ALBANY COUNTY — When Albany County awarded Genoa Healthcare a contract in 2019 to establish a location inside the county’s Department of Mental Health building in the city of Albany, pharmacist Zarina Jalal of nearby Lincoln Pharmacy was concerned about the potential impact to her business, and upset that the county appeared to disregard its long working relationship with Lincoln. 

Nearly three years later, Jalal is still angry — not because she’s continuing to compete with a corporation that just last week celebrated opening its 700th pharmacy, but because she feels the Department of Mental Health is unethically funneling prescriptions to the on-site pharmacy in a way that denies patients their right to choose their health care, in addition to creating a sense of confusion. 

“Patients will come to us asking for their refills, and when we go into their profile and try to fill the prescriptions, it will already have been filled at the pharmacy that’s at the Department of Mental Health,” Jalal told The Enterprise last month. 

Many of the patients that Jalal has lost were receiving long-acting injectable (LAI) antipsychotics, which are expensive medications that are complicated to administer because they work in the body for weeks at a time and require greater precautions and a relatively high level coordination between all involved. 

Genoa specializes in long-acting injectables and severely ill patients, which the company touts as a specialization that sets it apart from general pharmacies, but which critics say is a means of dealing solely with profitable medication, and leaving the slimmer margins to small pharmacies. 

Genoa’s business model also revolves around partnerships like the one it has with Albany County, where it inhabits a health-care center and takes unique standing in the area, shutting out competition. 

For example, in 2020, Genoa sought an exemption from the Iowa Board of Pharmacy Examiners for a requirement that its pharmacy be located at least 10 miles from another licensed pharmacy, arguing that, while Genoa fills all the same prescriptions as the three pharmacies it would be within 10 miles of, only genoa would serve the severely ill, as this population makes up “nearly 100%” of its patients. 

The location in question would give Genoa access to 3,000 patients across 10 counties, according to its exemption request. 

It appears to have been successful.  

In addition to leveraging the need for LAIs, Genoa encourages its patients to use just one pharmacy, as stated in the company’s Albany proposal.

The Iowa request also cited the same self-funded study highlighting its effectiveness that was included in its proposal to Albany County, touting an adherence rate of well over 90 percent.  

And, in at least the Albany County agreement, there was a non-compete clause that prevented the space Genoa now occupies from being used again were services to be discontinued, apparently justified by the fact that Genoa took on the upfront cost of modifying the space. This clause was struck from the renewal approved by the legislature last year, in a 27-to-12 vote. 

Genoa was ultimately the only bidder for the project, though Jalal said that Lincoln did not submit a proposal because she was unaware of the county’s request.

Local impact

Prior to the Albany County Department of Mental Health Genoa location opening in December of 2020, Jalal said that Lincoln Pharmacy was one of the only area pharmacies that reliably stocked LAIs and, for this reason, a strong working relationship was established between Lincoln, the providers at the Department of Mental Health, and the patients the providers sent over. 

Jalal called the arrangement “mutually beneficial,” explaining that the extra revenue earned from carrying this medication allowed Lincoln to invest in other aspects of its community-health mission, like free delivery service. 

But in 2021, the first year that the on-site Genoa pharmacy was in operation, Jalal said she saw a 30-percent drop in the number of LAIs ordered from the Department of Mental Health — nearly $1 million in volume, she said, which ultimately led to her pharmacy limiting its delivery services and cutting salaries and benefits for staff. 

It wasn’t until the end of 2021 — when a conversation with a patient about being switched from Lincoln to Genoa without consent left her concerned — that Jalal dug into the data. She found that the reduction had occurred all at once earlier that year, in February, and was concentrated around only some prescribers from the Department of Mental Health, including the department’s medical director, Dr. Tom Qualtere. 

According to Lincoln’s data, the pharmacy filled 322 prescriptions for 25 patients of Dr. Qualtere in 2019; 229 prescriptions of 24 patients in 2020; 29 prescriptions from 13 patients in 2021; and just 9 prescriptions from two patients in 2022. 

Jalal claims that, while patients may reasonably prefer the Genoa location to her own, there’s no legitimate reason for providers to have a preference since her pharmacy offers the same services as Genoa that have been brought up by supporters in legislative hearings, such as delivery and adherence packaging, while also offering more personalized care, such as serving patients after-hours, than is typical for a chain.

