What Do We Want Community Pharmacy to Be?

On Monday, I read a great article in Forbes about the collapse of chain drugstores.

It did a fantastic job of briefly recapping the history of pharmacy and touched on many of the things I’ve written about in Drugstore Cowboy (spoiler alert: PBMs stink). I highly encourage you all to check it out. Towards the end, it poses a deceptively simple question:

It’s an amazing question. And it’s one that almost never gets answered by the people most qualified to answer it.

Most conversations about pharmacy today happen far away from pharmacy counters. They take place in boardrooms, policy panels, earnings calls, and white papers. They are framed by people who see pharmacies as line items, distribution channels, or cost centers — not as places where medicine actually happens.

So today, I’m going to answer the question directly.

I’m a fourth-generation pharmacist. I run C.O. Bigelow, the oldest operating pharmacy in America (since 1838). My family has practiced pharmacy through pandemics, wars, the creation of modern medicine, insurance, chain consolidation, PBMs, mail order, algorithms, and now artificial intelligence.

I’ve watched this profession be slowly stripped of nearly everything that once defined it — except the responsibility.

And that gives me a very clear vision of what we should want community pharmacy to be.

Before we talk about what pharmacy should be, we need to be honest about what the system already treats it as.

If you look at how pharmacies are paid, regulated, and managed today, the answer is obvious.

The system wants pharmacy to be:

As I’ve written about extensively over the past few months, community pharmacies are reimbursed below cost and told to “make it up on volume.” They are forced to front cash for drugs they may never be fully paid back for. They are punished for spending time with patients. They are rewarded for dispensing more, faster, and earlier.

Mail-order pharmacies oversupply medication because the system pays them to. Auto-refills ship drugs patients didn’t ask for because inertia is profitable. Algorithms deny coverage and leave pharmacists to explain decisions they didn’t make.

If you follow the incentives, the system’s answer is clear:

Pharmacy is meant to process medication, not practice medicine.

It’s that simple.

And once you see it, you start seeing it everywhere.

When a PBM denies a medication, who gets yelled at? The pharmacist.
When a copay jumps from $10 to $400, who has to explain it? The pharmacist.
When a formulary changes overnight, who calls the doctor, proposes alternatives, and cleans up the mess? The pharmacist.

We have become the front desk of a system that refuses to face its own incentives. And the tragedy is that people think the front desk is the system.

For decades, pharmacists were told there were strict limits to what they could do. Despite four years of intense schooling and a doctorate degree…

We couldn’t diagnose.
We couldn’t prescribe.
We couldn’t initiate therapy.
We couldn’t be trusted with more responsibility.

Then COVID happened.

And almost overnight, those limits disappeared.

Pharmacists assessed patients. We triaged risk. We administered vaccines at scale. We counseled on side effects. We managed shortages. We operated with real clinical autonomy.

And something important happened.

The healthcare system didn’t collapse.
Doctors weren’t replaced.
Patients weren’t harmed.

The only thing that collapsed was the idea that pharmacists were incapable of doing more.

COVID didn’t expand the role of pharmacists. It exposed how artificial the limits were in the first place.

We didn’t suddenly become smarter in 2021 or spontaneously develop new skills. 

We were trained for this all along. We just weren’t allowed to do it.

And for a brief moment, when the country actually needed access, speed, and competent triage in real communities, the system admitted something it usually denies:

Pharmacists are a clinical workforce.

That’s the part that makes people uncomfortable.

Pharmacists are clinicians.

We are trained to diagnose straightforward conditions, manage chronic therapy, initiate medications under protocols, adjust doses, deprescribe, interpret labs, identify interactions, and manage population health.

And we already do much of this — informally, quietly, and often without compensation.

Every day, pharmacists catch errors before harm occurs.

Every day, we explain medications doctors didn’t have time to explain.

Every day, we talk patients out of dangerous combinations, duplications, or misuse.

Every day, we are the last human checkpoint before a drug enters the body.

The system relies on this work.
It just refuses to acknowledge it.

When pharmacists advocate for practicing at the top of their licenses, we’re told to “stay in our lane” — as if this is about ambition or ego.

It’s not.

It’s about wasted clinical capacity in a system that claims it’s overwhelmed.

We can help!!!

