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Sometime in 2007 or 2008, Samantha Jefferies came to her brother Trent and asked for a request: could he help the doctor find an easier way To sell prescription drugs to patients? Usually, when doctors want their patients to take medications, they will write out a prescription, and then the pharmacist (usually in a local non-affiliated pharmacy elsewhere in the patient’s community) will dispense the medication. But in the 1980s, more and more American doctors began to bypass pharmacies and sell certain drugs directly to patients. This practice is often referred to as doctor dispensing and is basically banned in many high-income countries (including Australia and Germany), but it is currently legal in 45 states in the United States, and this practice seems to be growing.

Samantha Jefferies works in healthcare management in Southern California. After reading an article on how this kind of office dispensing can bring new income to medical practice, she asked her brother for his ideas.

Trent Jefferies served in the U.S. Army Corps of Engineers, worked as an engineer at Black & Decker, and managed materials and logistics for a company that made carbon fiber components for aircraft. On the venture capital platform F6S, he described himself as a "mechanical engineer, six sigma black belt, lean expert and supply chain master". After hearing the news of his sister, Jeffries invited several other engineers and began to make plans. Their idea is simple: build a medicine vending machine that can be placed directly in a doctor's office or clinic.

In 2011, the group received the first round of investor financing and established a company, VendRx. In the second year, they applied for the first of four patents for equipment "used to distribute beneficial products." To build it, Jefferies and his collaborators hired a company that adopted a standard snack vending system — “just ordinary candy machines, because there is no better word,” Jefferies said — and integrated them into other applications In the process. When the relationship with the company deteriorated, Jeffries said he took the unfinished prototype and recruited a new engineer to build the rest of the machine in the team's own warehouse.

In 2017, the VendRx system distributed the first bottle of medicine to a patient in the Ross Legacy Medical Group office in Mission Viejo, California. (Samantha Jefferies, the executive director of the group, is now a member of the board of directors of VendRx.)

From the outside, this machine is a tall off-white powder-coated steel cabinet with a large touch screen. Internally, the system stores up to 500 packs of medicines, each pack is located in a V-shaped notch. When the doctor prescribes the medicine, the VendRx software transmits the prescription record to the machine. On the way out, patients can stop and tap their name and date of birth on the touch screen. This will send a robotic arm to the correct slot, where it grabs a pre-packaged, pre-calculated medicine bottle and transfers it to a small printer for labeling. The machine then transports the medication to the delivery tank.

The whole process takes about 70 seconds-the VendRx machine accepts credit cards. The company said that even small medical institutions can make five-figure profits from this machine every year.

Advocates of in-office dispensing believe that it is convenient and cheap for patients, and some say it can also bring extra income to doctors. Proponents believe that this arrangement can also bypass the complex and opaque vagueness of retail drug pricing, which often allows patients to pay far more than necessary drug costs in pharmacies. Given that a large proportion of patients will never go to the pharmacy to buy medicines even if they have a doctor’s prescription on hand, supporters also say that the convenience of getting medicines directly from a doctor helps close key compliance gaps and improve patients Overall health.

Not everyone agrees with these arguments-at least not all pharmacists. They and other critics believe that pharmacists play an important role in patient education, and they play a vital role in safety checks on doctors’ orders, helping to avoid potentially dangerous drug interactions or other complications. Critics of the doctor's prescription also say that this arrangement involves an inherent conflict: the doctor who prescribes the medication should not profit from it.

These critics can cite many examples, some of which made headlines, in which doctors abused office dispensing privileges by selling dangerous or overpriced drugs to patients to produce a variety of undesirable plans, ranging from fuelling the opioid crisis to The workers' compensation system that plundered hundreds of millions of dollars. While proponents of dispensing in the office might argue that these results are driven by a few bad actors in the benign system that benefits patients, a small set of studies from Europe and East Asia show that given the profit motivation, many doctors prescribe The way of medication is different from their non-dispensing colleagues.

"Doctors are also human beings, and when you look around, people respond to their financial incentives. They do," said Christian Schmid, a Swiss economist who studies physician dispensing. "I don't think doctors can turn off these incentives."

These concerns do not seem to curb the enthusiasm for this practice in the United States, where VendRx is part of the penetration economy of software vendors, drug repackers, and other market participants who seek to dispense more doctors Sit in the driver's seat with medication. In June 2020, the editorial board of The Wall Street Journal weighed this issue, describing doctor dispensing as an "easier and cheaper" option for obtaining medicines, and calling pharmacies an "unnecessary middleman." Sarah Callioras, sales director of Datascan, which sells software to dispensing doctors, said that doctors’ interest is “definitely and definitely growing.” Some industry sources stated that the Covid-19 pandemic has put financial pressure on many independent medical institutions and has also aroused new interest. In the past few years, dispensing has also been popular with doctors in the direct primary care movement—a rapidly growing clinical model designed to provide low-cost care without the need for insurance companies. Some supporters say that this arrangement provides special benefits to low-income communities that lack insurance because their direct care doctors can sell them medicines at or close to wholesale prices.

Recently, some advocates of doctor dispensing have tried to bring their cases in court. In 2019, the Institute of Justice, a public interest law firm that supports liberal causes, filed a lawsuit against doctors' prescription ban in Texas. (The law currently allows some exceptions, including doctors in certain rural areas.) Montana initiated a similar action in June 2020 to pass a law in the state legislature and the governor to legalize this practice Then it ends this year. The Texas complaint alleges that drug dispensing restrictions stifled competition in the drug market and violated the rights of doctors.

