Pharmacy Times Editor-in-Chief

Will medication therapy management become a routine part of most dispensing pharmacists' activities, or will a select group of pharmacists handle this role? 

Fred M. Eckel, RPh, MS; Pharmacy Times Editor-in-Chief

	Will pharmacy practice changes incorporate medication therapy management (MTM) as a routine part of most dispensing pharmacist activities—or will this role be handled by a select group of pharmacists who may even practice independently of the drug distribution process? I have been pondering this question lately as I think about the opportunities the health care reform law will bring to pharmacy. Both practice models exist currently, and evidence supports the success of both approaches. But which approach is best for the patient? Will we come to a different answer if we asked the question, “Which approach is best for pharmacy and pharmacists?”

	The fact that there will be more opportunity to receive reimbursement for MTM seems obvious, because MTM is mentioned throughout the new health care reform law. At the same time, many observers feel that there will be continuing pressure to reduce the drug reimbursement formula, making prescription dispensing activities less profitable. Although we may not like it, more health plans are forcing patients to use mail-order pharmacy for chronic disease medications, thus taking prescription volume from local pharmacies. These observations lead me to conclude that a pharmacy business model that relies primarily on filling prescriptions may be in trouble over the next 5 to 10 years.

	Maybe we can turn the tide so that the prescription product is no longer perceived by many as just another commodity, but I am not so sure. If we want to do that, more dispensing pharmacists will need to increase their face-toface communication with the patient. Performing an MTM intervention is one way to convey that we are interested in helping that patient make the best use of their medication. It will also help convey to that patient that pharmacists are knowledge workers—not just glorified technicians&mdash;as the pharmacist discusses the appropriate use of the medications with the patient.

	One MTM provider quoted in the March 2010 Medication Therapy Management Digest puts it this way— “Customers have a greater respect and trust in our pharmacists. Patients are more apt because of this to recommend our pharmacy to their physicians, friends, and family.” Another provider said, “Our clients/patients become longterm patients. They tell other patients and relatives to come to us. The wordof- mouth extends beyond our community to relatives and tourists who arrange for phone consultations.”

	If MTM can provide so much value to patients and pharmacy, why do we need to wait for a payer to reimburse us? Shouldn’t we just offer the service and charge the patient directly? Why are pharmacists so reluctant to just ask for the money? I wish I knew the real reason, but our profession has been giving away valuable services forever. There may have been a time when giving advice for free created customer loyalty that pharmacists made up for in other sales. Today, customer loyalty is harder to depend upon to assure increased business. I am also aware that many pharmacists are introverts. Maybe it is hard for that personality type to “ask for the money.”

	Not every patient may be ready to pay for such a service out-of-pocket, but some are. More will be willing to pay for the service once they are made aware of its value. Pharmacists can help make that happen by providing MTM services to those patients whose Medicare Part D plans offer the service through a local pharmacist. Offering the service to select other patients as a fee-for-service option can further grow that business. If getting paid for cognitive service delivery is critical to assure community pharmacy success in the future, becoming comfortable doing this needs to begin now. What is keeping you from getting started? %u25A0

Mr. Eckel is a professor at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He serves as executive director of the North Carolina Association of Pharmacists.

	We invite you to comment on this topic. E-mail editorsnote@pharmacytimes. com or go to 

 and submit your comments at “Commentary” by Fred Eckel.

Articles

Will medication therapy management become a routine part of most dispensing pharmacists' activities, or will a select group of pharmacists handle this role?

Medication Therapy Management: What is the Best Model?

Earning the right for pharmacists to substitute generic drugs in place of a brand name prescription order written by the physician was a major victory for the pharmacist’s scope of practice. Now that practice has become so commonplace that no one thinks of it as an issue anymore. But I do remember the battles well. Generic drugs were often positioned by the opponents of this new role as inferior products whose quality couldn’t be trusted. 

A study published in the January 2011 issue of 

 showed that physicians aged 55 years old or older were 3.3 times more likely than physicians between the ages of 25 and 34 to have negative perceptions about generic drugs. The study also revealed the fact that more than 23% of surveyed physicians had some negative perceptions about generic drugs’ efficacy. So the concern about quality still lingers.

 article (January 13, 2011), the concern about the quality of medications is heating up again—but this time around biologic products. The new health care legislation would make it easier for generic manufacturers of biologics to enter the market. Once again, the issue of quality is part of the argument against such movement in the market.

For me, this discussion raises several significant questions. Did we benefit consumers, payers, and the pharmacy profession by allowing the increased substitution of generic drugs for brand name drugs and also making entry of generic drugs to the market easier? Is the furor over biologic drugs more of the same—or is the science of biologic drug production such that the quality of generic products entering the market can’t be trusted? What do you think?