Jalal said that, while the option of walking out of a doctor’s office and into an on-site pharmacy is “awesome and idealistic,” not all patients live near the clinic or will be able to access it during its regular hours. 

Special attention should be given to patients with severe mental illness, Jalal said, since their decision-making will need to be guided and their relationship with a pharmacist may be more crucial to their health outcomes than it is for other patients.

These patients, she said, are also often less able to self-advocate.  

This made it all the more concerning that this particular population — who are grouped into Albany County’s Assertive Community Treatment (ACT) program, which treats those who haven’t responded to more traditional modes of treatment — are where she’s seen the most precipitous drop. 

In 2020, Lincoln filled 680 ACT prescriptions, while in 2021 it filled 347. For LAI prescriptions specifically, Lincoln filled 284 for ACT patients in 2020, and just 84 in 2021. 

Data cited by Department of Mental Health Director Stephen Giordano in a department email reviewed by The Enterprise states that, as of March 2022, 20 out of 27 ACT LAIs (74 percent) were being filled by Genoa, with the remaining seven filled by Lincoln. Meanwhile, the reverse was true of non-ACT patients — 79 out of 102 LAIs were being filled by Lincoln, while the balance were being filled by Genoa.

This, to Jalal, suggests that there may be undue influence involved, particularly since her work with these patients had been so extensive and successful prior to Genoa opening its location. 

She blames some of it on a letter sent out by the Department of Mental Health in October of 2021 that highlights the on-site Genoa location as an option for patients. 

“Ask your clinician or prescriber for more information, or just stop into the pharmacy and say hello the next time you are on-site and say hello to the friendly pharmacy staff waiting to meet you,” the letter read in part. 

While the letter does not at any point suggest that Genoa must be used by department patients, Jalal believes that some patients misinterpreted it that way and simply went along with it. 

Pharmacy selection, she said, “really needs to be a conversation with the patient … [Patients] need to have consistency and being switched around just starts them back at square one.”

Genoa manager

Also concerning for Jalal is the fact that this alleged practice of guiding patients to a particular pharmacy, known as script steering, would be occurring in conjunction with the fact that the manager of the on-site Genoa location, Alexa Daley, is the daughter of former Department of Mental Health Deputy Director Susan Daley. 

Alexa Daley could not immediately be reached for comment.

According to department emails obtained by Jalal and reviewed by The Enterprise, Susan Daley was party to a conversation between department officials and Genoa executives in which then-Associate Director of Clinical Operations Cindy Hoffman named Alexa Daley as the department’s preferred hire. 

Also involved in that conversation, and apparently in interviews with the candidates themselves, was Dr. Qualtere, who appears to have conducted the candidate interviews with Hoffman.

The process in which the county gave final approval to candidates selected by Genoa was laid out in Genoa’s proposal to the county for the on-site location, according to a copy of the proposal.

Alexa Daley, according to her LinkedIn profile,  graduated from the Albany College of Pharmacy and Health Sciences in 2019 and worked as a staff pharmacist for about a year before becoming the Genoa pharmacy manager. She held a number of internships prior to graduation, her account suggests.

Hoffman, in her recommendation to Genoa executives, wrote that Daley “possesses the most experience working with individuals with behavioral health challenges. Additionally, her personal approach would allow her to effectively engage those we serve as well as members of the treatment teams assuring a better overall outcome for patients.”

County response

Giordano denied to The Enterprise this week that patients were being switched without consent.

However, in an email to Albany County’s Director of Policy Mike McLaughlin in January of 2022, which was part of an email thread related to a review of patients on LAIs that the department was taking in response to Jalal’s complaints, Giordana acknowledged the shift from other pharmacies to Genoa and called it an “unintended consequence of prescribing practices in 2021.”

Referring to patients who are “more seriously disabled, mandated, and/or noncompliant,” Giordano told McLaughlin that those patients “are less likely to express a preference for a pharmacy of choice due to these factors. It appears that absent an expressed pharmacy of choice on the part of these patients, our prescribers tended to utilize Genoa in 2021 for injectable medications.”

The letter highlighting Genoa pharmacy that the department sent out was meant to inform patients of a change that was easy to miss since the COVID-19 pandemic had drastically reduced foot-traffic, Giardono told The Enterprise this week.