Nonetheless, the idea of ​​doctors selling medicines entirely — let alone selling them through vending machines — disturbs some experts who believe that regardless of the alleged benefits, doctors profiting from their own prescriptions will cause abuse. opportunity. Scott Knoer, chief executive of the American Pharmacists Association (APhA), said that doctors are experts in diagnosis, but he said that dispensing is different.

"It's shocking," Knoll added, "Anyone wants to get the pharmacist out of the medication process."

Advocates of doctor dispensing sometimes argue that they are reminiscing about an ancient way of medication, when the doctor will put a medicine cabinet in the back, and the patient can leave the clinic with the tonic. But history is a little more complicated-and full of competition. "The big thing here is a turf battle between pharmacists and doctors," said David Courtwright, a drug historian at the University of North Florida. "This competition has always existed between doctors and pharmacists."

Before 1900, American doctors usually sold drugs directly to patients. But they also rely on local pharmacists to mix or synthesize some of the drugs they prescribe. However, starting in 1902, federal lawmakers began to strengthen their control of the drug market. The "Pure Food and Drug Law" passed in 1906 established regulations on drug labeling. It also established a regulatory agency that will evolve into the U.S. Food and Drug Administration. In 1938, legislators acted again, adding new labeling requirements and requiring new drugs to be approved before they can be marketed. They also made a requirement that certain dangerous drugs can only be provided to patients who have a prescription from a medical provider.

Over the next few years, some patients continued to buy certain drugs from their doctors, and some pharmacists continued to compound drugs. However, with the strengthening of supervision, the diversified pharmaceutical market has begun to consolidate. Lucas Richert, a pharmacy historian at the University of Wisconsin-Madison, said that with this shift, pharmacists began to “get rid of the role of compound practitioners and move to the role of providing drug services in their own stores.”

In 1951, Congress passed the Durham-Humphrey Amendment, which clarified the definition of prescription drugs. By the middle of the 20th century, the now familiar model had materialized: a few pharmaceutical companies began to dominate drug manufacturing, and under the supervision of the FDA, almost all drugs were produced in centralized facilities. In order to obtain these drugs, patients usually take prescriptions to the pharmacy—and they still do it often today—and purchase the drugs from a licensed pharmacist.

In the years since this arrangement became routine, prescription drug spending in the United States has skyrocketed - reaching nearly $370 billion in 2019. By the 1980s, some entrepreneurs began to provide doctors with opportunities to take a share of the growing market. These companies buy drugs in bulk, and then repackage them into small batches and sell them to the doctor’s office, which in turn can label the drugs in accordance with national regulations and then sell them to patients for profit.

The fast-growing industry has shocked some policymakers. In 1987, Ron Wyden, then a young Democratic congressman from Oregon—he is now a U.S. senator—initiated legislation restricting doctors' dispensing. Wyden told the New York Times that year that these repackers were "a group of fast-earning artists" and they tried to involve doctors in a project to earn "easy money". At the Congressional hearing, Wyden brought samples of sales promotion sent by the repacking company to doctors. "Every time you sign a prescription," he quoted one sentence, "it's like writing a check for a pharmacy." Another advertisement he quoted promised to show doctors "how to earn this year without investment." US$52,000".

According to The Times, lobbyists flooded into the Houses of Parliament. Nancy Dickey, chair of the Committee on Ethics and Judicial Affairs of the American Medical Association, testified that although the organization believes that “doctors should avoid regular dispensing and retailing of drugs,” it opposed Wyden’s bill because it represented an “improper response to state affairs”. Intervention. At the same time, the pharmacy organization supports Wyden. So does Arnold Relman, MD and long-time editor of the New England Journal of Medicine. He wrote in an editorial: "Trust in doctors is an essential but fragile component of good health care." "It may not be able to afford to turn doctors into drug suppliers for profit."

The drug repacker won. Wyden's bill is dead.

Today, only five states—Massachusetts, New Hampshire, New Jersey, New York, and Texas—maintain extensive bans on doctor dispensing. (In the sixth case in Utah, legislators recently relaxed the drug dispensing ban, but for most clinics, this practice is still prohibited.) Even in states where this practice is basically prohibited, exceptions It is also very common. For example, in Texas, it is allowed to dispense medicines in rural clinics far away from the nearest pharmacy. New York has made an exception for drugs "under the oncology or AIDS agreement." In states where dispensing of medicines is prohibited, doctors can still provide free samples of medicines or dispense enough medicines for patients to take for 72 hours.

In other parts of the country, dispensing is completely legal. Some states do require doctors to apply for a simple license before dispensing medications, but most do not. Today, some companies specialize in repackaging medicines for doctors and pharmacists. Large national drug distributors that mainly supply pharmacies, including McKesson and AndaMEDS, also supply medicines to doctors.

It is difficult to grasp the current scale of the industry, especially considering that there is no single source to track the number of doctors who sell their medicines. One sign comes from MDScripts, a company that develops software for dispensing doctors. An industry source said that the company has a dominant market position. MDScripts says it serves more than 50,000 providers at more than 17,000 sites across the country. Last fall, company president Gary Mounce stated that MDScripts accounted for more than half of the total market share-although he pointed out that there is no reliable estimate of the total market size.

Although traditional insurance plans will reimburse the medicines dispensed by doctors, the rates can vary widely, which is usually impractical for clinics. On the contrary, dispensing often flourishes outside the umbrella of traditional insurance. This is especially common in clinics that provide services for workers' compensation patients who are injured at work or suffer from work-related diseases, and their follow-up care is covered by special forms of insurance. Dispensing medicine is also very common in professional fields, such as weight loss drugs and dermatology. If they think it is not medically necessary, insurance usually does not cover ordinary prescriptions.