Is the furor over biologic drugs more of the same-or is the science of biologic drug production such that the quality of generic products entering the market can't be trusted?

 Can Biologic Drugs Be Trusted?

	At the recent American Society of Health-System Pharmacists (ASHP) Mid Year Clinical Meeting in Anaheim, California, Henri Manasse, chief executive officer of ASHP, and Tom Menighan, chief executive officer of the American Pharmacists Association (APhA), discussed their organizations’ concerns about the accelerating expansion of pharmacy education. Earlier, they had released a discussion paper prepared by both associations which called for reconsideration by the pharmacy profession of the rapid increase in the number of pharmacist graduates. As I was writing this commentary, I received 2 e-mails that suggested that this call for reconsideration was needed and might even be too late. One e-mail was from a reader referring to my previous commentary, “Do We Need More Pharmacy Schools?” He said:

 “I can speak for my state, the proliferation of pharmacy schools…has been rampant. This to me is damaging to the profession. There are simply not enough positions to sustain the influx of graduates. Not to mention the dilution of talent that accompanies this out of control proliferation of pharmacy schools.”

	The second e-mail came from a former student who said:

 “I am contacting you essentially out of desperation at this point because after many months of searching on my own, I just have not been able to secure a full-time position as a community pharmacist anywhere in the area.” He went on to say: “I have 7 years’ experience in a high volume setting and great esteem and reverence for the practice of community pharmacy.” 

Unfortunately, this pharmacist is not the only one having trouble finding employment within commuting distance. Is this a temporary problem due to the economy? Once the economy rebounds will the pharmacy jobs follow? My feeling is that the problem is not only caused by the nation’s economy, but related to the serious overproduction of graduates.

	The APhA/ASHP discussion paper offers this information about the expansion of pharmacy schools: “

Before 1987, the number of pharmacy schools (72) in the United States had remained relatively constant for many years. Since then, there has been a rapid growth of new pharmacy schools and expansion programs (satellite pharmacy programs offered at other campuses of a university and expanding class sizes). As of July 2010, there are 115 U.S. based colleges and schools of pharmacy with accredited (full or candidate status) professional degree programs and five schools with pre-candidate status. As of December 2009, students are enrolled at 120 U.S. colleges and schools of pharmacy. An additional 20 schools have been identified where feasibility and exploration of new programs is underway.”

	The discussion paper also pointed out a number of issues caused by the expansion in pharmacy education, including 

“1) the actual effect on ameliorating the shortage of pharmacists, 2) exacerbation of the already-serious faculty shortage, 3) inability of practice sites to accommodate increased demands for experiential education (both introductory and advanced), and 4) the potential for a negative effect on the quality of education and, ultimately, on the quality of new graduates practicing pharmacy.” 

	The fact that there is an oversupply of pharmacists seems to be accepted by everyone. What we should do about it may not have as much agreement. Certainly the call by APhA/ASHP for 

“the pharmacy practice and educational communities to jointly and systematically assess the near-term and long-term workforce needs of pharmacy practice and plan how to best meet those needs”

 makes sense and should be aggressively pursued. Some suggest this may be too little, too late—and ACPE should simply stop accrediting new pharmacy programs. Or perhaps state boards of pharmacy should do something to keep new schools from opening. Others suggest that both of these options have certain legal, ethical, or practical elements that might make them difficult or even impossible to implement. Others say, just let the marketplace work. If graduates cannot find jobs, enrollment will decline and schools will have to close. The marketplace solution may work, but pharmacist graduates will surely be hurt by being jobless with a high debt load while the profession waits for the market to correct itself.

	Could the oversupply be viewed positively in that it will force graduates to pursue careers in nontraditional places? Graduates may be willing to accept a job at a lower starting salary in a related area. As they demonstrate their value, jobs may open up for more graduates in that field.

	There is a shortage of primary care providers. Could the oversupply of pharmacists create an impetus to push the appropriate recognition of our graduates as primary care providers, assuming nontraditional roles in rural health or for disadvantaged clientele? Although a revenue stream to support pharmacists doing chronic disease management is not well developed, will the oversupply push a more rapid implementation of this role?

	It is always easy to identify a problem after it becomes obvious. Offering solutions is not as easy.

	Care to Comment on this topic? E-mail editorsnote@pharmacytimes.com or go to www.PharmacyTimes.com and submit your comments at Commentary by Fred Eckel, where this and other topics are under discussion.

Mr. Eckel is a professor at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He serves as executive director of the North Carolina Association of Pharmacists. 

Will the Pharmacy Job Market Self-Correct?

