When community pharmacist Anaïs Webster Mennuti came under pressure to upsell vaccine jabs to her patients during the pandemic, she started to feel like she was running a fast-food joint rather than a pharmacy.

Increasingly unsettled, she knew she had to raise awareness of what was happening and turned to a few friends to help make a documentary. It started life as ‘Would you like Shots with that?’ but the name later changed to ‘Harmacy’.

You can watch a trailer of the work-in-progress documentary below.

“At the end of the day we’re serving patients, but patients are being harmed, and the pharmacists are being harmed by the system that is put upon us,” Mennuti tells C+D.

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“Pharmacists are an integral part of the healthcare system. And there wouldn’t have to be this harm if pharmacists were properly resourced.”

Catalyst crisis

The pandemic was the catalyst for the pharmacy crisis in the US. The vaccination programme shifted from public health clinics into pharmacies and for Mennuti, that tipped the balance. She says it was like the government said to pharmacists ‘now you can vaccinate the country’. But we still had to do everything else we were doing before, and now we had all this extra pressure to vaccinate people.”

There just weren’t enough hours in the day, Mennuti says. “Of course, pharmacists were worried about patient care, and they wanted to make sure people got vaccinated”.

But she says pressure to “upsell the vaccine came from above. We heard of pharmacists receiving text messages from their district managers saying, ‘Why didn’t you hit your shot goal?’. And there is a clip recorded by a pharmacist of a district manager saying: ‘We will cut your hours if you don’t hit your shot goal’”.

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Some drugs have higher rates of reimbursements for PBMs. Vaccines are one of these drugs, hence the economic pressure for pharmacists to vaccinate more people. More jabs, more profits.

Mennuti makes clear that “vaccines are good, and we want people to get vaccinated”. But she says the accompanying economic pressure to upsell jabs has the potential to “tip the balance” of when a vaccine might be considered necessary.

But Mennuti says the district managers are just the middlemen. The real pressure to meet targets is coming from insurers and pharmacy benefit managers, referred to as PBMs.

In the US, insurers use PBMs to act as intermediaries with drug companies. PBMs negotiate with drug companies to determine reimbursement rates. However, the reimbursement rates negotiated by PBMs are not necessarily the same as the price a pharmacy pays for the drug.

Impossible

In the UK, the government sets a uniform reimbursement price for each drug, meaning all pharmacies are reimbursed the same amount for dispensing that drug. In the US, the reimbursement amount for a drug in the US varies, depending on the patient's insurance plan.

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Mennuti says sometimes it’s lower than the pharmacy paid. “Pharmacists may be paying $10 for a drug and the PBM may come back and say here’s $7”. She explains that it’s impossible to recoup the cost of the drugs, let alone electricity and staffing costs.

This situation will be familiar to many in the UK, and from the interviews she’s done with pharmacists so far, Mennuti says the situation has been gradually getting worse over the last fifteen years but is becoming more acute with the rise of weight loss and diabetes injections.

“Those drugs have a very poor reimbursement rate for a lot of pharmacies. We’ve talked to a lot of people who have said they lose $100 every time they fill Ozempic.”

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To make matters worse, US pharmacists have no bargaining power. If a pharmacy requested full reimbursement or turned patients away, the PBMs could respond by saying “we are going to take all these people covered by this insurance, send them elsewhere and remove your pharmacy from the network”.

Patients have little choice either. Most cannot afford the drugs without insurance, so they have no choice but to go to the pharmacy their insurers prescribe.

Repercussions for speaking out

Mennuti says funding for the documentary has come from crowdfunding and individual investors. “We like to tell people that if we had a magic wand and all of the funding just descended on us today, it would take approximately a year to get the documentary made,” says Mennuti. The team is hoping to raise $300,000 in order to kickstart the production process, but believe the whole project will cost $450,000.

Mennuti is familiar with pharmacy in the UK as the Harmacy team interviewed Greg Lawton - a former Boots employee and the whistleblower whose concerns about safe staffing were covered in a 2018 BBC exposé.

While Lawton was able to call out the workplace pressure at Boots, some of the subjects in Mennuti’s documentary fear repercussions for speaking out. Many have shared information about the struggles they are facing but requested to remain anonymous.

Mennuti says employees know they are being watched. All metrics are tracked by district managers to ensure pharmacists are selling enough drugs, so people are worried that by criticising the system “they will get put on a list” and if any of their metrics slip and they are caught speaking out, they could lose their job.

“A lot of people are really scared for their livelihood, and they don’t feel protected.”

If that sounds over the top, Mennuti says one of her interview subjects was fired for being a stand-up comedian outside of work. “One of the district managers had come to his show and he said something too outspoken. They fired him for comedy.”

While Mennuti has taken on the challenge of presenting the woes of the pharmacy world to the public, she insists that “her heart is still in the community”.

She’s worked in retail and hospital pharmacies, and discovered a whole host of issues within the pharmacy ecosystem.

But as far as the public perspective of pharmacy is concerned, she people think pharmacists are “behind the counter, helping people out and helping them get their medications safely so they can live their lives”.

Her documentary wants to show that things aren’t quite as simple as all that.