Comments on advertisements and other marketing materials indicate that the business of serving pharmacists comes and goes. One man who has established a large and long-lasting business in this field is Brian Ward. Ward was a 6-foot-3 offensive guard on the Louisiana State University football team in the 1990s. He started working in drug sales shortly after graduation. Around 2008, when the pharmaceutical giant AstraZeneca he was employed by then offered an acquisition, Ward began to look for new business opportunities.

Ward said he got the answer after his father was injured at work. When his father went to see a doctor for work-related injury compensation, he received the medicine before he even left the office. Ward was impressed. He said that he removed the company name from the label from his father and started searching on the Internet. Soon after, he and his wife Jennifer founded a company in their home in Mobile, Alabama, to sell doctors' dispensing services to the clinic. The DocRx company essentially acts as an intermediary: they sell ideas to doctors to dispense medicines, manage bills, and comply with regulations. They provide software for doctors and help connect the practice with existing repackers. DocRx itself does not repackage drugs.

Ward said that when they started the company, most of the dispensing services in the area were for workers' compensation patients. Ward saw an opportunity. "I want to capture the patient who is insured and paid in cash, the patient who is self-insured, the patient who has a copayment of $30, but I can provide them with medicine for $10," he said.

Ward said that sales in Alabama, Mississippi, and Louisiana performed well, and the company signed a contract with doctors to start dispensing medications from their offices. When a competitor's salesman wanted to discredit the young company, he started telling the doctor that the ward didn't even have an office, and they rented a space. (Later, they hired competing salespersons.) Over time, DocRx expanded to other services. Today, in addition to the dispensing business, they also provide diagnostic tests for clinics, sell medical supplies, and even supply products to some pharmacies. As of last fall, the company's marketing and communications directors Ward and Jane Glover stated that DocRx has grown to approximately 150 employees, working with approximately 1,500 doctors, concentrated in the south.

On the phone, Ward said that he and his colleagues "usually do not discuss financial issues with doctors." He said that doctors "are doing this for patients" and most people don't make much money. Like other companies in the industry, the research cited by the company shows that as many as one-third of prescriptions have never even been matched. Ward and other advocates believe that the convenience of office dispensing can increase compliance and improve care.

Nonetheless, in online promotions to potential customers, the company emphasized that the revenue from dispensing medicines could be “substantial,” and explained that due to the low prices of medicines, “doctors can easily add significant markups and still pay lower or lower prices. The same price is provided to them. The price paid by many patients."

Ward's company sued a rival company that used a similar name, DocRx Dispense, for trademark infringement in 2014. Ward won, and the latter company seems to have ceased to exist. However, just last fall, an animated video appeared on multiple pages of Ward's DocRx, which outlined the benefits of in-office dispensing—produced by a now-defunct rival company. At the scene, an animated character strongly praised the profit potential of doctors' dispensing, and accused the comprehensive health care reform bill "Affordable Care Act" passed in 2010 for harming the income of private doctors.

"Yes," said the cartoon man wearing a yellow tie and raising his hands in gestures. "I can't emphasize enough. It provides you with considerable benefits for your practice." He explained that this profit "may be low." Up to US$50,000 per year. It can be as high as US$1 million to US$3 million per year, depending on the size of your clinic."

When asked about the video in a telephone interview, Ward sounded confused. After checking the website later, he said that his network administrator might have posted it by mistake. "This needs to be taken down as soon as possible, because that is not us," he wrote in an email.

Before long, the video disappeared.

In the United States, the rise of office dispensing has been accompanied by major developments in the pharmacy industry, which has moved towards broader and more advanced medical training. In 2000, it became the standard for all new pharmacists to obtain a doctorate in pharmacy (known as PharmD), which requires four years of professional study and at least two years of "specific professional preparatory courses" at the undergraduate level. According to the Association of Colleges, in terms of the biological, chemical, and physical properties of drugs.

Some pharmacy schools also require special entrance exams, and leaders in this field are also pushing new pharmacists for post-graduation internships.

Pharmacists must also pass the North American Pharmacist License Exam and the Pharmacy Law Exam before they can dispense medicines.

Advocates say this is a rigorous challenge that allows pharmacists to play a more active and clinically important role in supervising patients’ complex medication regimens, preventing potentially harmful drug interactions, and even providing some medical advice. "We are the drug experts on the medical team," said Micah Cost, who was the executive director of the Tennessee Association of Pharmacists in an interview in August 2020. "We are the only professionals who have received four years of targeted drug-related education. Therefore, we do have unique value in the system."

Industry advocates believe that laws that allow doctors to circumvent pharmacists are more in line with doctors’ bottom line than patients’ health. "This must be an income issue," said Noel, the head of APhA. "There is no doctor who is in a right mind-you can quote me-any doctor in a right mind would not want to undergo a safety check by a pharmacist," he continued.

"It goes against logic," Knoll said. "So it must be purely a financial issue to increase the income of the doctor's office."

Not every pharmacy advocate is firmly opposed to doctors dispensing medications, and some leaders in the field say they see its place. "Our position is that it can be done on a limited basis," said Alija Horton, executive director of the Maryland Association of Pharmacists. "But we do not support full-time doctors to be able to dispense anything while turning themselves into clinics and pharmacies." Her organization pushes for clearer regulations to ensure that doctors dispense medicines safely.

Horton said that during the Covid-19 pandemic, she saw doctors in the state advocate for expanded dispensing. However, she said, pharmacists will provide "a little check and balance"-perhaps especially during turbulent times.

