Since 1994, Amazon has sold the world on a vision of boundless, hyper-accessible goods and services driven by an obsessive focus on data, logistics and user experience. As a health crisis reshapes human life, Amazon’s latest pharmaceutical initiative is a topical addition to its promise of plenty.
On Nov. 17, Amazon opened an online drugstore at pharmacy.amazon.com, a project several years in the making. The announcement of the company’s acquisition of digital pharmacy PillPack in 2018 immediately dropped the share prices of retailers like Walgreens, Rite Aid and CVS, reflecting an industry fearful of Amazon’s dominating presence. The logistical savvy, size and convenience Amazon brings to a new market can devastate its entrenched leaders, as it did with Barnes and Noble, Sears and entire shopping malls.
Obstacles associated with the healthcare sector—regulation, complex administration and the need for connections—typically slow down rapid innovation and initially spared it from Amazon’s presence. To be approved as a digital pharmacy by the National Association of Boards of Pharmacy (NABP), Amazon needed to obtain pharmacy licenses in every state. Amazon also needed relationships with pharmacy benefit managers (PBMs), which connect patients and pharmacies with health insurers. Acquiring PillPack provided the company with licenses in all 50 states, connections with the PBMs Express Scripts and CVS Health and a delivery system of easy-to-use packages of pills.
However, Amazon’s move into medicine is looked at with sharp skepticism by some. Dr. Gareth A. Edel, university lecturer from NJIT’s humanities department, believes that these barriers to entry are not sufficient to ensure that Amazon will provide the same quality services in an ethical fashion.
“I’m concerned about a private company having healthcare access to information that’s not bound by HIPAA laws directly, or it is unclear if they’re bound by HIPAA laws,” Edel said. “I’m concerned about any of these companies having package security for life saving drugs: if they’re using the consistent pattern of delivery that they’re using for everything, they’re largely using second-hand outsourced workers, and it’s local companies that are contracted to drive Amazon vans that are picking up increasingly large amounts of the delivery. If you’re delivering expensive drugs, packages getting lost in the mail becomes an increasing problem. All of which may or may not happen, but it becomes that much more difficult to worry about.”
Edel teaches a senior seminar at NJIT called “Globalization and Medicine,” where topics are discussed such as professionalization within medicine—doctors vying for control of what is considered “medicine” versus “alternative medicine” or “not medicine”—and the introduction of technology in medicine.
“We talk in my class about the professionalization of medicine. And in the U.S. that is much more exclusionary towards pharmacists where doctors see pharmacists as competitors and don’t want them to have the authority to participate. In other countries, that role of pharmacists is much more active, and much more collegial and collaborative with doctors. But in the U.S. [it isn’t], and that process began before giant corporate pharmacies, it intensified with large corporate pharmacies which saw the expense of a pharmacist as being both a large expense in and of itself, but also one that can be decreased by having that pharmacist check off more and more prescriptions with less trained people doing more and more of the work.”
This trend away from the pharmacist acting as a healthcare practitioner, according to Edel, becomes an issue when considering legal implications. According to the laws surrounding pharmacy, written well before large chain pharmacies and mail-order pharmacies existed, the pharmacist is ultimately liable for the delivery and quality of the medication as well as the education of the patient. However, economic incentives have moved pharmacists to more of a supervisory role, with patients losing direct contact with the pharmacist and instead agreeing to terms and conditions at the point-of-service.
“In some ways,” Edel said, “this is a great business model for Amazon because they have a built-in fall guy in the form of a licensed healthcare practitioner who gets to sign off, because Amazon doesn’t have to maintain expertise—those pharmacists do.”
Another concern Edel expressed is that Amazon has a tendency to interweave their businesses together and create “user profiles.” Thus, the advanced data collection systems of Amazon bring together your Alexa queries, Whole Foods shopping tendencies and what was in your Amazon shopping cart. Adding personal health information to this mix could potentially be a violation of U.S. health information privacy law, as all of the businesses within Amazon could have access to patient information outside of a healthcare setting, however there is no precedent for this kind of action.
“I just don’t like the idea of transporting that onto an internet platform without any visibility or transparency to what those security issues, what those informational issues [and] what the long-term health challenges are for those things,” Edel said.
If Amazon does come into violation of the law, they are also harder to litigate against than smaller pharmacies. Edel said that “the size of Amazon and their incredible economic power means that they are less likely to be punished if they do something wrong than some generally small online pharmacy. The reality is that Amazon has been sued for all sorts of things, but Amazon is big enough and popular enough, and it’s difficult to imagine the federal government…going after Amazon for breaching what are fairly arcane and uninteresting-as-a-media-issue laws about public health information versus private health information.”
Despite the concerns, there is still the possibility that Amazon Pharmacy will prove to be a better alternative to current systems. Since patients are treated more as customers in the pharmacy now, and the consultation with a pharmacist has been all but replaced by checkboxes at the checkout line, a well-designed online platform may give patients a more relaxed environment to be properly consulted. Ideally, the health information would be put behind a strict firewall and kept separate from the rest of the Amazon system. Ideally, a large team of pharmacists would be overseeing the operation and ensuring that the patient comes before the profit. Ideally, Amazon would make the delivery and quality control of medications as safe as possible. At this point, we just do not know.
However, Amazon has not historically modeled themselves to the businesses they acquire, rather fitting businesses into their model. “Even a giant like CVS,” Edel said, “which came out of being a pharmacy first, has a strong connection to traditional medical ethics, and the legal requirements are clear. Those [of Amazon Pharmacy] are less clear, and there are none of those medical ethics applied to what is effectively not a healthcare company in the case of Amazon.”
Amazon’s push into pharmaceuticals has come with its fair share of criticism, but it has proven to be more of a statement on the broader direction of pharmacy today. Amazon is not the first online pharmacy, and they are simply expanding their business mindset into an industry that has already put business above patient care. “In an ideal case,” Edel said, “a pharmacist is both not just participating in informed consent with a patient but actually in the educational process with the patient, but then they’re also acting as an expert, who collaborates and assists the doctor. And as we decrease in practice both of those roles for a licensed pharmacist to be doing, we decrease both their authority to participate, but also literally their ability to help us have the right kind of drugs and the right kind of care. I think we lose something.”