Here we are, perched on the edge of a new century. As we look back at the past 100 years, many of us lament the little things we've lost along the way as we move to this brave new world of 00's, technology and lost innocence. Things like Mary, Rhoda and Mr. Grant; the independent neighborhood bookstore; ditto paper; disco; soda fountains; Mickey Mantle's graceful swing; the daily afternoon newspaper; and the friendly local pharmacist may be things we baby boomers can only tell our grandchildren about.

The friendly local pharmacist? Yes, as we enter the twenty-first century, there is a burgeoning growth of on-line pharmacies. Log on to the Internet, type in an address, and you can find an array of prescription and non-prescription medications, health & beauty supplies, just about anything else you would buy at your neighborhood pharmacy and more. Will a model initially designed for buying books and other consumer items on-line and delivered by mail work for the more personal world of prescription medications? A number of new companies are betting the answer is a resounding "Yes!"

Who Would use an On-Line Pharmacy?

The drugstore market is big business. In 1998, total retail sales of prescription drugs and all drugstore-related products exceeded $160 billion, and is expected to reach at least $180 million in 1999. Retail sales of prescription drugs accounted for about $102 billion of 1998's total sales. The sheer size of this market makes it an ideal target for on-line entrepreneurs, particularly now that 37 million households have on-line access.

Early Internet pharmacies were launched in 1998. These retail sites are primarily designed for people who generally pay cash for prescriptions - the 15% of the US population who do not have health insurance, and 39 million seniors with Medicare who do not have prescription drug coverage. People with insurance, who buy approximately 85% of US prescriptions, are typically directed to preferred pharmacy providers. Most health insurers today negotiate with large, mail-order pharmacies to provide long-term medications to members. Members can receive a 90-day supply of medicines they need to take on a daily basis to treat chronic diseases such as diabetes, high blood pressure and asthma. In 1998, Americans bought $13.8 million worth of prescription drugs through the mail, only about 13 percent of the total prescription drug market.  Clearly, this is a market segment with great potential for acquiring new consumers - new customers that could come from on-line pharmacies.

If people with insurance develop an acute illness such as an ear infection, they need to get  to their local drugstore to get antibiotics right away. But, incentives such as lower co-payments are built in to encourage members to use the mail-order business whenever possible. Since the mail order firms do not have to pay for retail space, and they buy in such large volumes, they can offer better pricing to health insurance companies than most local stores.

This pricing advantage has traditionally been restricted to negotiations between the pharmacy providers and the third-party payers, the insurance companies. But with breakthroughs in Internet retailing, that will soon be changing with the emergence of on-line pharmacies.

How do On-Line Pharmacies Work?

This year, there has been a great deal of concern among health care providers and regulators such as the Food and Drug Administration (FDA) about just how these business operate, and where the legal and ethical lines should be drawn.

There are basically two models of on-line pharmacy practice. The first takes all the principles of the corner drugstore and brings them on-line. Prescriptions are required for medications, the prescriptions come from the consumer's own health care provider, and their authenticity is verified. Prescriptions can be sent or faxed to the dispensing facility, and the medications are then sent to the patient.

The second model is the one that has raised the greatest concerns. This model may incorporate many aspects of the first, but it goes a step further, allowing consumers to type in answers on a questionnaire, pay a "physician's consultant fee" and receive prescription medications without ever being examined by a health care provider. The prescription is provided strictly on the basis of the consumer's typed answers on the questionnaire - there is no opportunity for independent validation of the information, no face-to-face conversation with the patient, and no physical exam. Some of these pharmacies are located in the United States and are subject to state and federal pharmacy regulations; others are offshore and well beyond the reach of US regulation.

One of the more well-known on-line pharmacies noted for on-line "consultations" and prescribing is medicalcenter.net. At this writing, they were offering Viagra, used to treat male impotence; Propecia, used to reverse male-pattern baldness; Claritin, an antihistamine, and Xenical, used to treat morbid obesity.

The front man for medicalcenter.net is William Stallknecht, a registered pharmacist in San Antonio, Texas. He declined to be interviewed for this article, explaining that his lawyer has instructed him not to talk to the press due to pending litigation. But, before his lawyer's gag rule, he has been vocal in his defense of his business.  He has owned the Pill Box Pharmacy, which has 5 branches in southern Texas, since 1971, and he took his business on-line two years ago. According to a story in the New York Times, he initially used the Internet and the World Wide Web simply as a way to advertise his retail Texas business. Today, the two web sites - the Pill Box and medicalcenter.com - are thriving retail businesses themselves.

In published interviews, Stallknecht has stated that he is a devoted Libertarian. He is reported to be disdainful of the paternalism of the medical establishment, which he says has a vested interest in putting him out of business. He thinks the establishment sees him as "cutting into [their] sacred cow." Stallknecht maintains that the drugs he chooses for on-line prescribing are those that are safe enough to prescribe without a physical examination, a view the FDA and other professionals do not share.

"We have significant concerns about on-line prescribing because quality pharmacy practice relies on the prescriber-patient relationship," says Susan Winckler, a pharmacist and the group director of policy and advocacy for the American Pharmaceutical Association in Washington, DC. "This doesn't necessarily mean a physical exam in every case," she explains, noting that physicians will often prescribe over the telephone after talking with a patient. But, the key is that there is an interchange, a discussion, and a relationship between the prescriber and the patient - not typed answers on a form that do not allow for a give and take between the prescriber and the patient.