For example, in the early days of the pandemic, after then-President Donald Trump began advocating for an unproven Covid-19 treatment, hydroxychloroquine, many doctors rushed to prescribe them for themselves, their family and friends. (Subsequent studies failed to show that the drug can treat Covid-19.) As Undark reported in March 2020, the surge in prescriptions has led to a shortage of the drug in patients who need the drug to treat lupus and other unrelated chronic diseases. In some cases, pharmacies will step in to resist arbitrary prescribing. Horton said that pharmacists have also intervened with doctors who have never been exposed to the drug before, unknowingly trying to obtain inappropriately high doses.

She pointed out that pharmacists are sometimes "obstacles to improper prescriptions."

Some dispensing advocates refute these arguments by pointing to recent reports that indicate that overworked pharmacists in chains such as CVS are making more mistakes that may endanger the patients themselves. The Chicago Tribune published a two-year survey in 2016. With the help of drug interaction experts and co-doctors, reporters were sent to 255 pharmacies in Illinois—Walgreens, CVS, Costco and Other chains, as well as independent pharmacies-seek to obtain two contraindicated, prescription-only drugs. In some cases, if the patient combines them, the permuted drug combination will be fatal. In the end, 52% of visited pharmacies filled out prescriptions without mentioning any possible interactions. The newspaper described it as "a stunning evidence of the failure of the entire industry, putting millions of consumers at risk."

Nonetheless, such errors in the real world start with doctors, pharmacy experts warn, and Knoer believes that most doctors have called pharmacists multiple times to alert them to major potential errors. "This is a team," he said. "So far, pharmacists have received more training in medication."

His colleague Daniel Zlott, who was an oncologist at the National Institutes of Health and is now an executive of APhA, agrees. He believes that more than 10% of handwritten prescriptions contain some kind of mistake. "As a pharmacist, one thing I have done," Zlott said, "is to find errors on the left and right sides and prevent them from contacting the patient."

In 2014, Geoffrey Joyce, a health policy scholar at the University of Southern California, sent students to 500 pharmacies near Los Angeles and provided the same set of prescriptions for generic drugs. He recalled that the unit price quoted by the pharmacy for them ranged from US$10 to US$200. "Uninsured consumers are really vulnerable," Joyce said.

In fact, although it is widely believed that generic drugs should save American consumers, millions of patients who buy drugs with cash—because they are uninsured or underinsured—are particularly vulnerable to the instability of generic drug prices. At the same time, doctors have found a way to sell generic drugs directly to patients, sometimes at prices much lower than those offered by pharmacies.

The life cycle of most generic drugs begins in China and India, where a huge network of factories produces basic chemicals that provide raw materials for the global pharmaceutical chain. Then they sell these chemicals to other manufacturers—again, usually in China and India, but also in Europe and the United States—and they use them to synthesize actual active pharmaceutical ingredients or APIs. Finally, the drug manufacturer measures and mixes the API into tablets, capsules, or creams to be marketed. Joyce said that for generic drugs sold in the US market, the third phase usually occurs in the US.

It is at this point that generic drugs enter a series of opaque financial arrangements, usually modeled on well-designed flowcharts. For many generic drugs, the manufacturer sets an average wholesale price or AWP-but this number is mainly a placeholder. "The list price may be related to the cost of the drug, or it may not be related to the cost of the drug," said Antonio Chasia, president of consulting firm 3 Axis Advisors and CEO of 46brooklyn, a non-profit research organization that studies drug pricing data. (The analyst joked that AWP means "ain't what's paid.")

On the contrary, the prices that consumers encounter in pharmacies have a lot to do with middlemen called pharmacy welfare managers or PBMs. In theory, PBM exists to help health insurance providers bargain at lower prices. But in practice, more and more experts, advocates and policy makers believe that a small number of PBMs now dominate the pharmaceutical market, making huge profits while pushing up prices. Ciaccia said that in that Byzantine system, "everyone in the supply chain," including pharmacies and PBMs, was sometimes motivated to look for higher-priced products from suppliers because they knew it would enable them to be on the production line. To get bigger payments.

When a drug arrives at the pharmacy, each participant in the chain has already occupied a large share.

A 2017 report by scholars from the Shafer Center for Health Policy and Economics at the University of Southern California found that for every $100 spent on generic drugs, only $18 was actually spent on manufacturing costs.

Consider cyclobenzaprine. In 1956, the drug was first synthesized by a pair of chemists—one was an employee of Merck and the other was a consultant of the company—in 1956, the drug entered pharmacies as a muscle relaxant and analgesic in the 1970s. Named Flexeril. It is usually used for injured people in the workplace. In 1989, Merck's drug patent expired. Today, any pharmaceutical manufacturer registered with the FDA can apply for approval to produce and sell the generic drug cyclobenzaprine. According to federal pricing data, when pharmacies buy directly from generic drug wholesalers, the final drug is often quite cheap—about 2.5 cents per 10 milligram (mg) pill, or about 75 cents for 30 pills.

However, according to data from the drug coupon company GoodRx, when patients pay in cash at the pharmacy, the average price of a bottle of 30 capsules is $18.23. With coupons, you can buy them at Wal-Mart and other stores for $12.09, which is cheaper, but still has a high markup.

Ciaccia says that pharmacies have little control over the final pricing. But dispensing doctors operate outside the system, and they can get low wholesale prices. For example, the internal pricing table of a dispensing clinic in Wichita shows that a large drug distributor sold cyclobenzaprine directly to the clinic in August 2021 for less than 2 cents per tablet. The doctor can take that bottle of medicine for an additional $10 and provide it at a cash price that is still lower than the local pharmacy-and lower than some insured copays.

