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Each issue will include an editorial on a topic that is important for the profession of pharmacy, as well as a review of a new drug that includes a comparison of the new drug with previously marketed drugs that are most similar in activity, and a New Drug Comparison Rating (NDCR) for the new drug. Read on for this month's issue.

September 2016 Issue [Download PDF format]
EDITORIAL:

Our Profession and Our Patients Need Independent Pharmacists!
But Can We Keep Them?

I recently read the book, If You Can Keep It: The Forgotten Promise of American Liberty, by Eric Metaxas. It is excellent and I highly recommend it! The book title is a quote from Benjamin Franklin in 1787, the year the Constitution was drafted. A woman asked Franklin what the founders had given the American people. "A republic," he responded, "if you can keep it." The book by Metaxas examines the freedoms and liberties provided by the Constitution, and the unprecedented system of governance by the people of the United States, as distinct from a dictatorship or monarchy. But he voices concern about the erosion of some of these freedoms over the years, and warns that, if we as individuals and a society do not demonstrate a stronger commitment to protect and promote what the founders entrusted to us, we are at risk of losing the greatness and exceptionalism that has characterized our country.

As I read this book, I was struck by what I consider to be the parallels to what has been occurring in the profession of pharmacy. The "founders" of the profession of pharmacy in the United States were independent pharmacists/apothecaries. They founded the Philadelphia College of Pharmacy in 1821 as the first college of pharmacy in the United States, and provided leadership in the formation of the American Pharmaceutical Association in 1852. Over many years independent pharmacists have been the public identity and the "face" of our profession. They usually live in the communities in which their pharmacies are located and have become a trusted health professional and friend to their patients/customers in relationships that often continue for decades. It is not uncommon for these owners of independent pharmacies to have served several generations of many families. They also are often very involved in and provide civic leadership for their communities. When surveys of the public consistently rank pharmacists so highly with respect to qualities such as integrity and ethics, it is most likely independent pharmacists of whom respondents are thinking in responding so positively. They are the ones who have earned the respect and excellent reputation for our entire profession, and from which all of us benefit even though the personal responsibilities of those of us in other areas of pharmacy may be invisible and unknown to the public.

Although many pharmacists have excelled in their responsibilities in hospitals and other practice settings, as well as in colleges of pharmacy, pharmaceutical companies, and research programs, their interactions with individual patients and the general public are much more limited and brief in duration compared with the number of opportunities community pharmacists have for getting to know and establishing long-standing relationships with those whom they serve.

During the last several decades the number of independent pharmacies has significantly declined, while the number of chain pharmacies has greatly increased. There are tens of thousands of very capable chain pharmacists who would enjoy getting to know their patients well. However, the management-imposed policies and metrics of many chain pharmacies often result in high-prescription volumes and understaffing that allow very little time for speaking with patients. A very common scenario is a technician receiving a prescription and entering the pertinent information in the computer, and a technician providing the completed prescription to the patient in the "sign here" phase of the transaction, without there being any communication between the pharmacist and patient. In addition, many chain pharmacists may "float" among several stores within the chain or be transferred to another store which, combined with the high turnover rate many chains experience, result in much less opportunity for pharmacists to come to know patients and serve them on a continuing basis.

The financial pressures that both independent and chain pharmacies are facing also compromise the amount of time that pharmacists can spend with patients. Pharmacy benefit managers (PBMs), insurance companies, and government programs provide inadequate compensation for medications and pharmacy services. Some of these organizations are reducing the size of their networks of pharmacies, and independent pharmacies are at greatest risk of being excluded from these networks, thereby losing patients and their prescriptions and other purchases. To provide a perspective, if Target stores with their size, purchasing power, and layers of management expertise can't operate their pharmacies without losing money, with the result that they sold their pharmacies to CVS, the challenge for independent pharmacies is even greater.

The above factors are colliding during a period of time when the elderly are the fastest growing segment of the population. The elderly are taking more medications and have the greatest need for the expertise, time, counseling, and monitoring that can be provided by pharmacists. In my opinion, the greatest need in the provision of health care is for physicians and other prescribers, and pharmacists, to spend more time with individual patients. More comprehensive and personalized communication will result in better patient understanding of their medical problems and the medications prescribed, better compliance with the instructions for using medications, a reduction in drug-related problems, and a reduction in physician visits and hospitalizations for the management of drug-related problems.

Independent pharmacists are strategically positioned and the most readily accessible health professionals to provide counseling and monitoring regarding prescription medications. They are highly valued by their patients and communities and are, by far, the most visible representatives/ambassadors for our profession. However, their survival is threatened! I have voiced in previous editorials my continuing strong opinion that the future success of the entire profession of pharmacy is inextricably entwined with the extent to which independent pharmacists can not only survive, but thrive (please see my editorial, "Pharmacy's National Treasure – Community Pharmacists," [April 2014 issue of The Pharmacist Activist]).

But can we keep them? WE MUST! And I have the following recommendations.

