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    Provider status is fine and dandy, but pharmacists need to get paid

    The debate taking place among Drug Topics readers online and in print has more angles than a hall of mirrors. And as in a hall of mirrors, some perspectives may disguise the obvious. The pharmacist who wrote the following wants to refocus attention on the bottom line.

    The latest craze in the pharmacy world is provider status. From students to deans to pharmacy organizations, provider status is front and center and considered of the utmost importance.

    See also: Provider status: Important to pharmacists, critical to patients

    Why the urgency now? Why such a strong push to get this over and done with?

    25 years of nothing doing

    To put it bluntly, the profession of pharmacy is dying. The internet, cheap generics, FTC's ineptitude in keeping monopolies at bay, and legislation designed to sidestep pharmacists are just some of the reasons for the demise of the profession. The causes deserve a lengthy discussion beyond this article. Realizing that the profession may crumble, like an aging fortress, interested parties want to apply the patchwork of provider status.

    See also: Is community pharmacy a dying profession?

    From the APhA website: "Provider status: What pharmacists need to know now …. Pharmacists’ services have grown well beyond functions tied only to dispensing medications."

    We were fed the same nonsense 25 years ago when I went to pharmacy school. We were told that we would become a part of the inner circle of the healthcare team. However, for 25 years, every single national organization did absolutely nothing to educate either the general public or the lawmakers about the importance of the role of the pharmacist.

