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    Where to from here? Pharmacy's evolving options

    In Drug Topics August 2012 “In My View” column, contributor Stan Illich suggested some directions in which contemporary pharmacy might seek to grow. He expands upon those ideas in this accompanying blog post.

    You can read several articles a day written by disgruntled pharmacists who are being used as insurance jockeys, prescription checkers, etc. These dedicated professionals never have the opportunity to talk to a patient. If you are lucky, you might have the opportunity to counsel four patients in a day or work with a provider once or twice a day. I repeat — if you are lucky.

    I have endured this “stuff” for 44 years and I am sick of it. Articles on the plight of pharmacists caught up in this state of affairs are numerous; they have been written over and over again.

    I am one who has contributed to the whining. I wrote my first treatise on the subject when I was a senior in pharmacy school in 1969.

    How do we dig ourselves out of this mess?

    So, how do we dig pharmacy out of this mess? Let’s do some brainstorming. And it’s OK to be unrealistic. To my knowledge, nothing that is realistic has happened to change our plight for at least 40 years.

    Here are a few suggestions off the top of my head.

    Change the law . . .

    Would changing the law on ownership be the answer?

    Currently the practice of pharmacy is regulated and controlled by the states. For example, there is a law on the books in Michigan that says a pharmacist must own at least 25% of each pharmacy, but it is not enforced.

    In North Dakota there is a law that mandates that a licensed pharmacist must own a controlling interest (52%) in every pharmacy. Some pharmacies have an exception to the law. They were grandfathered because they existed before the law was passed in 1963.

    The North Dakota pharmacist ownership law has been challenged by Snyder’s Drug Stores Inc. and Medcenter One. In both cases, the pharmacist ownership law was upheld by the North Dakota Supreme Court and the United States Supreme Court. Pharmacist ownership has been very successful for North Dakota pharmacists and the patients that they serve. Licensed pharmacists own the controlling interests in 90% of pharmacies in North Dakota.

    Change the pharmacy model

    During my time in the U.S. Army, I worked in an outpatient pharmacy that processed an average of over 2,000 prescriptions a day. As you might imagine, the pharmacy was heavily automated.

    This pharmacy went through several operational changes, but my favorite was the “Bank Teller” system. In this system we had eight “windows”. Patients were checked in at a concierge desk, given a number, and asked to take a seat in the waiting room. Each window was staffed with a pharmacist and a technician. Staffing of the eight windows was dependent on the patient flow, which was monitored using automation. There might be three windows open in the early morning and up to eight windows open when it was the busiest, and then later down to two or three windows as the number of patients decreased.

    When the pharmacist was ready for another patient, he/she would push a button, the patient’s number would flash, and the patient would come to that window. The pharmacist would pull up the prescription on the computer (Electronic Order Entry), review it, and consult with the patient and provider if necessary. The technician would count, pour, and label the prescription; have it ready for the pharmacist to perform the final check; explain the medication to the patient; and answer any questions. Every patient was seen by a pharmacist.

    This model was possible and came into being when it did because an innovative director of pharmacy convinced the commander and medical staff that this would provide the best opportunity for a pharmacist to be a member of the team caring for the patient.

    This model is more expensive in terms of automation and staffing; however, the investment paid off handsomely.

    • The patients and the providers appreciated it.
    • Waiting time dropped dramatically.
    • Waste of medication decreased, because the prescription was not filled until the patient came to the pharmacy counter.
    • No bags were left lying around to be confused when they were handed out or to put back in stock when the patient never came in to pick them up.
    • The constant labor of returning 200 prescriptions to stock each week was no longer an issue.
    • There were fewer medication errors, and fewer prescribing errors reached the patient.
    • The pharmacists and technicians were happier.
    • The patients’ No. 1 concern is convenience — and the fact that they would like to speak to a pharmacist, if it is convenient. So they were clearly happy.

    This was my favorite model, which I felt at the time was an excellent interim solution.

    If this were the model in the retail environment, there would be opportunities for sales. Insurance issues would be resolved, with the coordination of a pharmacist and a technician.

    Could a chain store do this? Would it make a chain store money? There are lots of smart people in these organizations, and anything is possible.

    Patient-centered medical home

    What about a medical home?

    This model has been around for quite a while. It is my understanding that Kaiser Permanente has done business this way for many years. A very simplified description is as follows:

    The Medical Home is served by one to three teams. Each team consists of MA(s) or LPN(s), RN(s), physicians, NP(s), and/or PA(s). The team has access to a patient’s medical records ahead of time. Each morning there is a team meeting called “The Huddle.” When there is a pharmacy onsite, the pharmacist is an integral part of the team. Pharmacy is also a part of the extended team, to provide specific clinical support when necessary.

    The Army is currently transitioning to this model, as are many federally qualified health centers.

