Is Walmart Blacklisting Doctors?

By Pat Anson, PNN Editor

Carolyn Eastin has been a nurse practitioner in Arizona for nearly a decade. She is the only licensed prescriber at a busy pain clinic in Scottsdale, where many patients are on high doses of opioid medication.

Eastin says she was “mortified” by a letter last month from Walmart’s corporate headquarters that said the retail giant’s Walmart and Sam’s Club pharmacies would no longer fill her prescriptions for opioids.

“In reviewing your controlled substance prescribing patterns and other factors, we have determined that we will no longer be able to continue filling your controlled substance prescriptions,” the letter states. “We regret any inconvenience this may cause you or your patients.”

“It was very humiliating. I was upset about it,” says Eastin. “We’ve already had patients who can’t get prescriptions there.”

The unsigned Walmart letter has all the appearances of a form letter. It makes no mention of any complaints against Eastin, whether any of her patients have overdosed, or if her prescribing is medically inappropriate.

Eastin writes prescriptions for nearly 500 chronic pain patients at the Absolute Rehabilitation and Pain Medicine clinic. Most are on high doses of opioids, at levels well above those recommended by the CDC in its 2016 opioid guideline. Eastin believes she was red flagged by Walmart after a prescription database search and is now on a “blacklist” of prescribers.

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“I’m the only one who writes prescriptions here. So I would have higher numbers than the average nurse practitioner,” she told PNN. “I’m not doing anything wrong. I’m tapering my patients. I’m trying to do my part to bring people into compliance.”

Does Walmart blacklist doctors who prescribe high doses of opioids? Is Walmart practicing medicine without a license? We posed those questions to Walmart and received a one sentence reply.

“Walmart does not comment on our patients or their prescribers,” wrote Erin Hulliberger, Walmart Corporate Communications in an email.

Corresponding Responsibility

What Walmart is doing isn’t illegal. Under federal law, pharmacists have a “corresponding responsibility” when filling medications -- a legal right to refuse to fill prescriptions they consider unusual or improper. Most pharmacists will call the prescribing doctor to double-check before turning away a patient, but in some cases there’s a “hard edit” – pharmacy jargon for when a company database tells a pharmacist not fill a prescription.

“It may be appropriate for a pharmacy to not fill a prescription because of a dangerous dose or even an inappropriate drug,” says Lynn Webster, MD, a pain management expert and past president of the American Academy of Pain Medicine.

“However, if they are refusing to fill a prescription because the doctor has met some arbitrary dosage threshold by the company without understanding the circumstances, it would be inappropriate and potentially harmful to the patient.”   

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A former Walmart pharmacist told PNN the company closely monitors prescriptions and doctors at every store.

“They had assembled prescription numbers for every doctor who had filled prescriptions at my store. They knew the exact number of medications ordered and sold down to the tablet. They knew what drugs the doctors wrote for and what percentage of the total each drug they wrote for," said the pharmacist, who asked to remain anonymous.

Walmart recently began using Narxcare, a private healthcare database developed by Appriss Health, which analyzes the prescriptions and medical claims of millions of Americans. Every patient evaluated by NarxCare is assigned a “risk score” based on the past two years of their prescription drug use, medical claims, electronic health records and even their criminal history.

Is Walmart using Narxcare data to blacklist doctors? A spokesman for Appriss denies it.

“No, we do not provide provider risk scores to Walmart, or anyone else,” said David Griffin, Vice President of market and communication for Appriss Health.

Prescription Data Mining

The data mining of opioid prescriptions has become increasingly common in healthcare and law enforcement. Doctors, pharmacies, insurers, and federal and state regulators are all using prescription drug databases to look for signs of opioid “overprescribing.”

In addition to Walmart, the Absolute clinic has drawn the attention of the Arizona Medical Board. Last year the clinic’s owner, Dr. Steve Fanto, signed an agreement with the medical board to stop practicing medicine after he was accused of overprescribing Subsys, a potent fentanyl spray.  

Although Fanto is no longer involved in the day-to-day management of the Absolute clinic, it remains under scrutiny. Last December, the clinic was raided by DEA agents, although no charges were ever filed as a result of that investigation. The clinic has also received over a hundred letters from insurer United Healthcare warning about the high dose prescriptions Carolyn Eastin is writing.

“It’s a bullying technique,” says Jessica Webb, the office manager at Absolute. “We’re afraid if we don’t taper down, the insurance companies will file a complaint on Carolyn. If Carolyn’s license is revoked, we’ll have to shut down. She’s the only reason we’re still open.”