Chris Lupold is a family doctor in Ronks, Pennsylvania and has been dispensing medications since 2017. He said that he would not increase the price of the drugs he dispenses for profit, but instead promote low-cost office drugs as a service to potential patients. (Lupold’s approach is to make money by charging patients a monthly membership fee.) During the visit , Lupold often guides patients to understand the pricing of medicines and shows them the wholesale prices of regular prescriptions. He estimated that he could exceed the price of the pharmacy "probably in 97% of the cases."

Some patients find these conversations disturbing. "I heard some foul language," he said. "'I paid a copayment of $20 for that bottle of wine," the patient would say, "Can you buy it for me for $2? What are you talking about?'"

However, not all dispensing doctors sell their medicines at such low prices. Some experts echoed the concerns expressed in the 1980s that doctors' dispensing might open the door to unethical behavior—even distorting the decisions of well-meaning doctors.

At the request of Undark, Matthew McCoy, a medical ethicist at the University of Pennsylvania, reviewed the details of general doctors’ dispensing arrangements and said: “There must be improper financial incentives.” McCoy studies health care. Conflict of interest, he pointed out, just because there is a conflict of interest does not mean that doctors must take action. "But objectively it is true," he said. "If you are one of the ways to increase your income through drug sales, then you have an incentive to prescribe more drugs to your patients."

Ciaccia was even more blunt: "You essentially gave the doctor a printing press for money."

Advocates of doctor dispensing pointed out that in other cases, the doctor's medical decision will affect their income. "What is the difference between [dispensing] and a doctor who owns an X-ray machine and makes money on it?" Trent Jeffries asked.

McCoy acknowledged that conflicts of interest also exist in other areas. However, he believes that this is not a reason to allow newcomers to enter the doctor's office. He said: "I think we still have a responsibility to work to eliminate the additional unnecessary conflicts that may arise in the way we do business in the United States."

At least one medical association has expressed similar concerns. In Australia, as of 2018, only about a dozen rural clinics are allowed to dispense medicines, and the Australian Medical Association opposes the dispensing of medicines for “material benefits”. That year, the organization's then chairman of ethics warned that such sales "may undermine trust in doctors."

In the United States, the country’s flagship medical association supports allowing physicians to dispense medicines in accordance with their ethical guidelines. The American Medical Association’s Code of Medical Ethics stipulates that doctors “can dispense medications in their offices, provided that such dispensing primarily benefits patients.” The code continues to warn doctors to “avoid direct or indirect effects of economic benefits on prescription decisions.” But this did not directly prevent doctors from selling medicines for profit.

When asked to comment on the position of the American Medical Association, AMA's media relations manager Robert Mills sent a copy of these ethical codes. He pointed out that the AMA policy supports “doctors who dispense medicines in accordance with the AMA Code of Ethics and are not subject to legislative restrictions that conflict with patients’ access to appropriate prescription drugs.”

In the United States, there is little research on whether dispensing drugs will change doctors’ behavior. But studies from some European and East Asian countries show that McCoy's concerns have indeed occurred-and have raised questions about the AMA's position.

The great laboratory for doctors' pharmaceutical research is Switzerland. This mountainous country is divided into 26 autonomous prefectures; some prohibit doctors from dispensing medicines, some allow them, and some have no restrictions. The resulting patchwork created a series of natural experiments that allowed economists to match similar practices, and then tried to tease out from years of prescription data whether the prescriptions of the dispensers were different from those of their counterparts who did not dispens.

Sometimes the environment provides perfect case studies for these researchers. In 2008, after 57 years of banning this practice, the cities of Zurich and Winterthur, located in the German-speaking part of northern Switzerland, voted to legalize doctors' dispensing. The law came into effect in 2012, after pharmacists raised legal challenges and failed. Doctors who have referred patients to pharmacies for years may suddenly start selling some drugs themselves.

Swiss economist Schmid and two colleagues recently began to comb the prescription data before and after the policy change. They want to see if doctors will start prescribing different prescriptions after making a profit. Schmid said the data is clear: they did it. "They don't treat patients worse. But they use this system to make more money," said Schmid, head of the CSS Institute of Empirical Health Economics, a research center in Lucerne that belongs to a company Large Swiss insurance company.

The team found that after 2012, doctors prescribed more expensive drugs. They also seem to like small packages of medicines. Under the Swiss healthcare system, the income per pill is higher. According to economists’ estimates, these additional costs add up to an additional cost of 30 to 40 Swiss francs per patient per year, or 32 to 42 US dollars. (The team has presented their data at the conference and released a working draft of the paper in July 2020; it has not yet been published in a peer-reviewed journal).

This finding reflects the conclusions of the peer-reviewed research done by Schmid as a graduate student, as well as the research of several other economists in Switzerland. "I'm pretty confident that we see doctors dispensing medicines increase health care expenditures," Schmid said. However, he emphasized that the data only focuses on costs, not health outcomes: "I don't know whether treatment will get better or worse."

Researchers are now also carefully examining the dispensing practices in England. There, patients away from the pharmacy can dispense medicines, which means this is most common in rural clinics. According to a study, about one-eighth of the practice does this.

As part of a doctoral dissertation at the Institute of Competition Economics in Düsseldorf, economist Olivia Bodnar and three colleagues recently studied prescription data from nearly 8,000 clinics in the UK. The researchers chose dispensing practices and then tried to match them with non-dispensing practices that were similar in almost all aspects—size, patient demographics, doctor’s age, and many other variables—except that they didn’t dispense. Then, they compared matching practices to see if their prescription patterns were different.

As in Switzerland, data shows that British doctors behave differently when selling medicines. They prescribe more drugs than their non-dispensing colleagues, including more opioids and antidepressants. They also prescribe drugs in small packages, which allows doctors to charge higher fees. "We found evidence that they responded to economic incentives," Bodnar said.

There are no comparable statistics in the United States. However, as in the 1980s, advertisements for doctors indicate that profits are an important motive for many dispensing doctors—and that these revenues can be substantial. California’s major repacker BRP Pharmaceuticals stated on its website that this practice “increased profits by 50%-without any additional patients, staff or equipment.” First Coast Health Solutions is a supplier in Jacksonville, Florida. It tells doctors that each prescription can bring in "12 dollars, 15 dollars, 18 dollars or more", and "annual net income is as high as 100,000 US dollars." (Neither company responded to multiple requests for comment.)

"If someone tells you that as a doctor, you can make an extra $75,000 to $200,000 per year without having to see any additional patients, work more hours or increase your administrative expenses, don't you want to know?" Asked 2008 Video of MedXSales. MedXSales is a company based in Akron, Ohio, that provides doctors with "assisted income products and services," including dispensing medications. In an interview, MedXSales President Gary Silbiger said that the company stopped using the video nearly ten years ago and no longer put profits in practice, but instead emphasized the benefits of higher compliance and patient convenience. "We just no longer promote the economic opportunity of dispensing medicines in any type of marketing," he said.

He added: "We don't want to attract doctors whose primary goal is to prescribe drugs."

Jefferies and the automatic dispensing machine company VendRx did make a profit forecast: a slide previously posted on the company's website showed that doctors added $10 to each sale. Among them, $2 is transferred to VendRx as a transaction fee, and the rest is income from the clinic. The company estimates that doctors who write 30% of prescriptions on the machine will make a net profit of $18,000 per year.

Jeff Coulter, owner of PharmaLink, who provides software for hundreds of dispensing practices, said the interest of potential customers tends to ebb and flow. When income shifts—for example, from changes in insurance payments to doctors—interest in dispensing medicines increases: Whenever insurance companies change their reimbursement policies, he says, “We usually see a lot of new interest ."

Robert Palm, Calvin Scott's vice president, repackages and sells specialty drugs for weight loss clinics. He said that some practices in the company's network sell drugs at cost. Some people charge a fee of $10. He admitted that others "marked it as a crazy amount."

There are also cases of direct abuse, especially when doctors peddle opioids. Khay Rigg, a substance abuse researcher at the University of South Florida, said: “Doctors dispensing medicines are a major part of the early stages of the opioid epidemic.” In the 2000s, to map this phenomenon, Rigg and colleagues would stand in Florida Interview users outside the shady pain clinic in the south. "Many of them reported that they would go to find doctors and pain clinics, and they would dispense their own medicine," Rieger said. He said that the dispensing clinic allowed illegal seekers of opioids to "exclude pharmacists," and he jumped to different doctors to eliminate "another chance of being caught."

In 2010, according to data from the U.S. Drug Enforcement Administration, the top 90 oxycodone doctor dispensers in the United States were all in Florida. That year, the state passed new regulations on pain clinics, and then in 2011 restricted doctors from dispensing opioid painkillers. The mortality rate of overdose has decreased.

Today, Rieger said, prescriptions are no longer the main driver of opioid addiction and death. But in many states, some doctors continue to sell painkillers directly to patients.

Christopher Jones, acting director of the National Center for Injury and Control of the US Centers for Disease Control and Prevention, studied the role of doctors' prescriptions in opioid use. He said that in general, he is concerned that “allowing the pharmacist to leave the prescriber-patient-pharmacist cycle may increase the risk.” He said that in some cases, the doctor’s prescription “may be very important to the patient and the provider. Significant". However, he said that this approach is "possible"-as some of Jones's own research has proven-"cause bad actors to participate in the process."

Rieger was skeptical of dispensing medicine. "I think most doctors are ethical, and most doctors are good people," he said. "But the truth is that when doctors start to profit from the drugs they prescribe, it is not a small financial incentive we are talking about. In most cases, we are talking about tens of thousands of dollars a year, sometimes even a few dollars. One hundred thousand U.S. dollars". He warned that these incentives would affect the behavior of doctors.

"The person who pushes the doctor to dispense the medicine is the doctor," he said. Rigg pointed out that some doctors said that the prescription is mainly for convenience, or to improve patients' access to drugs. "The truth is, this is not true," he said. "This is to make more money."

Perhaps the most profitable corner of the doctor's dispensing industry can be found in workers' compensation claims. Under the workers’ compensation system, injured workers go to see a doctor, who provides care, and then bills the patient’s employer (or, more commonly, the employer’s insurance company). In most states, employers or insurance companies are legally obligated to pay for appropriate care, even if the cost is very expensive.

“Therefore, patients do not need to consider the cost of care at all, which is good because you want patients to get the care they need without worrying about costs,” said Joe Padada, a healthcare consultant. Prolific blogger on workers' compensation issues. However, he added that this arrangement also creates opportunities for "unscrupulous suppliers" to play with the system "by coming up with creative ways to provide inappropriate services, provide excessive services, and charge excessive fees." ."

Paduda and other analysts say that dispensing is a way for these suppliers to make money. Alex Swidlow, chairman of the California Workers' Compensation Institute, a non-profit organization, said he began to notice problematic behavior in the early 2000s. He and his colleagues discovered that some doctors dispense cheap generic drugs at 10 or 11 times the pharmacy price.