Recommendations

  1. Support from our entire profession – The entire profession of pharmacy must strongly support the role and services of independent pharmacists.

  2. Relationships among independent pharmacists – Independent pharmacists must make a stronger commitment to communicate and work with each other. When the number of independent pharmacies was much larger than it is now, they often viewed each other as competitors. At the present time, the smaller number of independent pharmacies very seldom view each other as competitors. Often, independent pharmacies are very confident that they can effectively compete with the chain pharmacies in their communities. Rather, it is the mail-order pharmacies owned by PBMs that unfairly compete by stealing patients from independent and chain pharmacies with program restrictions and mandates, and/or financial incentives to use their mail-order pharmacies.

    In efforts to improve their purchasing power and efficiency, most independent pharmacists have established working relationships with one or more major wholesalers, are investors/participants in wholesaler collaborative companies, and/or are members of buying groups. However, an irony exists. Although the independent pharmacies may not be competing against each other, these organizations with which they are affiliated compete with each other to increase the number of independent pharmacies they represent. Efforts must be strengthened to have all of these organizations work more closely together for the benefit of all independent pharmacists.

  3. Association support – All independent pharmacy owners and their employee pharmacists must be members of the National Community Pharmacists Association (NCPA), the American Pharmacists Association (APhA), and their state and local associations. We must have stronger professional organizations, and that requires increased and involved membership. Many local, and even some state, associations of pharmacists have become inactive. We must reactivate these organizations and also identify other strategies through which the collective voice and importance of the role of independent pharmacists can be communicated. The associations are essential for providing the forum and influence through which pharmacists can unite and more effectively address legislative and many other issues.

  4. Appointment of task force – The NCPA and APhA should appoint and provide the necessary resources for a Task Force on Independent Pharmacy (TFIP) comprised of independent pharmacy leaders and appropriate consultants whose single priority will be the development of plans and strategies for the promotion of the advancement and growth of independent pharmacy.

  5. Advocacy for small businesses – Our profession must be aggressive in revising federal and state laws, policies, and tax structures that favor big businesses but place small businesses at a disadvantage or represent disincentives for individuals to start a small business. Every big business started as a small business but not every small business aspires to become a big business. Small businesses are the essential fabric of communities. and it is very important for communities to provide the necessary opportunities and incentives that will enable both small and large businesses to thrive. If a large business considers relocating its corporate headquarters from one state to another, its current home state will often offer tax relief and other incentives worth millions of dollars to keep it in its present location. However, when a small business experiences financial challenges that may force it to close, there is no relief or support.

  6. Relief from antitrust laws – Independent pharmacists must be provided relief from antitrust laws. The current system in which large insurance companies and PBMs are able to exclude pharmacies from their networks, and permit participation only under the terms of their "take it or leave it" agreements is both inequitable and anticompetitive. Independent pharmacists must be granted an exception, or the laws should be changed, in a manner that will permit these pharmacists to work together to negotiate more favorable agreements and equitable compensation.

    Several large PBMs have recently announced changes in their formularies for 2017 that will result in some widely prescribed medications being excluded or "demoted" from coverage. These changes are being made for the financial benefit of the PBMs and, supposedly, their clients. Pharmacists must commit considerable time to explaining these changes to patients and providing counseling regarding the drug and dosage changes and other information pertaining to the alternative medication to which they are being switched. How do the PBMs recognize the value of the time and service provided by pharmacists in these situations? They don't! Pharmacists should be able to charge a fee for their services that are necessitated by formulary changes made by the PBM. A fee of $100 for each patient for whom such a change is made would be a reasonable starting point.

  7. Establishing pharmacy's own PBA – The profession of pharmacy should establish its own national prescription benefit administrator (PBA). Why should the large PBMs and insurance companies be able to extract many millions of dollars in profits from the healthcare system for the dispensing of medications by pharmacies when they have contributed nothing to the quality and scope of pharmacy and other healthcare services? They shouldn't be able to! I feel certain that the profession of pharmacy could establish a national PBA with programs that provide prescriptions and medication therapy management with positive therapeutic outcomes, and that provide much greater benefits for patients, and equitable compensation for pharmacists, at a lower cost than the programs available from CVS Caremark, Express Scripts and others. In my opinion, this opportunity has such excellent professional and financial potential that it would quickly attract both support and investment from within and outside of the profession. However, majority ownership must be held within the profession of pharmacy to prevent acquisition by others who are not committed to the same goals. This opportunity should receive a very high priority from the new Task Force to be established.

  8. Advocacy for entrepreneurism – Our profession must do much more to encourage entrepreneurism, and to provide business and management programs that will help assure success when a pharmacist purchases an existing independent pharmacy or opens a new one. Colleges of pharmacy must make students aware of these opportunities. Many pharmacy students have limited or no awareness of independent pharmacies because their family has used a chain pharmacy and they work part-time in a chain pharmacy. Very unfortunately, this latter experience has resulted in many students concluding that they don't want to work in "retail" when they graduate. However, there is just as great, if not greater, need for highly capable graduates to enter community pharmacy practice as there is for them to enter other areas of practice.