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    • Anonymous
      Unfortunately, there is nothing any of us can do to save this profession; it is too far gone! Requiring all Pharm.D. programs didn't help this profession in any way. It was just another way of all the professional organizations to push their agendas and gain more money in the process. It must be nice to live in the pretend world; not many of us have ever had that "luxury"!
    • Anonymous
      I would like to add to this discussion by saying that the reason pharmacists are not currently being paid much for so-called clinical services like MTM, medication reviews, and disease-state management may be that there isn't much need for a pharmacist to provide these services. Although we like to consider ourselves the drug 'experts' most drug information is readily available via software or medical reference--and lets be honest --considering that every drug lists 30 or more side effects, and most drug regimens have multiple rare but possible interactions--is it really possible to be an 'expert' here? Do we really bring anything to the table clinically that doctors and nurses don't already possess? It is certainly impossible and impractical to memorize this amount of information, and so most of us rely on software to screen. So are we then 'experts' in software utilization? I know that is hard for some to hear but it is something worth talking about -- considering we have increasingly large numbers of young people going into debt to enter this profession who are being sold some incorrect ideas. Considering pharmacists lack the ability to diagnose, prescribe, or treat, we are reduced to duplicating and double-checking the work of the physician. A medication review session, for example, is something that all doctors should already be providing--are pharmacists really bringing anything new to the table here? MTM also features guideline based therapy recommendations--which again is something all physicians should be familiar with and following according to their clinical judgement. If physicians are unable to effectively manage drug therapy regimens then maybe the answer would be to improve their education or to produce more doctors, PA's, and nurse practitioners. Another strange idea I have seen circulating is that of the pharmacist "coach" which appears to be a sort of cheerleader helping the patient with adherence and disease-state management. Again I don't see any need for a pharmacist to provide this--the doctor and nurse should be managing disease-states like diabetes--performed by certified diabetes educators for example. Adherence is important but also difficult to make much of an impact--pharmacy school doesn't exactly prepare pharmacists for this, and in the end you can't force a patient to do the right thing with diet, lifestyle, or adherence issues. The best answer here may lie with auto-refill functions, again using pharmacy software. I am not seeing a need for pharmacists outside of our dispensing role--as painful as that is to consider--and I have yet to see meaningful, unbiased (meaning not produced by pharmacy organizations or pharmacists) studies that contradict this. The sad truth may be that the profession will never see a role outside of dispensing, and that the dispensing role may be replaced or drastically reduced by automation, mail-order, and central fill.
    • TrumanLastinger
      Jose, Thanks a bunch for this article. This is what I have been talking about for years. There seems no way that the majority of pharmacists will ever stand together because they are too busy meeting production requirements. They apparently feel that our organizations and schools are in control but the only control the schools and organizations have that I see is their desire to further their own goals which is to ensure they have more students who can readily pay for their education because of quick access to student loans. Once the student graduates he is captured by the chains because he has to pay off these loans. He is effectively enslaved by the system. This access to loans has caused more and more pharmacy schools to open all in search of this easy money. This situation began in the 1960s when our organizations and academia convinced the majority of us to accept a professional fee for our service and our product. This is actually price fixing which the government tells us is illegal. Then the government was at the forefront with the advent of Medicaid which enforced the acceptance of the professional fee. Until this time we were paid for our product with a markup which covered our professional service and each individual pharmacist controlled his markup. Suddenly we were forced into a situation which left us with no control over our own individual business or our service. Thanks Again Truman Lastinger, Pharmacist
    • TrumanLastinger
      Jose, Thanks a bunch for this article. This is what I have been talking about for years. There seems no way that the majority of pharmacists will ever stand together because they are too busy meeting production requirements. They apparently feel that our organizations and schools are in control but the only control the schools and organizations have that I see is their desire to further their own goals which is to ensure they have more students who can readily pay for their education because of quick access to student loans. Once the student graduates he is captured by the chains because he has to pay off these loans. He is effectively enslaved by the system. This access to loans has caused more and more pharmacy schools to open all in search of this easy money. This situation began in the 1960s when our organizations and academia convinced the majority of us to accept a professional fee for our service and our product. This is actually price fixing which the government tells us is illegal. Then the government was at the forefront with the advent of Medicaid which enforced the acceptance of the professional fee. Until this time we were paid for our product with a markup which covered our professional service and each individual pharmacist controlled his markup. Suddenly we were forced into a situation which left us with no control over our own individual business or our service. Thanks Again Truman Lastinger, Pharmacist
    • Dr. S Giorgianni, Jr., PharmD