    This model does require more support staff, but the results are wonderful. The practice is more patient-centered. There are fewer medical/medication errors. Accreditation is through the National Committee for Quality Assurance (NCQA). The Patient Centered Medical Home is a huge undertaking. It usually takes 2-3 years to achieve accreditation.

    Could this be integrated into the world of corporate pharmacy, such as chain-store and grocery-store pharmacies? Some of these big operations are adding clinics. Why not make them patient-centered medical homes?

    Not only does it seem possible; in the long run, this could be a much larger profit center for such operations, if only patient care were their overriding reason for being.

    You can become educated about the patient-centered medical home at several sites on the internet and especially at the NCQA site.

    Pharmacists could/should work in physicians’ offices

    Why wouldn’t it be a good thing for pharmacy and medicine to station pharmacists in the offices of physicians?

    The pharmacist’s tasks should not be drug identification, labeling, counting, and pouring. None of these actions add value to the prescription. I am positive state boards can be convinced of this.

    The pharmacist in a physician’s office could see the patient after the provider does, review the prescription against the patient’s medical record and any medication reconciliation documentation received from a hospital or carried by the patient. Any issues with the prescription or any of the medications could be resolved on the spot in consultation with the provider.

    Wouldn’t you feel more at ease if a pharmacist were calling in prescriptions as the doctor’s agent, rather than the way it is done these days?

    Pharmacy technicians are fully capable of drug identification, etc. The literature demonstrates that pharmacy technicians are more accurate than pharmacists at these technical tasks.

    Pharmacists working in the doctor’s office would have reviewed the prescription and counseled the patient. The technicians would be responsible for drug identification, not interpretation or clinical decisions.

    Chains would then be able to handle their workload with one or two pharmacists, who would be there to manage the operation and handle issues beyond the scope of a technician.

    Accreditation of community pharmacy practice

    As I researched the issues that have plagued our profession for so long, I thought about accreditation and how it has helped hospitals — and hospital pharmacies in particular.

    Many of the concerns that pharmacy needed to have implemented might never have happened without Joint Commission standards. We, as a profession, would do well to promote the accreditation in all community pharmacy settings.

    You can read more about the evolution and implementation of such standards in articles posted at the websites of the American Pharmacists Association (http://www.pharmacist.com/) and the National Association of Boards of Pharmacy (http://www.nabp.net/).

    What is the interim money solution?

    Why don’t we separate the practice of pharmacy in the retail pharmacy setting from the dispensing of medication? How’s that for an original idea?

    It might work like this. After the prescription is filled, the pharmacist meets with the patient, in a real office with walls. The pharmacist reviews the prescription with the patient, counsels the patient, and works with the patient’s doctor to ensure that there are no prescription errors, medication errors, food or drug interactions, etc.

    There would have to be remuneration for this. For example, the pharmacist might begin by accepting $20 dollars for a 30-minute consultation with a patient. At 30 minutes per patient, for 16 patients in an 8-hour day, the calculation would be 2,080 hours/8 hours = 260 days or 260 days X 16 patients a day = 4,160 patient encounters. The income for this calculation would be $80,000 a year.

    An alternate model might be $10 for a 15-minute encounter. Would the patient accept it in addition to the co-pay? Would retail pharmacies accept the profit from the sale of the drug and allow the pharmacist to have the charges per patient as his/her salary?

    This example might be way off in terms of charges; however, I believe there are some really smart pharmacists out there who can come up with a viable way to do this.

    Issues and a vision for pharmacy

    Certainly social mores play a large role when such radical changes are proposed. However, money is the most significant issue, not the patient’s habits.

    What would a pharmacist accept as a salary, in order to work as a pharmacist rather than as a highly paid technician in a sweat shop?

    What would a physician be willing to pay a pharmacist on his or her staff?

    These questions seem like studies waiting for academia. It is my opinion that once a provider has worked with a pharmacist in his/her office for a period of time, the extreme value of having a pharmacist onsite would become obvious.

    What is the ultimate solution?

    What does it look like in your best dreams?

    Do we really want to be medical doctors, doctors of osteopathy, physician assistants, or nurse practitioners? Is giving shots an example of what gives pharmacy its legitimacy as a profession?

    Why can’t we make what has become a recurring wish to “build a vision for the entire pharmacy profession” a reality now — or at least start somewhere?

    Judging by recent shifts in pharmacy practice, it is certain that we will not continue on the same path. I have presented a few ideas. What solutions do you have to offer?

    I hope to see an article in the near future, written by some outstanding pharmacist or group of pharmacists, that sets pharmacy practice along a solid pathway to resolving these issues that the pharmacy profession has been facing.

    Stan Illich has practiced in chain-store pharmacies, owned a drugstore, served as an army pharmacy officer and a civil service employee, and been vice president/COO of a community health center. Currently he practices at Peak Vista Community Health Centers in Colorado Springs, Colorado. You can e-mail him at [email protected]

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