Caught in the middle of this tug of war are Absolute’s patients – who could be faced with the difficult task of finding new doctors if the clinic closes. Their painful medical conditions -- and the human suffering that comes with them – appear to be non-factors in Walmart’s decision not to fill Eastin’s prescriptions.

“I can’t tell you the number of patients that made the comment to me, ‘I might as well die. I don’t have any other options but to take my own life because I can’t live without this medication,’” Eastin said. “It’s very difficult to look these people in the eye every single day and say, ‘I want to help you but I’m going to take more away from you.’”

‘I Hope It Doesn’t Harm Patients’

Pain management experts say its unethical to use data mining alone to judge whether a prescription should be filled.

“It appears that Walmart is trying to reduce their risk of being charged with criminal conduct and paying more fines. It is hard to know. But whatever their reason I hope it doesn't harm patients,” said Webster.  

“Without further explanation about the basis for their decision, and without information about any previous interventions attempted by Walmart, this seems remarkably punitive and capricious,” said Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management.

“I would hope that companies that review prescriber records would attempt a series of less drastic interventions with the prescriber before reaching this point. There may be issues of concern, but the appropriate step is to discuss those with the prescriber and try to reach an understanding about what is going on, and about what needs to happen to ensure that everyone is prescribing and dispensing safely. I’d be interested to hear from Walmart about whether they have such a graduated policy and if not, why not.”

Carolyn Eastin says there’s only so much she can do. Abruptly tapering patients or cutting them off from opioids could cause more harm than good.

“We’re trying to follow the CDC guidelines. We’re trying to comply with the insurance letters asking for tapers,” she says.  “I’m doing my part to taper my patients. But these things have to be done delicately. We just can’t go, ‘Okay, give me all your meds.’”  

“We’ve pushed them to get physical therapy and cognitive behavioral therapy, and patients are having good results with that,” says Jessica Webb. “But we have some patients, if I had to take their meds away, I couldn’t go to sleep at night. They’re that sick.”   

Walmart to Limit Rx Opioids for Acute Pain

By Pat Anson, Editor

Walmart has announced plans to restrict opioid prescriptions for short-term acute pain to no more than a 7-day supply.

The new policy, which is similar to one already adopted by CVS, will begin “within the next 60 days” and be implemented at all Walmart and Sam’s Club pharmacies in the United States and Puerto Rico.

“We are taking action in the fight against the nation’s opioid epidemic,” Marybeth Hays, executive vice president of Health & Wellness and Consumables for Walmart U.S. said in a statement.

“We are proud to implement these policies and initiatives as we work to create solutions that address this critical issue facing the patients and communities we serve.”

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In addition to the 7-day limit on opioids for acute pain, Walmart and Sam’s Club pharmacists will also limit the dose to no more than 50 morphine milligram equivalent (MME) units per day. The company said its policy was “in alignment” with the Centers for Disease Control and Prevention’s opioid guidelines.

However, those 2016 guidelines are voluntary and only intended for primary care physicians who are treating chronic pain. They say nothing at all about pharmacists being required to limit the dose or duration of opioid prescriptions for acute pain:

“When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”

Several states have already adopted policies that limit opioid prescriptions for acute pain to seven days or less. Walmart said when state law limits prescriptions to less than seven days, Walmart and Sam’s Club pharmacists will follow state law.

The company’s pharmacists will also be trained and required to counsel patients about the CDC’s guidelines, while “focusing on using the lowest effective dose for pain management for the shortest time possible.”

In 2020, Walmart and Sam’s Club will also require e-prescriptions for controlled substances such as opioids. The company said e-prescriptions are less prone to errors, cannot be altered or copied, and are electronically trackable.

By the end of August 2018, Walmart and Sam’s Club pharmacists will also have access to a controlled substance tracking system called NarxCare. NarxCare analyzes a prescription database to provide pharmacists with a patient’s “risk score” for potential drug abuse.

Would You Support a Boycott of CVS?

By Pat Anson, Editor

One of the most talked about issues in the pain community over the last two weeks has been CVS Health’s announcement that its pharmacists would soon start restricting doses of opioid pain medication and limit the supply of opioids for acute pain to 7 days.

The policy only applies to customers enrolled in CVS Caremark’s pharmacy benefit management program, but it quickly triggered an online backlash from pain patients – including many who called for a boycott of CVS.

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“I refuse to patronize companies that practice medicine without a license,” wrote Jeannette on PNN’s Facebook page.

“Don’t go there anymore. Hit them in their pocketbook,” wrote Lauren.

“I very rarely use a CVS and will never go there for prescriptions or anything else,” said Jackie.

“I left CVS years ago for Walgreens and I’m guessing many more will be doing so,” wrote Amanda.

"CVS has some nerve. The use of opioids, or any other drug, really, is up to the doctor and his or her patients, not a pharmacist. This is a terrible precedent, which will drive an even bigger wedge between physicians and patients,” cardiologist Arthur Kennish, MD, told the American Council on Science and Health.

The CVS boycott soon had its own hashtag on Twitter.

“Wrong way to handle, CVS! I will join the #BoycottCVS. You make it more difficult for the sick w/ no impact on the crisis,” Stephanie tweeted.

The online outrage even spilled over onto CVS’ Facebook page, where many negative posts were apparently deleted by the company.

“CVS Pharmacy, why did you take down all your Posts and comments regarding your big announcement over overriding doctor's orders and limiting patients' rights to their pain medication?” asked Lauri. “Where did they all go?”

People are so passionate about this issue that we started an online poll asking if they would support a boycott of CVS. Click here if you’d like to participate.

Would a Boycott Work?

But while there’s plenty of online enthusiasm for a boycott, it’s unlikely to be effective without the support of patient advocacy groups.  An informal survey of pain organizations by PNN found most were critical of CVS’ decision, but opposed to a boycott.

“I think boycotting CVS is not a good idea. I think a better idea is working with them for better care and finding the good in what they are doing and amplifying the bad.  They want better education, they want better disposal, and many other things we all fight for,” said Paul Gileno, President of the U.S. Pain Foundation.  “I don't think a boycott would work or be effective and can come across in a negative way. We need a loud conversation with CVS.”

“I don’t typically like boycotts” said Barby Ingle, President of the International Pain Foundation and a PNN columnist. “But if enough people have a bad experience or don’t like the CVS policies, they will see a drop in the market and will have to reevaluate what their policies will be.

“I wouldn’t call it a boycott, I would call it a shift in patients understanding that we have power and that we can choose to go to the healthcare places that fulfill our needs. Unless CVS changes their practices, I can see them continuing to lose business.”

Penney Cowan of the American Chronic Pain Association did not respond to a request for comment.

One patient advocate who gave full support for a boycott was Cynthia Toussaint, the founder of For Grace, a non-profit that supports women in pain.

“The lack of patient advocacy support for the boycott is totally surprising,” Toussaint wrote in an email. “We’ve all been beating the ‘don’t get between a doctor and a patient’ drum for years, and now that we can put our names behind that, we’re being sheepish.

“For Grace is ON BOARD with the boycott! This is chilling news for the pain world - and I hope our support helps many people. We understand CVS’s very real concern about the opioid crisis, but this new policy is too heavy handed and will greatly harm the chronic pain community!”

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CVS is not the first pharmacy to restrict access to opioid medication. In 2013, Walgreens gave its pharmacists a “secret checklist” to help them screen patients with opioid prescriptions. Any red flags, such as a prescription written by a new doctor or a patient paying in cash, could result in a prescription not being filled. The policy was implemented after Walgreens was fined $80 million by the Drug Enforcement Agency for violating the rules for dispensing controlled substances.

CVS has also been fined hundreds of millions of dollars for violations of the Controlled Substances Act and other transgressions, many of them involving opioid medication.

A Florida pharmacist who was fired this year by Sam’s Club for not following the company's opioid policy says pharmacies are driven by profit, not patient care, and a boycott is unlikely to change their bottom line. 

“Patients won't need to boycott. CVS doesn't want the business anyway,” says Karl Deigert, who was fired after complaining that patient rights were being violated at Sam’s Club, which is owned by Walmart.  “Corporations are only acting in their own best interest and have no concern for the patient. Patients can save their breath and energy as any complaints filed will fall on deaf ears. 

“Overzealous corporate policy makers have no desire or interest to protect the patients' well-being. Their policy making is self-serving to protect their assets from DEA scrutiny and monetary penalties. The corporations and the majority of retail pharmacists simply do not care to help the chronic pain patient population.”

The new opioid policy at CVS doesn’t go into effect until February 1, 2018. But CVS Caremark is already tightening the rules for some opioid prescriptions. 

A Caremark client who has been getting fentanyl pain patches at CVS for years was recently notified by letter that new limits are being placed on the patches “to help ensure that your use of opioid medication for pain management is safe and appropriate.” 

But is it really about safe and appropriate use?

The letter goes on to say the patient will still be able to get the fentanyl patches, but without prior authorization they “will have to pay 100 percent of the cost.”