The 'Unattainable Triangle' of Community Pharmacy

Quality, speed, and price has been referred to as the "Unattainable Triangle". Fast, good, cheap-pick 2. Every business faces this question every time the doors are open for business. You can’t possibly have all 3. When you try to improve 1 side of the triangle, the other 2 sides will be impacted.

PRICE: Price seems to get the most attention. The monetary aspects of our profession seem to govern most of its workings. The insurance companies and government have put the squeeze on the community pharmacies for the last 4 decades-they want lower and lower prices; our patients want lower and lower prices. It comes at a price. Most pharmacies are always cutting staffing to satisfy the demand for the price side.

Many patients are forced to go to one of the preferred chains in their insurance company’s “preferred network”. They get a 90-day supply for the same price as they would pay for a 60-day supply at my pharmacy, if I’m not in their network. A family member recently went to one of the preferred pharmacies in his insurance plan’s network to get the new nasal glucagon. The cashier asked the obligatory question “do you have any questions for the pharmacist?” He replied “Yes, I do; how do you work this thing?” The pharmacist hurriedly came out read him the directions on the box and said, “use it like any other nasal spray.” That is not how you use the nasal glucagon. My relative got a good price from the preferred pharmacy, but the quality sure wasn’t there. Thank heavens he has a relative in the profession!

SPEED: In the store I have staffed for the past 11 years, we have a huge Medicaid population. It never ceases to amaze me that the first question a patient asks is “how long is it going to be?”

I smile and tell them “10 minutes, it is always 10 minutes” I tell my student pharmacists that you only have to know 3 answers to staff the pharmacy: 10 minutes (how long); we won’t know until we run it through your insurance (how much); no we don’t (have a public bathroom!). Price doesn’t matter to our Medicaid population, speed does.

QUALITY: This is the aspect of the Unattainable Triangle that appeals to me the most as a pharmacist. I frequently hear pharmacists describe how they can “bust out” 400 prescriptions in an 8-hour shift. It scares me. Today at the pharmacy I had a bag flagged for consultation. It was a 15-year-old who was put on Flovent 110, who was new to my store. Her mom was in to pick up the prescription. She informed me that her daughter was on this medication and this was a dosage increase. In my usual fashion, I continued with my speech about mechanism, adherence, and of course rinsing and spitting after each dose.

The mom said, “We’ve never been told that before, I’ll have her come in.” I described how inhaled corticosteroid therapy worked and the importance of adherence, as well as rinsing and spitting. The daughter agreed to use her Flovent in the morning before school and at bedtime before brushing her teeth. I went further and gave her a free peak flow meter from my stash. I set her peak flow meter and instructed her on its appropriate use and handed her an asthma action plan. They were both delighted with the quality care I provided. We both sacrificed speed for a quality engagement.

Our owners struggle with the triangle, but think about our individual struggle with the triangle. How many of us are in low quality, high stressed jobs because of our “price” (salary)? In a fulfilling pharmacist career, the focus is always on quality.