For example, one of the drugs prescribed on-line is for morbid obesity. With a face-to face encounter with a licensed health care provider, it would be immediately obvious from the patient's appearance whether he or she would be a candidate for the drug. This key opportunity is lost when the patient simply completes a typed questionnaire, as the drug is not recommended for people who want to lose a quick ten pounds to look better in a bathing suit.

Others are more forceful in denouncing Stallknecht's practice. Craig Frances, MD, the chief medical officer of another on-line pharmacy, yourPharmacy.com finds the practice unethical. "It is upsetting to think that these companies allow people to get meds that are not indicated," he said.

YourPharmacy.com, by contrast, is the first on-line pharmacy that is able to accept insurance reimbursement. This is possible because this company is a wholly owned subsidiary of Express Scripts, Inc, one of the nation's largest pharmacy benefits managers with 47 million customers. Express Scripts buys $10 billion worth of prescription drugs each year through volume purchases, and for the first time, the discounts once offered only to insurance companies will now be available to the cash customer who orders through yourPharmacy.com.

Unlike medicalcenter.net, whose site prescribes on line, "yourPharmacy.com will only accept prescriptions written by the patient's own prescriber," according to Gregg Rotenberg, the company's president. They do not provide prescribers for the patients. The first prescription is sent in by mail, or pharmacists will contact the patient's health care provider. Once the validity is confirmed, the prescription is sent on to Express Scripts for dispensing.  Each order is checked by four pharmacists before it is sent out to ensure accuracy and safety.

Being a Savvy Consumer

How can you tell the difference between ethical and unethical on-line pharmacies? "First off," Winckler says, "check to see that the on-line pharmacy is licensed to serve patients in your state."  Frances agrees. "We are working closely with the National Association of Boards of Pharmacy (NAPB) to help develop the criteria that will be used to identify ethical on-line pharmacies," he says. The NABP is planning to issue a seal through the Verification of Internet Pharmacy Practice Sites (VIPPS) program, which will require on-line pharmacies to meet established standards for legitimate practice. This seal should begin appearing at on-line pharmacy sites around the first of the year.

Second, according to Winckler, is to "make sure you have access to a pharmacist through email or telephone so you can have your questions answered. Be sure to ask what the response time is to patient questions." Frances explains how they address this aspect of on-line dispensing. "We have set up a network of licensed pharmacists with special training in drug information. When a patient has a question, we can send it to an expert in that particular subject area anywhere in the country by email. We guarantee a response within 24 hours."

The third important consumer tip is, "Pick one pharmacy provider and stick with them," Winckler says. By getting all of your prescriptions from one place, the pharmacists can help guard against drug interactions. They will know all the different medicines that have been prescribed for you, and they can help your health care provider by automatically checking for drug interactions each time a new drug is prescribed. This is particularly important if you see more than one doctor, who might not be aware of what others have prescribed for you.

Finally, if you are going on-line, Winckler says it is important for you to find out what protections are in place to protect your privacy and keep your interactions confidential. Check for secure technology any time you are required to enter personal information at an on-line pharmacy site.

The Future of the Local Pharmacist

Will this brave new century spell the end to the community pharmacy? Not according to our experts. Winckler points out that "pharmacists can't provide all of their services over a modem." She explains that in many places in the country, pharmacists are checking patients' blood pressures; they teach people how to use inhalers properly, watch the patients and make corrections in their technique; and in some cases, they give flu shots. It will be a long time before that personal interaction is replaced by a computer interface.

Rotenberg and Frances agree. "We did research before we launched our site," they explained. "We learned that a face-to-face discussion with the local pharmacist is very valuable to people with acute illnesses, particularly when they are not going to the doctor and trying to select self-treatments at the drugstore." They agree that for acute illnesses requiring prescription medication, patients will continue require access to a local pharmacy where they can receive their medicine right away so there is no delay in treatment.

For long-term medicines for chronic conditions and traditional retail drugstore purchases, there is no doubt we will see a major change in the coming years. It is expected that on-line sales of drugs, vitamins and personal-care products will reach about $2.3 billion by 2003, compared with a negligible dollar volume in 1998.

For patients who are paying cash, the ability to take advantage of huge quantity discounts once only available through an insurance plan will have a major impact on their ability to afford their medications. This will be a tremendous boon to seniors, as  Medicare does not provide prescription benefits. Older Americans spend about 18% of their income on health care, and this new way of buying drugs at lower cost can make a significant improvement in their quality of life. By 2003, there should be a 40 percent rise in the number of senior households on-line, which will only help the on-line pharmacy business grow in this population.

Alas, Mickey Mantle and ditto paper are gone forever. But, there's no need to say goodbye to your local pharmacists - they'll be there to serve you for years to come. Clearly, on-line pharmacies are here to stay. By being a savvy on-line consumer, and choosing a site with safety and ethical practice in mind,  you can begin by saving enough money to buy an extra bottle or two of bubbly to ring in this exciting new century filled with possibilities.