      I regrettably have to agree with much of what the author writes. In my way of thinking 2 fundamental philosophical points drive a good deal of the professional woe's we have. They both revolve around money. First, unlike any other profession - health care or other - we are inexorably tied to the product, what we "sell". Did anyone every hear a lawyer say that he only charges 3-cents per page of contract or a physician saying that he will stitch you up for $2.7 per stitch? The other is the what most students are taught as a mantra - "...we can save you some money" or "...this a very expensive drug and I can give you something much cheaper." or "...pharmaceutical industry is ripping everyone off". Unless we finally find a way to bill for cognitive services we will stay in a very narrow zone of being the only "product reimbursed" profession.
    • Anonymous
      Seems to me a large scale walk out, at least for retail pharmacists, may be the only way to convey the message that we are needed. Maybe if Senator McCain can't get his heart meds because there are no pharmacists to dispense immediately he might change his politics. Tell him "I'm sorry, we don't have any pharmacists today but you can order from Canada and expect delivery in 3-5 business days." Maybe that would also send a message to the large chains that while more expensive than techs, pharmacist would be worth the cost. Imagine what would happen to their profits and reputations if for 1 day not a single prescription in say 1 town, or 1 county, or 1 state could be dispensed. Since it seem that all they care about is their bottom line, hit 'em where it hurts.
    • LarryLaBenne
      ​Great article! In fact, one of the best I have ever read. While, the actions (or lack of) of chains, academia, FTC, government, etc., clearly all play a significant role in the current state of the profession, I would dare to argue that pharmacists at large may have the biggest role. The profession at large is many fold bigger than all other responsible parties combined and therefore would appear to have most accountability for the current state of the profession. There are two major factors that we, and only we, can and must change before we can expect the state of the profession to improve: 1.) Professional unity. Simply put there is strength in numbers. I am not talking about giving money to APHA so they can keep talking while we sit and wait for them to take some real action. I am talking about the majority of pharmacists coming together and taking action and refusing to accept the current status quo. Just as one of the comments challenges the chains to accept temporary legal and financial ramifications of doing what is best for the long term survival of the profession, some or many of us may lose the job that we complain about by taking action. So what? Is that not a bearable sacrifice? So how do we get pharmacists to come together? Perhaps a good first step would be for pharmacists to get over the fears that employers instill and speak out without hiding behind a pen name or making anonymous comments. Take a lesson from John Handcock and get your name and voice out there. You just might influence others to do the same; 2.) Pharmacists need to do a better job!!! I am not talking about working harder to achieve enigmatic metrics set by corporate so we can get an e-mail from our RPM or a plastic award at the next corporate meeting. You know who you are: unquestionably filling anything that resembles a prescription and having no desire to do nothing more than verify accuracy and achieving business goals. We all need to examine our daily actions, and ask ourselves, am I really being a good pharmacist? There is good reason for this. Something that is even far more powerful than a unified profession is consumer demand. At large we need to let the public know that we can provide services that are useful and valuable, that they need and want, and can't get from any other health care provider. Similar to the electronic gadgets that people now find indispensable in their daily lives, that people didn't even know that they wanted just a decade ago, we need to demonstrate the value of our services, or the services that we want to provide and receive fair enumeration for. Bottom line, if the public wants services that we want to provide, it will happen. The best way to create such a demand is by being the best pharmacists that we can be each and every day. Many are quick to place blame their employers for not providing suitable working conditions for practicing good pharmacy, but keep in mind that the pharmacists working under those conditions do so day after day voluntarily. If your situation precludes you from practicing good pharmacy, then take a stand or choose another option. If all or many would stand up, speak out, and/or get out, employers would have no choice but to change the conditions. In the case of both factors of professional unity, and pharmacist at large needing to do a better job, it will likely require many pharmacists to make some temporary sacrifices. Who's willing? I'm in.
    • Dr. MCrown
      I think it has a lot to do with the typical Pharmacist personality type. In myself and other Pharmacists, I see a strong tendency towards Type A, doing things right, going above and beyond and killing ourselves in the process. The Pharmacists who buck the system (I call them outliers) either get fired, encouraged to leave or get the heck out. My point is that we have been too busy doing a good job to stop what was coming. It is sheer comedy that we provide extensive counseling, immunizations, MTM's, advice for Medicare insurance sign-ups and don't see an extra cent in our paychecks yet middle management continues to scream about cutting hours and building volume. What a joke! Corporations are tripping over themselves to figure out how to push Pharmacists out, we are just too expensive. Look at mail order, they don't even have to follow the same counseling regulations as other Pharmacies! Rx drugs pushed to OTC. Between this mess and the generally unscrupulous nature of big Pharma, I am over it. Sadly, my job is only a means to an end, and not likely for long.
    • Anonymous
