Filling 12-month prescriptions is one practical way to help the pharmacist crisis

Pharmacies could be called the most “rock solid” entity in our health care system. Even before Covid, pharmacies were held in high esteem; during the pandemic, they raised their game by making it easy for tens of millions of Americans to get vaccinated, fulfilling a long-standing ambition of pharmacists to provide more expansive clinical services.

But in recent months, it has become clear that pharmacists, and pharmacies, are fed up with working conditions. Recently, many overwhelmed pharmacists at chains, including Walgreens and CVS, have organized walkouts, saying that they are worried their working conditions are unsafe for patients who depend on their attention to detail.

The ramping up of pharmacies as care centers may have been part of this: Companies may not staffed up adequately, creating some risk to safely dispensing medications. To paraphrase from the song by Johnny Mercer, something’s gotta give.

One would assume that increased revenue to pharmacies from new clinical services enabled pharmacies to add staffing. However, at the same time pharmacies were growing revenues, it appears they were being reimbursed less by insurers. This pressure has pushed pharmacies into an uncomfortable set of choices: 1) Make less money by scaling back clinical services, 2) add more labor, or 3) just do more with the same amount of resources. Some pharmacists are saying that the corporate owners of pharmacies have chosen the third option. If that’s true (and it seems to be the case), I have one idea for something that might help: increase the use of 12-month prescriptions, by which I mean not prescriptions that are valid for a year, but those that you have to fill only once to receive a year’s supply.

The other solutions all seem like nonstarters. The pharmacists organizing the walkouts might most want more staffing to help, but that’s unlikely to happen given the immense pressure to meet Wall Street earnings expectations. Nor are pharmacies interested in losing or transferring patients that causes a drop in prescription revenues.

Getting higher reimbursement from insurers seems awfully unlikely, too. From a strategic perspective, it doesn’t make sense for chains to stop offering the valuable clinical services that proved vital during Covid and are diversifying their financial model for the future. And yes, pharmacies can close unprofitable stores, but unless they reinvest savings into more labor for overworked stores, it might not change working conditions in the busiest of pharmacy locations.

So dispensing fewer prescriptions seems like a great solution. Specifically, instead of dispensing 30- or 90-day prescriptions, convert patients to receive six or twelve months of medication in a single prescription pick-up. I’m not talking about new prescriptions a patient is trying for the first time, where titration is still occurring, or controlled substances. I’m talking about the long-term chronic medications on which a patient is stable on therapy.

According to IQVIA data, 4.5 billion prescriptions (unadjusted) were dispensed in the U.S. in 2022. Nearly a quarter of them — 1.1 billion —were 90-day. If 75% of these 90-day prescriptions could be converted to 12-month fills, it would reduce total prescriptions dispensed by roughly 18% (825 million). No doubt a reduction of this magnitude would help reduce pharmacist workloads. It seems almost obvious to say, but dispensing a prescription once per year is three fewer opportunities for error than dispensing every 90 days.

Dispensing six- or 12-month supplies of medication was largely unthinkable a few decades ago when brand medications were roughly half of all prescriptions dispensed and the cost of these medications was much higher. Most insurance plans shied away from the risk of paying for unused medication that might cost hundreds or thousands of dollars, hence we typically had 30-day fills that eventually became 90-day fills.

Today, more than 90% of prescriptions are for low-cost generic medications that typically cost pennies per pill. As such, if a patient receives 12 months of medication instead of a 90-day supply, the incremental cost may be only a few dollars, certainly not more than $10 or $15 for the entire supply. Quite often, the majority of a cost in filling an inexpensive generic medication is the pharmacy labor and overhead instead of the actual cost of the pills. As it turns out, receiving one prescription versus four can make a lot of financial sense for patients (especially those who must drive and pay for the gas or pay delivery fees).

Pharmacists themselves think it’s a good idea. A 2021 study conducted by Ipsos asked 400 U.S. pharmacists and physicians what they thought of dispensing six- and 12-month prescriptions, and 74% of pharmacists said they would like to dispense these prescriptions to patients on long-term stable regimes if they could. Seventy-three percent said it would be safe for patients, with 81% agreeing it would save patients money and 92% saying it would save patients time.

Physicians were even more supportive of the idea, with 89% of physicians saying they would like to write prescriptions for six or 12 months. Eighty-four percent of physicians and pharmacists agreed that prescriptions longer than 90 days could improve adherence. And a whopping 91% said it would reduce administrative burdens for their practices.

Getting pharmacists, physicians, and patients onboard with six and 12-month prescriptions isn’t the biggest obstacle. Nor is policy: State pharmacy laws already allow physicians to write a prescription for a single dispensation of up to a 12-month supply of a maintenance medication if the patient is paying cash. (Controlled substances are excluded.) In fact, insurance companies that cover federal employees who spend extended time overseas actually instruct beneficiaries how to get prescribed and dispensed a 12-month supply of medication.

The real challenge is getting insurance companies to cover six- and 12-month supplies for select maintenance medications for all beneficiaries. The vast majority of patients use their insurance for prescriptions, especially because many medications suitable for extended fills have no copay or a very small copays (such as $10).

The good news is that of the two major chains where pharmacists have spoken out, one, CVS, is owned by a very large insurer who could make this idea a reality. It appears they may already have done so for employees and beneficiaries at NYU, where 180-day fills are covered through mail order. Allowing other plans to participate in six- and 12-month fill programs might even help clients save money, on both prescriptions and medical costs from non-adherence. There’s no doubt it would reduce some of the burden on these overworked pharmacists.

I once managed a pharmacy that provided six- and 12-month cash prescriptions to patients, and I can say that it works well once providers are educated about the option to prescribe extended quantities. Now, as a patient who now gets a 12-month supply of medication from a retail warehouse pharmacy, I absolutely love it. My doctor does, too — and, I bet, so do the pharmacists who only have to see me once a year.

Stephen Buck is a pharmaceutical supply chain expert.