In response, legislators in California, Illinois, and other states passed laws that tried to tie the market price of drugs dispensed by doctors. However, in 2012, Vennela Thumula, a policy analyst at the Massachusetts non-profit research company Workers' Compensation Institute, and her colleagues noticed more unusual activities. Dispensing doctors in California and Illinois are selling new doses of cyclobenzaprine and several other common cheap generic drugs: for example, 7.5 mg cyclobenzaprine tablets instead of the existing 5 mg and 10 mg pills. The difference lies in the price: in California, doctors dispense a 7.5 mg bottle of cyclobenzaprine and charge about $3 per pill, instead of other doses of 35 to 70 cents per pill supplier.

Analysts say this is a clever solution: States require doctors to sell drugs to injured workers at prices linked to the price of the manufacturer's trademark. As a result, some manufacturers have proposed new dosage products—new, exaggerated prices—for doctors to dispense medicines.

This is not the only time a pharmacist has discovered a loophole that allows them to overcharge. "This is one of a series of innovations that occurred when doctors' dispensing reforms were implemented," Tumula said. Swedlow agrees: Over the years, he said, a small number of dispensing clinics have shown "a certain degree of creativity" in finding new ways of operating the system.

"The vast majority of doctors, and most of the doctors I have contacted, are not part of this problem," Svedlow said.

"Cost-driven behavior is actually driven by very few suppliers," he continued. "In other words, you don't need a lot of doctors to tip the system."

The continuous play of moles has angered some industry analysts. "To completely deceive employers and taxpayers is a brilliant strategy," Paduda said of the new dosing plan. In the past, Paduda served as a consultant to PBM, a position that included discussions with policy makers about doctor dispensing issues. He also personally clashed with some people in the industry: A few years ago, a software company that provided services to dispensing physicians sued him for defamation based on his blog post. (The case has been dismissed.) Padada said that today, many insurance companies have simply given up fighting the excessively high cost of doctors’ dispensing, treating it as a relatively small drain in the U.S. workers’ compensation market, which covers The annual medical cost of more than 30 billion U.S. dollars.

Paduda does not believe that doctors dispense medicines and help patients recover faster by making it easier for patients. "This is obviously wrong," he said. "There is no data, no research, no science to support this." Moreover, Paduda insists that the damage caused by the dispensing is real and lasting. A 2014 study of injured workers in Illinois found that those who received the care of a dispensing doctor were unemployed longer and received more drugs. And the financial costs do add up: Paduda estimates that through the practice of dispensing drugs at high prices, “it may lose $200 million” each year from the compensation system of American workers.

"This is the money these doctors and pharmacists stole from employers and taxpayers."

These concerns have not stopped a new generation of advocates from arguing that doctors can dispense medicines responsibly-this may be a way to help patients obtain medicines more conveniently and at a lower cost. Among them is Michael Garrett, a family doctor in Texas. About ten years ago, Garrett moved from Indiana to Austin, Texas. In 2014, he opened a direct primary care (DPC) clinic in the western suburbs of Austin.

In DPC practice, patients pay a fixed fee to facilitate medical treatment, while paying wholesale prices for laboratory tests and other medical services—including in states that allow doctors to dispense medicines. In the past decade, hundreds of DPC practices have emerged across the country. This model is popular among doctors who are frustrated with insurance companies. A disproportionate number of DPC doctors seems to think that Ayn Rand has an impact.

According to DPC doctors, their patients prefer this model for various reasons. Some people do not have health insurance. Others are insured, but want more doctor opportunities than usual. Garrett's clinic charges adult patients between $60 and $110 per month, depending on their age. Since he opened the clinic, his patient list has increased to 550 people.

In most states, one of the services provided by DPC doctors is to obtain wholesale medicines and distribute them directly to patients, usually with little or no price increase. As a doctor in Texas, Garrett cannot do the same. This rule disturbed Garrett. Like Lupod in Pennsylvania, he said that he often sat down with patients to help them review their drug costs. Using the online wholesaler catalog, he said, "I can pick up the medicine there, and I can see, oh, wow, I can buy a thousand of these pills for 8 dollars, and my patients will pay 8 dollars at Walgreens 30 pills.'”

A few years ago, Garrett and several colleagues lobbied the Texas Legislature to repeal the drug dispensing ban, many of whom were colleagues at DPC. Efforts to support dispensing have indeed won supporters, including Republican Representative Tom Oliverson from Cypress, a suburb of Houston.

Oliverson, a licensed anaesthetist, was widely praised for experimenting with bipartisan legislation aimed at lowering prescription drug prices. (The left-leaning "Texas Monthly" included him on the list of best legislators of 2019 based on this work.) He recalled that a group of doctors who supported dispensing showed him how to compare the cost of CVS diabetes medications with those available through the office. The rate at which the medicine is dispensed. "It's like saving 80%. This is shocking," he said. "Compared with wholesale procurement costs, the price increase for some of these drugs is simply fantastic." In 2019, Oliverson and two colleagues (one of them is a Democrat) Dispensing drugs is legalized, and doctors are prohibited from dispensing drugs, such as opioids. He said the resistance was "very strong." "It turns out that in Texas, as a large country, almost every House district has independent pharmacists. This is a problem they don't like very much." The bill died in the committee along with companions with the same goals. . (The same is true for another bill introduced this year.)

As the legislation was in trouble, the liberal legal organization "Institute of Justice" approached Garrett, hoping to join the lawsuit. he agrees. "I hope it won't take the litigation route," Garrett said. But "we failed by other means." He said that dispensing the medicine will enable him to best meet the needs of patients. "I really believe this is correct," he said. "I think it will make the world a better place."

The Institute of Justice has launched anti-regulatory cases in many states and has received funding from the Koch family, the De Vos family, and other major conservative donors. The organization’s lead attorney in charge of the case, Joshua Windham (Joshua Windham) said that Texas law “is not really designed to protect patients. It is designed to protect pharmacies from competition.” In Montana State, Wyndham and his colleagues recently filed similar cases there, and all three plaintiffs operate DPC practices.

The Texas Medical Association and the Texas Family Physician Association support efforts to allow doctors to dispense medication. The Texas Pharmacy Association did not respond to a request for comment, but CEO Debbie Garza told D Magazine in 2019 that the organization “opposes doctors dispensing medications and believes this practice puts the health and safety of patients at risk In."

So far, the lawsuit has not been successful: the Travis County District Court in Texas upheld the state's drug dispensing ban in December 2020. In a press release, the Institute of Justice said it would appeal the decision. (IJ dismissed the Montana case in May, when Governor Greg Gianforte signed legislation to end the state's dispensing ban.)

Oliverson said that his argument that doctors cannot safely dispense medicines is "suspicious at best." He emphasized that cost is a major issue for him: "In this era of high prescription drug prices, I think we need all the options on the table."

One argument for the Oliverson method is 1,200 miles north, in Grand Rapids, Michigan, where Belen Amat opened a small DPC clinic in 2017. Amat comes from Mexico. Most of her patients are Spanish-speaking people and work in factories and farms in the west of Michigan. She estimates that about 70% to 80% of them are uninsured. Some are undocumented.

Amat only stocks cheap generic drugs, which she sells to her patients at cost. She said that when patients need drugs that are not in her small inventory, she will place special wholesale orders for them. If the patient cannot come and pick it up, she just needs to drop it in the mail at the post office near her clinic.

"When people count money, if you can save some money on drugs, it's a big difference," Amat said. "It also helps with compliance. Now it's not a problem-can I take the medicine? You can afford it, and you can accept it." She said that since she started dispensing the medicine, who is taking the medicine and who is missing the medicine. Have a better understanding. "It opened my eyes," she said, adding that she knew better "because I was the one who gave them the medicine."

Lupold, a dispensing doctor in Pennsylvania, also runs the DPC clinic. Like Amat, he said that dispensing medicines helped him learn more about when his patients were taking or not taking medicines. Lupod is very friendly with the pharmacist on the streets of their town. He knows that his choice to dispense medicine may harm this man's business. "But that's the truth," Lupold said. "I have to do what I think is best for the patient."

When asked about the possibility that the doctor made a mistake in a conversation last fall, Lupold paused. "Let me speak carefully," he said, noting that some pharmacists were "excellent" in helping him deal with complex patients.

"Unfortunately, most pharmacists, in my opinion, most of them are button pushers," he continued. They are racing to deal with a large number of prescriptions. He said that sometimes the pharmacist would call him to double check a detail. But found a serious prescription error? "I can't tell you when it was the last time," Lupold said. "It's been 19 years since I left medical school."

When it comes to the issue of doctor dispensing, almost everyone agrees that the boundaries between pharmacists and doctors are changing-and some territorial encroachments are moving in the opposite direction, and many retail pharmacies are beginning to look and behave more like doctors Office. In 2006, CVS cooperated with Minute Clinic to open walk-in clinics composed of doctor assistants and practicing nurses in many pharmacies. These clinics provide basic health checks, vaccinations and other services. Other major national drugstore chains have also launched similar plans. These clinics were upgraded in August 2020, when the U.S. Department of Health and Human Services began to allow pharmacies to conduct routine child immunizations. The then HHS Minister Alex Azar said in a statement that this decision will make it easier for "our children to obtain life-saving vaccines."

Doctors resisted many of these changes, and they saw it as an infringement on their own field of practice. However, for some supporters of doctor dispensing, the fact that pharmacies open clinics should leave room for the clinic to make it more like a pharmacy. Garnet Coleman, a Texas Rep. and Houston Democrat, explained why he and Oliverson co-sponsored a doctor’s prescription bill. He said: “Things that are good for the goose Good for goose." "Traditional lines," he added, "is disappearing."

Physical pharmacies are facing fierce competition from a new model of providing drugs to patients. For a long time, mail-order pharmacy services have shocked traditional counterparts in particular. At the beginning of the Covid-19 pandemic, many people experienced a surge in new orders. In November 2020, online retail giant Amazon opened a mail-order pharmacy, promising to provide discounts and two-day free shipping to Amazon Prime members. The stock prices of CVS and other drugstore chains plummeted.

For Trent Jefferies and VendRx, the upheaval in pharmacies has not yet translated into a lot of business. Only 10 fully automated vending systems are running. Recently, the company launched a more streamlined product, similar to an airport check-in kiosk, which can handle the sale of medicines, but does not actually distribute medicines.

Nonetheless, Jeffries envisioned a future where, for cost and convenience, most patients get their medicines by mail, courier or from their doctor's office. He believes that in that world, most physical pharmacies will disappear. The rest will help doctors manage new or unusual drugs, and they will act as hubs to provide services to a network of automated dispensing stations.

Jefferies compared VendRx to Redbox-Redbox is a ubiquitous automated DVD rental kiosk located outside grocery stores and gas stations across the United States. He asked, why did Redbox help kill the brick-and-mortar rental company Blockbuster? Because people want convenience. Although Redbox faces new competition from streaming services such as Netflix, Jefferies is more confident in the future of pharmacy alternatives: "You can't stream drugs."

 This article has been updated by Undark to clarify that in addition to funding from the insurance industry, the Work Injury Compensation Institute also obtains funding from other sources.

This article was originally published in Undark. Read the original text.

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