    In my opinion, every pharmacy student should participate in an Advanced Pharmacy Practice Experience (APPE) rotation in an independent community pharmacy. This will not only provide a patient-centered professional practice experience, but will also provide the opportunity to observe and learn about the involvement of the pharmacist owner in her/his community, and the benefits of owning a pharmacy and having the personal responsibility for making practice and business decisions.

  9. Political action – We must increase our legislative influence. Buddy Carter of Georgia is the only pharmacist in Congress, and a small number of pharmacists serve in state legislatures. These individuals are to be congratulated for being so highly respected in their communities that they have been elected to their offices, and they have represented their constituents and our profession in a distinguished manner. When pharmacy-related and other healthcare legislative proposals are being considered, these pharmacists are the trusted peers whose opinions are valued by their colleagues in the legislature. However, additional opportunities exist. Our profession should be doing much more to encourage pharmacists to become active participants in legislative and policy issues, and to identify and support pharmacists who are willing to be candidates for civic positions and legislative offices.

    It is very likely that every legislator and/or a family member needs medications, and our professional associations should learn who the pharmacists are who know them on a personal basis. This information will facilitate a strong and timely response to support or oppose proposed legislation that has important implications for our profession. We should more frequently invite elected officials and candidates for these offices to speak at meetings of our professional associations.

    On a personal basis, we should invite our legislators to visit our pharmacies. We can host "meet and greet" receptions in our homes at which neighbors and other friends can speak with legislators, and, prior to elections, we can place signs on our lawns in support of the individuals we consider to be the strongest candidates.

  10. Many opportunities – Numerous opportunities exist to increase the scope and value of services provided in community pharmacies. The provision of immunizations in pharmacies is an excellent example of what can be done. Twenty years ago immunizations were not provided by pharmacists. Now, they are provided in most community pharmacies, for the benefit of both the public and our profession as a much larger number of individuals are being protected against the occurrence of potentially serious illnesses.
Examples of other community-pharmacy based initiatives that have the potential for patient, professional, and financial benefit include:
  1. Collaboration – Collaborative working relationships can be established with groups of family practice and internal medicine physicians. Some chain pharmacies have allocated space for a clinic that is staffed by nurse practitioners. An independent pharmacist owner could establish a referral service in which patients could be referred to a practice group or particular physician based on their medical needs, or an arrangement could be made in which a local physician could be available for consultation in the pharmacy during certain designated time periods.

  2. OTC products – Our role in the recommendation of OTC products (and referrals to physicians as appropriate) can be greatly strengthened. In many pharmacies, patients select an OTC product from a self-service shelf or display and purchase it without speaking with a pharmacist. Pharmacists have an excellent opportunity to be recognized as the authoritative experts regarding OTC medications and their appropriate use. Products for specific symptoms that a pharmacist has or would personally use or recommend for use by a member of her/his own family could be identified in a section with a designation such as "The Pharmacist's Choice" or "The Pharmacist's Formulary." Certain of these products could be kept behind the counter in a manner similar to what is done with pseudoephedrine-containing products. This medication also provides an excellent example of how the value of our knowledge can be demonstrated. For an individual for whom the use of an orally-administered nasal decongestant is appropriate, I always recommend a product with pseudoephedrine, and do not recommend a product with phenylephrine, because pseudoephedrine is more effective and is available in extended-release formulations that are administered less frequently. A higher price for the pseudoephedrine-containing product is also justified as it should include the value of the pharmacist's time and recommendation.

  3. Natural products – Extending our role with respect to the use of natural products (e.g., dietary supplements, herbal products) and products such as probiotics has excellent potential. For many of these products, there is very little authoritative information regarding effectiveness, safety, and dosage. Pharmacists are in an excellent position to respond to questions and make recommendations. If we are aware of safety concerns for a product, or questions as to whether it is effective, we should recommend against its use and recommend an appropriate OTC product for which definitive information is available. As with certain OTC medications, certain natural products (e.g., melatonin, St. John's wort) could be made available only from behind the counter for the purpose of assuring discussion with a pharmacist.

  4. Smoking cessation – Pharmacists have expertise regarding the products used to help individuals stop smoking and many pharmacists have been leaders in programs to discourage individuals from starting to smoke and to encourage current smokers to quit. However, we can do much more!

  5. Health information resources – Pharmacists can designate an area of the pharmacy as a center for information regarding common medical problems and the appropriate use of medications. Many literature and other sources of information can be made available with an emphasis on speaking with the pharmacist.
These and many other opportunities are ones which I do not expect chain pharmacies to develop, but they can be quickly and effectively implemented for the benefit of patients, independent pharmacists, and the profession of pharmacy.

For all the reasons discussed above, we must move forward in a strong and urgent manner to protect and promote independent pharmacists as if the future of our profession depends on it. BECAUSE IT DOES, AND WE MUST KEEP THEM!.

Daniel A. Hussar

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