On the question of how patients were approached about pharmacy choice prior to any changes implemented following the review, Giordano told The Enterprise that patients are “asked which pharmacy they wish to utilize for their prescriptions. If they fail to, or are unable to answer, then the prescriber must find a means of getting the patient their very necessary medication. A conversation is had with the patient about available options.”

Giordano also told The Enterprise that no operational changes were made after the review because Jalal’s concerns were “without merit.”

However, in a 2022 email to McLaughlin, Giordano had said that, following the review, department prescribers “will be more cognizant of the aforementioned unintended consequence of managing injectable medication prescriptions. 

“As it relates specifically to Lincoln Pharmacy,” Giordano wrote, “absent an expressed patient preference to the contrary, we will only utilize Genoa Pharmacy in those instances of documented non-compliance and in those instances when medications need to be started immediately.”

Still, Giordano told McLaughlin that a “significant number of the injectable scripts ended up at Genoa precisely because of medical necessity — i.e., highly unstable patients, expressing no preference for pharmacy, with a history of non-compliance and an urgent need to administer an injectable.”

While Lincoln has to order these injectables, Genoa keeps a supply on-site, he said, and so short-notice prescriptions are sent to Genoa. 

Giordano told The Enterprise this week that, in cases where urgency alone is the reason for sending the script to Genoa, patients still have the option of switching to another pharmacy, stating that “the County has no role in deciding where a patient gets their prescription.”

However, he added that patients without a stated preference will have Genoa suggested to them for their convenience, and he reiterated that “the prescriber reserves the right to utilize Genoa when medical necessity or clinical urgency prevails.”

Giordano also told The Enterprise about the department’s review of the patients whose pharmacies were switched, and said that “all cases were deemed to be appropriately managed.” 

Notably, most patients subject to the review were not consulted about their experience because the few who were approached by the department became symptomatic and/or upset, as Giordano explained to McLaughlin last year.

As for the hiring of Alexa Daley and how the county ensured that there was no conflict of interest, beyond Susan Daley excusing herself from the interviews, Giordano initially responded, through county spokeswoman Mary Rozak, that his department “was not involved in the candidate selection process nor the hiring process.”

When The Enterprise noted the apparent contradiction between that answer and the department emails, Rozak responded nearly two hours later that Giordano’s response had been truncated through a transposition error and that his entire response had included this:

“Genoa did the advertising and candidate recruiting. Genoa said there were three candidates. They requested that we complete the interview process and make our recommendations to them. That was it. The individual in question applied the same way other candidates did and was the only applicant with experience in this industry.”

It is unclear whether there would be any connection between the alleged script steering and the alleged nepotism, as The Enterprise was not able to confirm whether or not pharmacy performance would result in higher compensation for the pharmacy manager. 

Giordano said that department staff have “absolutely no knowledge of, or investment in, boosting Genoa numbers for Genoa staff compensation purposes.”

Deaf ears

In her efforts over the past few years to bring her concerns to the attention of those empowered to meaningfully respond, Jalal has traversed through the inner workings of county government, managing to enlist support from colleagues, Department of Mental Health employees, not-for-profit groups, and some county legislators along the way, but ultimately failing to convince those she most needed to.

After Giordano had conducted a review of switched patients, McLaughlin all but ceased communicating with Jalal, emails show, instead alerting county officials to times Jalal or “others who are now aware of the issue” attempted to make contact.

Amid the review, Giordano noted in an email that he had been in contact with Jalal and had agreed to follow up on “two specific patient concerns” but had not “engaged her on any of the broader issues.”

The emails included one from a Times Union reporter to Mary Rozak, in which the reporter raises questions about the county’s request-for-proposal and other matters related to Jalal’s concerns. 

It is not clear whether answers were ever given, but no article on the controversy has appeared in that publication or any other, save for one brief story from CBS6 Albany noting that legislator Jennifer Whalen had called for an ethics investigation following the renewal vote last December. 

Jalal herself, however, has received plenty of local media attention for — among other things — being a pharmacist in Albany’s South End, a pharmacy desert; for being an independent pharmacist facing the COVID-19 pandemic and big pharmacy benefit managers (like Optum, which owns Genoa); for facing COVID a third year; and for pressing Governor Kathy Hochul to sign legislation providing relief for small pharmacies at risk of closing or cutting services.