The beginning of a year is a good time to make resolutions or identify new personal goals. An interesting article in the January/February 2011 issue of 

 asked business and management leaders what projects they plan to take on in 2011. The HBR editors said they hope that the projects discussed will inspire HBR readers to pursue similar lofty goals.

 readers too. My own personal project is to promote the development of a new pharmacy business model in community pharmacy. This is a difficult project to accomplish right now; however, I want to see the pharmacist become more of a midlevel practitioner receiving reimbursement for delivery of care, rather than delivery of a product. The challenge is the fact that the current reimbursement model primarily pays for a product delivery, not care delivery. Changing the pharmacist’s current mindset about what is the most important thing they do is where I plan to start.

What project do you plan to take on in 2011?  I invite you to share your goals here with all of us and help to inspire 

 readers to pursue lofty projects in 2011 too.

What lofty projects are you planning to undertake in 2011?

Resolutions Anyone?

The pharmacy profession is on the cusp of major changes, but individual pharmacists must be willing to step up to the plate.  

A Winston Churchill quote I frequently use in my remarks at graduation is, “This is not the end, nor is it the beginning, but maybe it is the end of the beginning.”

Churchill made this comment after a successful battle during the Second World War. I reflected on it after our state pharmacist association convention this fall because I left with the strong impression that pharmacy practice was finally at the “end of the beginning” of the change to a new practice model.

For a number of years, I have been suggesting that the pharmacy practice model needs to change to be more in line with the Joint Commission of Pharmacy Practitioners Organizations Vision of Pharmacy Practice in 2015, which states, “Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes.” I feel strongly about pharmacists assuming this role because I think this is what society needs most from our profession.

There are a lot of reasons why this change must happen. I know many pharmacists think they are “doing things right” (and generally, they are), but I am still concerned that some pharmacists are not doing the right things.

Recently, I participated in a Webinar in which the presenter tried to predict what prescription drug pricing schedule Medicaid would use in the future. He felt strongly that the actual acquisition cost would become the norm and many other programs would follow this lead. In my opinion, this will create even more pressure to reduce any extra margin from prescription drug reimbursement. Even if they increase the fee to what it actually costs to fill a prescription, keeping that fee in line with inflation will be difficult at best. A pharmacy practice model that does not include new revenue streams for clinical services may not last beyond the next decade.

The other reason I think our practice model needs to change is the growing recognition of how much nonadherence costs society. As we approach health care reform, the emphasis will certainly be on drug therapy outcomes. Pharmacists must be in a position to step up to the plate and make the right drug therapy outcomes happen. We don’t do this very well in our current practice model.

As I left the meeting, I had the feeling that this message had been heard, because there was so much energy present. We had more than 800 attendees, including 300 students. They heard Tom Menighan, chief executive officer of the American Pharmacists Association, open the meeting and tell the audience that pharmacists will be the solution to our nation’s medication use problems, provided that they take authority, function with autonomy, become accountable, and focus on outcomes.

The meeting closed with Troy Trygstad, pharmacy director for Community Care of North Carolina (CCNC), talking about the role of the pharmacist in the medical home.

As he described what has happened with this program in the past 8 years, I got a glimpse of how pharmacy practice might change as health care reform unfolds. He stated that we are 2 presidential cycles—that’s only 8 years&mdash; away from bankruptcy of our current health care system. Change is inevitable. As he described the expanding role pharmacists are assuming in the networks associated with CCNC, he mentioned that the model is not identical in each network, as each one experiments with the best ways to empower the pharmacist. Troy also emphasized how quickly the number of pharmacists employed has grown and how much growth he expects in the future. Tom Menighan said he was not too concerned by the pharmacist oversupply because he saw an opportunity for many more pharmacists to be engaged in drug therapy outcome management. The CCNC program demonstrated that this is really possible and can occur anywhere in this country.

What is needed are pharmacy leaders who acknowledge that the present pharmacy practice model is not achieving the needed results, are willing to think “out of the box,” and are able to take some risks to change what pharmacists do. I left this meeting feeling that our profession in my home state is well positioned to be part of the solution as we change our health care system over the next decade to focus on prevention and management of chronic diseases. No one is better prepared to execute this strategy than the community pharmacist.

Is pharmacy still at a “crossroad” or has the change process begun? Let us know your thoughts. PT

Has the Pharmacy Practice Transformation Started?

The elections have brought change to Washington’s congressional makeup.  This has invited speculation about how the Patient Protection and Affordable Care Act might change. Those who are unhappy with the bill have suggested changes that range from a complete repeal to elimination of mandatory participation in health insurance to restricted funding for implementation.

Pragmatists feel these possibilities are very unlikely as reality sets in, however. At the very least, the results of the recent election will impact the course of health reform in the months to come.

We’d like to hear from you. What do you think is likely to happen with the Affordable Care Act when the new congressional session opens in January? What changes would you like to see?

How will changes brought by the election affect the future of health care reform?