Amazon is now in the pharmacy business

Amazon announced just before Thanksgiving that it was entering the pharmacy business. On its face, this is a good thing. Amazon has grown so large that it is a de facto arm of the federal government, and it is incorporated as much as utility companies into many of our lives. The move isn’t sudden; some analysts have framed this as a natural extension of their 2018 purchase of PillPack, a pharmacy service to coordinate, organize, and deliver prefilled medication containers. So we can be confident Amazon will offer efficient, seamless delivery and good prices, two things that are often missing from our experience in American health care. It’s no surprise, then, that the announcement was catastrophic to the stock price of several pharmacies whose shares fell by a tenth or more. GoodRx, a quasi-pharmacy benefit manager (PBM) designed for discounts for uninsured and underinsured patients, lost a fifth of its value.

How it works

Amazon Prime customers will get medications delivered for free within two days. They’ll also qualify for discounts of up to 80 percent off generics and up to 40 percent off brand-name drugs. (some have pointed out that people who can’t afford Prime will be cut out of these offerings, an example of a systemic problem in American health care that Amazon won’t or can’t fix)

I did a quick road-test of Amazon Pharmacy today. The interface is, as one would expect, pretty intuitive and slick. If nothing else, Amazon has mastered simplicity. Just by seeing my routine demographics and the last four digits of my social security number Amazon was able to find my insurance information automatically, a task which I can tell you from both the physician side and the patient side is not easy. Then, after entering medications I currently take, I was given the option of transferring those prescriptions from my current pharmacy. I did not do this (my commitment to this project only goes so far), but it looked like the process would have been seamless on my end. I do not know what nightmarish snarl of paperwork it may have generated for my existing pharmacy or my doctor, though.

Allegedly, were I to have gone ahead and tried to check out, I would have been shown two prices: one with my insurance benefits, and one with my Prime discount. I would have chosen my preferred price, and the medication would have been delivered within two days. It remains to be seen how Amazon Pharmacy would handle one-off prescriptions for an infection or injury, although their same-day delivery in cities and by drone aircraft point toward that being a future feature.

Where do pharmacists fit in?

But the practice of pharmacy is more than the cheap, reliable delivery of medications. We at KBGH see pharmacists not as people who take pills out of a big bottle and put them into a small bottle to sell to you, but as highly trained medical professionals [note: KBGH has CDC funding to promote, among other things, team-based patient care including pharmacists]. Pharmacists’ training is toward the upper end of medical professional training in terms of time and testing requirements. After a minimum of two years of undergraduate classes with strict prerequisites (and some schools require additional coursework), pharmacists since 2000 have universally completed a Doctor of Pharmacy (Pharm.D.) degree, a four-year professional degree program which makes them eligible for licensure by their state Board of Pharmacy. The Pharm.D. degree is often followed by one or two years of a postgraduate residency program to increase the pharmacist’s depth of knowledge in a specific area of focus like inpatient care or chronic disease management. Pharmacists interested in research may do fellowship training beyond residency.

Pharmacists, like physicians, utilize “extenders” and technologies to increase their capacity. This theoretically allows pharmacists to spend more time on direct patient care roles like providing evidence-based medication recommendations, monitoring therapeutic responses to drugs like anticoagulants and blood pressure medications, and reconciling medications as patients transition from one care setting to another.

Pharmacists are capable of contributing to extraordinary patient outcomes. A meta-analysis of randomized trials, for example, showed that pharmacist + physician dyads are much more effective than physicians alone in treating patients’ cardiovascular risk factors. Teams with pharmacists had patients with blood pressures 8.1 mmHg lower, bad cholesterol levels 13.4 mg/L lower, and a 23 percent lower likelihood of smoking:

Some pharmacists, in collaboration with other practitioners, offer testing for high blood pressure, infections like strep throat, and markers of chronic disease management like cholesterol and blood sugar levels. In 2015 the State of Kansas authorized the creation and use of “Collaborative Practice Agreements” between pharmacists and physicians for patient care. Amazon Pharmacy has promised to try to virtually recreate the “counter conversation” with the pharmacist that many people desire, so while it is hard to see Amazon tiptoeing into the collaborative practice water any time soon, it is not impossible to imagine long-term. Amazon already offers telemedicine to its employees. Expect telemedicine for the rest of us next. And expect those telemedicine providers to work with Amazon Pharmacy somehow as the company learns what it takes to provide more comprehensive physician-pharmacy services. Maybe PillPack’s existing expertise in counseling will translate into more traditional brick-and-mortar pharmacy-style interactions. With time, it seems inevitable that Amazon will be labeled a preferred pharmacy for most health insurance plans. After that, it will surely follow CVS’s lead and become or acquire a PBM.

Staying out of stores is unquestionably safer in the COVID-19 age, a system-delivered advantage for Amazon. So if your employees begin using Amazon Pharmacy I’d make sure they know some basics, like that if they opt not to use their insurance but instead just take the Amazon Prime discount, their purchase may not count toward their health insurance deductible.

But for now, for complex patients with complex medication regimens that include potentially dangerous, potentially interfering drugs, the use of a community pharmacy familiar with your employees seems the most prudent course. Many community pharmacies already offer delivery and PillPack-like services designed for ease of drug administration, all with a more recognizable over-the-counter pharmacist interface. Grocery stores adapted when Amazon bought Whole Foods, and I would expect pharmacies to do the same.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.