With Genoa, though, opinion seemed to follow Giordano and McLaughlin, who remained committed to the on-site pharmacy throughout occasionally-tense legislative meetings and committee hearings leading up to the contract renewal, while media attention remained suspended. 

Legislature Chairman Andrew Joyce, in one health committee meeting, made a show of asking Giordano what would happen if the contract weren’t renewed — wouldn’t the legislature essentially be putting patients in harm’s way?

“I believe so … In the moment, it would definitely disrupt the service,” Giordano replied. 

The notion of depriving patients of their preferred pharmacy was a steady refrain among supporters of the renewal on the night of the vote. Several supporters also expressed the idea that, because Genoa was the only bidder, there was little justification for complaint.

Those opposed, meanwhile, were able to point to arguments made by a good number of citizens who spoke out in support of small pharmacies, and against Genoa.

Among these citizens was Diana Drake, who said she had spent 8½  years of her 33-year career as a psychiatric nurse at the Albany County Department of Mental Health, and wrote highly of her working relationship with Lincoln Pharmacy and the pharmacy’s dedication to high-needs patients in a letter to the legislature. 

In addition to using the same strategies as Genoa, she said, Lincoln has “extended hours of operations” compared to Genoa, which is open from 8 a.m. to 4 p.m. Monday through Friday, and Lincoln has greater personalized care.

“Their staff would take the time to make an extra delivery if needed,” Drake wrote. “The staff at Lincoln Pharmacy also assisted with resolving insurance issues when needed. Many of the patients live in the same neighborhood where Lincoln Pharmacy is located and have talked about what a good relationship they felt they had with the staff.” 

Lincoln Pharmacy is located at 300 Morton Ave. in Albany.

Former Department of Mental Health psychiatric nurse Barbara Morrison also wrote in, stating that Genoa had explicitly asked that staff order LAIs from Genoa.

“Some prescribers switched most, if not all of their injections to Genoa because of this conversation,” Morrison wrote. “Informing patients that their pharmacy is being changed goes against the concept of having the patient be an active participant in their treatment. A patient’s compliance is influenced by many external factors; not necessarily the physical location of their pharmacy.”

She, too, praised Lincoln for its flexible patient accommodations. 

“On several occasions, Lincoln Pharmacy provided patients who lost their medications (due to disorganization related to their illness) at an unbelievable low cost so that they could maintain their compliance,” Morrison wrote.

Another writer was Raghu Thota, who owns Lindsay Drug Company in Troy and Marra’s Pharmacy in Cohoes, and who has had a similar experience to Jalal. 

“Between my two pharmacies I have had a handful of patients from the Albany County Department of Mental Health,” Thota wrote. “Early this year, I reached out to one of these patients as we have patients enrolled in our cycle fill program. I should explain [that] his program is one where we monitor patients’ compliance not only in filling prescriptions but also verifying that they actually took a medication. 

“I asked this individual about their own refills, and they informed me that they had switched to Genoa Pharmacy because their doctor wanted them to use that pharmacy,” Thota wrote. “They were not supportive of this as they had been long standing and compliant patients however since there are limited mental health professionals, they felt pressured to follow their doctors demands.”

Speaking before the legislature in person the night of the vote, a decades-long customer of Lincoln Pharmacy called local businesses “the glue that holds communities together,” and that letting local businesses be eliminated by big competitors is “not good for the neighborhood.”

One woman got up to express her gratitude to Lincoln staff for “getting me through my cancer adventure.” She also said that, when COVID-19 vaccines became available, Lincoln called its list of clients over 65 and reminded them of the availability. 

After the public comment period, Legislator Beroro Efekoro told his colleagues that they had a chance to correct the mistake they made authorizing the contract in 2019. He said he believed it was authorized “with the best intentions” but that it is a “small-business killer” because it supports “a corporate monopoly.”

A few legislators noted that, throughout the process of renewal, Genoa had not sent any representatives to argue the company’s case.

Legislator Jennifer Whalen, who would later call for an ethics investigation, asked why no one had yet brought up the “serious allegation” of nepotism. That point was not responded to.

Jalal told The Enterprise that she had submitted an ethics complaint to the county’s ethics board; she believes, based on the minutes from the ethics board’s December meeting, that it has begun a preliminary investigation. 

The Enterprise is awaiting response for a Freedom of Information Law request for minutes of ethics board meetings held after that point.