      Thanks for bringing this up, Jose-- I think the real heart of this problem is our response to requests for unpaid services. Oddly enough, Chain Pharmacies could provide the solution: 1) We are being asked to provide more and more services without reimbursement, or for ridiculous reimbursement. If an APhA or any other Pharm organization tells us not to do them unless paid, the Antitrust mechanisms of government will suddenly waken from their 50-year sleep and squash said organization for antitrust activities. Here's where the Chains come in. All it takes is one Chain to set reasonable prices for Government mandated services. For example, you want counseling? It's $6.00 for 10 minutes. You want a mandated leaflet with your Warfarin? It's $3.00. You want a Complete Medication Review? Its $250.00 for the first one, and $100.00 for next year's annual review. Of course, there would be court action over this, but the Chains can afford it, and it is in their interests (and all of ours) to see it discussed in court. Compelling someone to work for nothing has a technical name. This name is 'slavery.' Slavery is illegal (at least it is illegal anywhere not controlled by ISIS). No one, not even pharmacists, can be compelled to provide services for free. I believe a corollary is that no one can be compelled to provide goods, even medicines, below their acquisition cost. I believe the most correct legal interpretation of all the mandates is that we must OFFER these services. We will continue to offer them, just not at no charge. Our patients are also free to decline our offers, or pay to receive services. Any one Chain that adopts this policy can drastically decrease its costs for services that we have been providing which many people do not actually want, and start to make money for the things our patients DO want. Imagine the savings in just ink and paper to print all those leaflets, if the patient says, "No thanks, I got a leaflet last time." Imagine the bump in profitability for paid counseling. How about it, Chains? Because of their market share, Chains have the ability to write optionality of services into their contracts with insurers. They can also specify that counseling fees collected in the pharmacy go to the chain, not the insurer. All it takes is one Chain to do this, and the others will follow suit.
    • JoseLopez
      This is the heart of my argument. Lets get paid for our services. A reasonable fee not just some coin thrown into our bucket. Also FTC has to split this cozy relationship between Chains and insurance plans. Its a complete conflict of interest, and in our society its unacceptable. We as a profession cannot function this way any longer, because the conflict of interest brings no interest to our side.
    • Anonymous
      Provider status = let's provide pharmacists with more work at no extra pay. I cannot even convince myself that much of us will be around longer. Some of us will be fed up and just quit, most of us will be pushed out by younger and hungrier pharmacists ready to chop at their debt. I am thankful my debt has been wiped clean and ready to take on managerial work at Five Guy Burgers if needed.
    • JoseLopez
      Most of the >55 year olds are getting out. A lot of my friends sold their businesses and are going into anything other then pharmacy.
    • Anonymous
      The demise of pharmacy. I have been watching my profession circle the drain for 25 years now. Pharmacy has once again become the ugly step-sister of healthcare. The animosity and prejudice towards community pharmacy remains constant. The legislators, the insurance companies, and even our own state board despise us. We have even been betrayed by our own organizations. No other profession has to endure this. Pharmacy is the only profession in which you get punished for being good at it. If you can fill 800 rxs in an hour with no help, then that's what they make you do. With the glut of pharmacists, and the flood of new grads, we have become disposable. I sincerely doubt provider status is going to save the profession. Re-imbursement is the name of the game. You will have to ask yourself, if the hoops they make you jump through for 50 cents a month is worth the blood, sweat and tears. We need to tell the prospective students to run for their lives. Unless you truly have your heart set on becoming a pharmacist (and for the love of God, why??) do not pursue this. If anyone out there has an answer, a REAL answer, not some fairytale "someday" answer let me know. I am afraid for my profession. We are going down the drain, this time, for good.
    • JoseLopez
      Couldn't agree more. The frustrating part is that there's no one on our side. Everyone is pushing their own agenda for their own benefit.
    • Anonymous
      Thank you for this commentary. Finally, an article that is actually relevant. I think you speak for 99% of us working folks. It is a shame that out of medicine, podiatry, dentistry, physical therapy, and pharmacy, the latter group has the biggest disconnect between academia and real world. It is a shame that prospective pharmacy students and future graduates are clinging onto the hope that provider status will magically bring about jobs that just don't exist. Our bread and butter will always be dispensing and verification, and we need to make sure that automation and technology do not replace us in the near future. I am not confident in this, however, as these organizations that are supposed to represent pharmacy are too busy feeding lies to vulnerable students. I am turning 60 years old this upcoming April, and I will be happy to work at my major chain for a few more years until a new and hungrier DM comes in and overhauls our current staff for cheaper labor. I have two children graduating from college soon, and I was relieved to hear that they will not be pursuing a dying profession through pharmacy school. There is no doubt that pharmacists have done a wonderful part in serving the public, but I fear that is no longer the case with incompetent students flooding the retail sector reliant on their iPhones rather than their knowledge base and experience. -Alexis James
    • JoseLopez
      All your points are 100% right. We will be replaced by automation, and the notion that we will be smarter then the supercomputer is ridiculous. For those of us who have 15-20 years to work, have to find some niche. The grads are in for a rude awakening. I actually feel sorry for them. The chains will replace the pharmacist with a vending machine (Walgreens is looking to partner up with a manufacturer of precription vending machine). The only real jobs will be in hospitals. Retail, which employs the bulk of pharmacists, will slowly disappear.