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Article
OTC Guide
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The opportunity to optimize all medications, not just those that require a prescription, is long overdue.
Nearly all OTC products were prescription-only at some point in time. That means that pharmacists in the twilight of their career have, at some point, filled a prescription, engaged in drug utilization review, filed insurance claims, and counseled per the Omnibus Budget Reconciliation Act of 1990 regulations for many of the products now found in front of the counter. Loratadine, omeprazole, famotidine, and scores of others were blockbuster prescription-only products at some point in history and were used by hundreds of millions of Americans.
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A 2022 publication purported $167 billion in savings in ancillary health care cost avoidance through the widespread use of OTC products in the United States. Two-thirds ($110 billion) was attributed to avoidance of provider encounters and one-third ($67 billion) to the use of OTCs as a cheaper alternative to prescription-only drug products.1 For perspective, the entire prescription-only medication spend (after rebates) is estimated to be roughly $435 billion.
Post–COVID-19 legislative and health plan actions have greatly expanded the ability for pharmacists to bill for encounters in the same fashion as every other health care provider. Although some states have a large number of codes and a wide scope of practice to serve patients and bill Current Procedural Terminology codes to health plans, others are more limited to oral contraceptives and point-of-care testing, evaluation, and prescribing events.
Pharmacists in community pharmacies, in particular, have a long history of giving counseling and cognitive services away for free using retail economics, wherein the pharmacy buys low and sells higher, and the service cost to the pharmacy is absorbed in that retailing buy-sell gross profit margin. However, those margins have shrunk dramatically for most medications, whether prescription-only or OTC, to the point where the consumer expectation of service through review, safety, and counseling is not covered by gross profit of retailing.
Troy Trygstad, PharmD, PhD, MBA, is executive director of CPESN USA, a clinically integrated network of more than 3500 participating pharmacies. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He recently served on the board of directors for the Pharmacy Quality Alliance and the American Pharmacists Association Foundation.
Billing for encounters and counseling would not drive up encounter costs within the savings associated with OTC use. To the contrary, it would likely add to the savings, as anybody who has concerns, needs, or questions about OTC requiring any time beyond pointing to the correct aisle has a high probability of utilizing the health care system more broadly. The pharmacist’s formal encounter will likely set them on a path toward successful treatment, or identify a concern that needs referral to another provider that will avoid adverse events or rapid disease progression, leading to even more cost, morbidity, and potentially mortality.
Let’s finally get serious about providing services related to OTC evaluation and use—and bill the health plans, pharmacy benefit managers, and taxpayers who benefit from those pharmacist-provided encounters.
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