And I want to be clear about what I mean by that. This is not about replacing doctors or pretending pharmacists are something we’re not. It’s about the enormous category of everyday healthcare that is currently being handled in the least efficient, least human way possible.

Simple acute conditions. Medication side effects. Chronic disease maintenance. Inhaler gaps. Delayed therapy because appointments are booked months out. Prior authorizations that stall treatment until a manageable problem becomes an emergency.

We already see these patterns. We already see the risk. We already know what’s coming next.

But we are forced to operate with our hands tied behind our backs.

So patients end up in urgent care for problems that could have been solved in ten minutes. They end up in emergency rooms because a form didn’t clear in time. They ration meds. They abandon therapy. They stop trusting the system entirely.

And then we act shocked that the system is overwhelmed.

In my opinion, medicine stays human through four things:

Proximity. Continuity. Accountability. Judgment.

Community pharmacy has all four.

Patients don’t need appointments to walk in. Pharmacists see the same people over years, not minutes. Pharmacists cannot hide behind portals or scripts. Pharmacists live with the consequences of their decisions.

Unlike centralized mail order or telehealth platforms, conversations happen in real time. Confusion is visible. Abandonment is obvious. Mistakes have faces.

That’s why I keep saying something that sounds counterintuitive in a business-obsessed healthcare system:

Friction in medicine isn’t inefficiency. It’s safety.

When you remove all friction, you don’t get better care.
You get faster harm.

This doesn’t mean medicine has to move slowly. I’m not nostalgic for fax machines or hold music. There’s a middle ground between ancient workflows and the lightspeed of modern technology.

But the people trying to “optimize” healthcare often don’t realize (or care) that the friction they’re removing isn’t accidental.

Sometimes it’s the only guardrail left.

A human conversation is a guardrail.
A pharmacist noticing something is off is a guardrail.
A patient being able to say “this doesn’t feel right” is a guardrail.

You can’t replace that with an app without losing something that matters.

C.O. Bigelow has been a pharmacy since 1838.

Before antibiotics. Before insurance. Before chain drugstores. Before PBMs. Before mail order. Before algorithms.

The tools changed.
The business models changed.
The responsibility didn’t.

People still walk in confused, scared, or overwhelmed. They still ask the same questions. They still need someone to take ownership of the answer.

That continuity matters.

Not because the past was perfect — it wasn’t — but because it reminds us of something we’re at risk of forgetting:

Medicine is not a product. It’s a relationship.

And that matters even more now, as healthcare tries to behave like e-commerce.

Click. Ship. Subscribe. Auto-renew. Open a chat window if something goes wrong.

Human bodies are not Amazon orders.

At Bigelow, we know our patients. We know who lives alone. Who gets confused. Who can’t afford surprises. Who is grieving. Who has a history that makes certain drugs dangerous.

You can’t build that in a call center.
You can’t outsource it to an algorithm.
And you can’t automate it into existence.

Here’s the uncomfortable reality.

Human medicine is hard to make financially viable under the current incentive structure.

It doesn’t scale cleanly. It doesn’t optimize neatly. It doesn’t fit into dashboards. It resists automation by design.

Community pharmacy practiced at the top of its training is bad for middlemen.

It questions formularies. It challenges denials. It slows unnecessary dispensing. It prioritizes judgment over volume.

So it gets sidelined.

Not because it doesn’t work — but because it works against certain incentives.

The system doesn’t underpay pharmacies by accident. It underpays them because it wants them weak.

A strong community pharmacy is a counterweight.
A strong community pharmacy pushes back.
A strong community pharmacy creates accountability.

But the modern healthcare machine doesn’t want accountability. It wants compliance.

It wants pharmacies interchangeable.
Patients steerable.
Care scalable.
Judgment abstracted away.

But you know who this version of pharmacy does work for?

Patients.

And that’s the only answer that should matter.

So… what do we want community pharmacy to be?

Not a nostalgic relic.
Not a retail aisle.
Not a fulfillment warehouse.
Not a loss leader.

We want it to be:

Community pharmacy should exist to protect patients from the economic incentives of the healthcare system, not to participate in them.

That is the choice in front of us.

And if we get it wrong, no amount of technology or optimization will bring the humanity back.

Giddy up.

Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy