stage ideal for retail pharmacies to enter the market. This would also factor in the convenience of the patient, removing the need to travel to the research center after the trial has ended.
Site identificationSite initiation duration for Phase II and III studies has been increasing, lasting nearly eight months. As such, improving site initiation is a priority improvement area cited by research executives. Additionally, a high percentage of sites fail to enroll or under-enroll patients representing a significant and ineffective investment of personnel time and financial resources during initiation.2 Interviewees noted the potential for retail pharmacies to help improve the site initiation process. More specifically, the offering included the ability to identify which areas have a large enough sample of patients fitting the target population and applying that insight to select investigative sites.
Concerns StaffingThroughout the interviews, there were 51 mentions of concern over staffing at retail pharmacies. While some concerns over staff expertise were specific to screening for eligibility, most were focused on retail pharmacy models in which patients would be receiving care in-person at the pharmacy or via telehealth or DCT models. These concerns spanned from the expertise, or perceived lack of expertise, of the staff that may work at a retail pharmacy, to staffing shortages that are currently plaguing sites.
"Nursing staff is actually hard to come by these days. And trained nursing staff from a research perspective…there's a limit there." – Interview #5; Innovation, Large Pharmaceutical Company
It is well-known that staffing shortages exist across the healthcare system, particularly since the COVID-19 pandemic caused an exodus of workers from the industry. But sites have felt the pressure of a shrinking workforce as only a small proportion of healthcare providers contribute to research. Retail pharmacies entering the space and offering services will likely face the same barriers. This may even be a more significant barrier for retail pharmacies that note their positioning among more remote and rural communities—areas that may experience disproportionately high workforce shortages.9 Specifically, pharmacies have proposed that if patients in rural areas can have some or all site visits at a retail pharmacy location, they can increase patient access.10 However, interviewees noted that remote areas are less likely to have a large pool of potential candidates, narrowing options for clinical trial staff. Retail pharmacies have suggested various telehealth and digital models to circumvent this barrier, but interviewees expressed concerns over a primarily remote oversight model in clinical trial execution.
Due to shortages of staff, sponsor personnel were concerned that retail pharmacies may attempt to train research-naïve healthcare providers, or hire individuals directly out of a training program, instead of hiring seasoned clinical trial professionals. The perception was that these junior staff members would not have any supervision or guidance from more experienced professionals. This was of particular concern due to most oversight and monitoring positions being remote. Coupled with a junior workforce, these remote oversight positions were seen as insufficient to ensure compliance with regulatory requirements. Interviewees also questioned whether principal investigators (PIs) would be comfortable with remotely overseeing a large number of sites, as any regulatory issues or mistakes would be the PI's responsibility.
The administration of lab work and collection of vital signs by the retail pharmacy has been suggested as a strategy to offer patients the option of going to the retail pharmacy instead of the site for routine monitoring, but any activities conducted at the pharmacy would still be overseen by a traditional site.4 Most interviewees supported this option because it only involved basic procedures that are typically present in clinical practice and can be executed by most healthcare providers. However, for more advanced or technical procedures that are specific to clinical trials, interviewees were concerned that pharmacy staff would not have the expertise to conduct trials effectively and safely.
Protocol complexity and infrastructureIn cases where clinical trial participants would go to the retail pharmacy for any type of service, interviewees questioned existing pharmacy infrastructure and whether these organizations are set up for clinical trial services. While recent entrants have begun adding medical clinics to their infrastructure, they are not as ubiquitous as traditional pharmacy locations.11,12,13 In order to fulfill the value of providing a convenient location for site visits, the organizations would need to expand specialty clinic locations, as interviewees did not see the typical retail pharmacy location as appropriate for clinical trial procedures. Specifically, sponsor personnel were concerned that these locations would not have the space to accommodate regulations such as a dedicated space for documentation and storage of drugs. However, the entrance of retail pharmacies in clinical trials is still novel, and interviewees acknowledged that this infrastructure could be built with significant time and investment.
"If they are going to set themselves up as a site, they are going to need the same kind of infrastructure that any other site has. And so, they'll have to make that investment, and that's another risk." – Interview #9; Health Equity, Large Pharmaceutical Company
Finally, since pharmacies likely do not have the capability to test samples, any sample taken from a patient would need to be transported to a lab for testing. Contracting a pharmacy to collect blood samples, for example, to decrease the number of site visits, may add complexity to the trial because it adds additional operational considerations.
"The more complexity you add…there's just operational factors involved and potentially delay of data involved in receiving the sample, then actually getting the data back into the right hands to interpret." – Interview #5; Innovation, Large Pharmaceutical Company
Challenges Patient identificationThe primary value proposition of retail pharmacies is the large databases of patients with information that will help target potentially eligible research subjects. This has emerged as a frequently suggested clinical trial service offering from retail pharmacies with discussions revolving around its potential to enhance participant diversity and expedite the recruitment process.
A few interviewees suggested that pharmacy involvement in recruitment could be more beneficial if the retail pharmacy also contributed to screening. However, others questioned the training and ability of retail pharmacy staff to effectively screen patients. Interviewees who were hesitant about the idea suggested that retail pharmacy staff may misinterpret screening guidelines, or not have the patient data or resources to effectively screen patients. Apart from questioning the expertise of the pharmacy staff, interviewees suggested that sites may not be satisfied with retail pharmacy screening and would screen the patient again once they arrived at the site, which the sponsor would need to pay for—essentially being double charged for the same service. In this case, some type of prescreening was suggested so that the site will still have primary control over the screening process, but the patients being sent to the site have a higher probability of meeting eligibility criteria.
"From the site perspective, they have concerns about this because they want to make sure that they have the right information from a screening perspective. So, they want to be in charge of the screening. And of course, then the biopharma we don't want to pay for screening twice." – Interview #5; Innovation, Large Pharmaceutical Company
"It's meant to give them [the site] 50 patients who have already been prescreened so that their chances of them getting onto a trial from an eligibility perspective is very high. And I do feel like they have a chance for that through some prescreening processes." – Interview #9; Health Equity, Large Pharmaceutical Company
However, interviewees still had mixed feelings about the feasibility of this proposal and identified several barriers to fulfilling these promises.
DiversityInterviewees highlighted that retail pharmacies had not yet proven their ability to recruit patients at the speed, diversity, and quantity that they have promised. While some retail pharmacies participated in recruitment of patients for COVID vaccine studies, interviewees pointed out that the climate at the time was different, with many volunteers either wanting to help or wanting early access to the vaccines.4,5 Additionally, COVID vaccine trials studied healthy volunteers—a much larger pool of potential interviewees than most clinical trials. Therefore, interviewees were skeptical of the ability of pharmacy retailers to meet diversity promises in "real life" (i.E., non-COVID trials).
According to interviewees, there are many variables that impact recruitment of diverse populations, such as lack of trust of the healthcare and pharmaceutical industry, and having larger databases or being located in diverse areas is not a comprehensive solution.6,7 Retail pharmacies have stated that they are trusted actors of the community, and this will contribute to their ability to recruit patients.5 However, they have yet to prove that they are trusted enough by these communities to be able to convince patients to enroll in a trial or that they can compare to traditional community groups or leaders in their relationships with the community. Data on retail pharmacy ability to recruit patients in a variety of trial types and indications would be needed in order to convince sponsors of the value.
"I'm not necessarily convinced that, okay, if you went with this model, you would solve all of your diversity issues. I think it's a much bigger nut to crack." – Interview #3; Clinical Development or Operations, Large Pharmaceutical Company
Others saw the value of retail pharmacies in increasing diversity, despite highlighting potential caveats.
"So, for me, I do believe that pharmacy chains could play a pivotal role, going forward, especially around increasing diversity of these patients in our trials." – Interview #9; Health Equity, Large Pharmaceutical Company
Recruitment funnelThere were similar mixed feelings among sponsor company executives when considering the proposal that retail pharmacies could make recruitment faster based on location and access to a larger database of patients. Some interviewees agreed that having a larger database could lead to faster recruitment. However, a number of interviewees brought up the "recruitment funnel," described as an outcome of inviting a large number of patients to the study to undergo screening where only a small number will actually be eligible to participate.
Interviewees were concerned that if a large quantity of patients were sent to a traditional site for screening, understaffed sites would struggle to screen patients, and the investment of time and manpower to screen the patients would be wasted as many would be ineligible for the study. Some sponsor employees even suggested that sites would refuse to screen that many patients because they do not have the resources to do so.
"One of the drawbacks of going to these pharmacy chains which has access to many, many, many more patients than a site would is that the site will then get a deluge of patients who are potentially ineligible. And they are not going to like that." – Interview #9; Health Equity, Large Pharmaceutical Company
ConclusionsEach retail pharmacy chain entering the market has stated their value proposition as being able to increase the diversity of clinical trials due to large databases of patients and strategic locations. Press releases and websites detail the current lack of diversity in clinical trials—an issue that the industry has long tried and failed to remedy—and propose that retail pharmacies can drive equity in clinical trials.14 While interviewees recognized the benefits of retail pharmacy participation, some pointed out that there is more to equitable access and participation in clinical trials than basic referral, including community and patient trust, travel support, and decreasing patient burden. Fulfilling this promise and gaining the trust of both patients and sponsors were seen as major challenges for retail pharmacy success.
Sponsors are also concerned about the current staffing and infrastructure of retail pharmacies and questioned whether these locations are set up to effectively conduct trials in compliance with good regulatory practices. However, most acknowledged that if pharmacies were willing to invest the time and funding to build an infrastructure that matched other sites, and data was available on the success and capabilities of retail pharmacies, the strategy could be successful.
Most importantly, clinical research sponsors want to see clear evidence—unbiased, empirical data—demonstrating the value proposition of retail pharmacy involvement in clinical research. In its absence, the value proposition remains largely theoretical and uncertain.
Emily Botto, Ruby Madison Ford, MPH, Hana Do, MPH, and Ken Getz, MBA; all with the Tufts Center for the Study of Drug Development (CSDD), Boston, MA
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