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"But those who hope in the Lord will renew their strength. They will soar on wings like eagles, they will run and not grow weary, they will walk and not be faint." Isaiah 40:31
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.

August 2022 Issue [Download PDF format]
In this issue:
• Concepts and Strategies for Rescuing and Rebuilding Independent Pharmacy
EDITORIAL:

Concepts and Strategies for Rescuing and Rebuilding Independent Pharmacy

Most of the editorials I have written have addressed problems facing pharmacists and the profession of pharmacy, and have been critical of those who caused those problems or failed to address them. Although these editorials have elicited many supportive comments from readers, with few exceptions, my concerns and recommendations have been ignored or rejected by those having the authority to take action that would result in positive outcomes. I and our profession have generally failed to anticipate challenges until others have made decisions and actions that would negatively impact our profession. The consequence is that we then are in a "reactive" position in which actions that have already been taken are very difficult to rescind or even influence. Although many of our challenges result from external factors and organizations, others are self-inflicted. Our addressing existing problems and voicing criticism continue to be essential, but we are doing very little to be "proactive" in recognizing and seizing opportunities. Or in other words, the best defense is a strong offense!

Part of the title of my editorial in the July issue of The Pharmacist Activist is: "The Suicide of our Once-noble Profession – Unless there is a Revolution!" The primary theme of that commentary is that the ability of independent pharmacies/pharmacists to survive and thrive is inextricably linked to the ability of the profession of pharmacy to thrive in the future. That was a "reactive" commentary and, if you have not yet read it I encourage you to access it at www.pharmacistactivist.com. I received more favorable comments from readers about the July editorial than for any commentary I have previously written. The respondents lamented that our profession is in a desperate situation that will require strong vision and leadership. Toward the end of my July editorial I noted: "I have not given up and want to be part of that revolution!* My editorial in the August issue will include strategies and recommendations." I was delighted that several individuals immediately responded that they would like to be involved in the development of the strategies and I have shared a pre-publication draft with them for their critiques and comments. Their expertise, experience, and perspectives have been very valuable in the substantial revisions of the initial draft.

*It was suggested to me that the word "revolution" could imply that immediate or abrupt action would be taken. In considering the breadth and scope of the concepts and strategies that are proposed for possible inclusion in this initiative, it is clear that it will take considerable time to accomplish desired goals. In addition, the probability that the momentum for this initiative will not come from the top down, but rather from the bottom up within our profession, adds to the time frame necessary to identify and convene the pharmacists (and consultants) who will provide leadership and the network of the pharmacists who are supportive and wish to be involved. Accordingly, at least for the present, I am placing the designation "revolution" on hold, but will also not replace it with the word "evolution" that could imply that outcomes would not be accomplished on a timely basis.

I will reiterate that I have not done enough to give back to my profession, and I claim no special expertise or vision. However, I would like to think that my long-term experience and my knowledge of the initiatives that have been highly successful and also those that have failed, prepare me to propose concepts, strategies, and recommendations for active consideration. Deliberations and debate with like-minded colleagues, as well as respectfully listening to and considering differing opinions will subsequently result in revised and stronger plans of action. Accordingly, I view the commentary that follows as a "draft" that is "proactive" in the development of concepts and strategies.

Concepts and strategies

1. Steering Committee

A steering committee will be appointed to establish the vision for the initiative, and provide leadership, direction, and monitoring of the strategic process. The committee will include individuals who support the concepts proposed and have a commitment to move the initiative forward on a timely basis. Colleagues from within and outside of the profession of pharmacy will be valued contributors on selected issues.

2. Independent pharmacist organizations/groups

If it is interested and wishes to be involved, the National Community Pharmacists Association (NCPA), as the largest organization representing and advocating for independent pharmacists/pharmacies, would be well positioned to convene a summit conference of national, regional and local organizations, wholesalers, and buying groups that are exclusively committed to, owned by, and/or provide leadership for independent pharmacies. Examples of other national organizations that could be considered for participation include the American College of Apothecaries (ACA), Community Pharmacy Enhanced Services Network (CPESN), and the Alliance for Pharmacy Compounding.

Value Drug based in Pennsylvania is one example of an independent pharmacist-owned wholesaler collaborative, and there are numerous buying groups in which independent pharmacists participate. Independent pharmacists who are participants in networks of pharmacies that are owned and/or operated by corporations with non-pharmacist executives could be represented through their involvement with other organizations that are participants.

Some of the participants in the proposed conference may be in geographic locations and/or have programs that would be competitive with those of other participants. Any areas of competitiveness must be put aside so that the exclusive focus of the conference is on initiatives in which individuals can participate in a collegial, constructive, and collaborative manner.

Concepts and goals: Examples of concepts and goals that could be considered at the conference include, but are not limited to, the following:
  1. The establishment of a communications system that will provide all independent pharmacists (owners and employee pharmacists) with important, pertinent, and timely messages.
  2. The recruitment of more pharmacists who will consider the establishment of an independent pharmacy.
  3. The provision of to-be-acquired funding support for 1) existing independent pharmacies that are at risk of closure or being sold for documented financial concerns; 2) start-up financial incentive grants for establishing new independent pharmacies; and 3) continuing operational financial support for existing or newly-established independent pharmacies in geographical areas with limited accessibility to pharmacy services (e.g., rural areas [pharmacy deserts]), limited transportation options, or higher operational costs (e.g., increased security staff/systems).
  4. The establishment of stronger working relationships with colleges of pharmacy to provide introductory pharmacy practice experiences (IPPEs), advanced pharmacy practice experiences (APPEs), community pharmacy residencies, and employment opportunities.
  5. The establishment of a national community pharmacy formulary for high-cost medications and, as appropriate, the identification of preferred agents in therapeutic classes with similar therapeutic alternatives, with the selection of such agents based on efficacy, safety, convenience of administration, and cost.
  6. The planning of meetings with the FDA and pharmaceutical companies that provide high-cost medications only through specialty pharmacies, to arrange to supply through independent pharmacies those medications that do not have highly complex preparation, administration, distribution, or storage requirements.
  7. The exploration of strategies through which the participating organizations/groups can collaborate to establish a large independent pharmacy purchasing program that can negotiate the most favorable terms and prices for medications with pharmaceutical companies.
  8. The exploration of strategies through which the participating organizations/groups can collaborate to establish a large independent pharmacy network that can negotiate the most favorable terms and compensation with pharmacy benefit managers and prescription insurance programs.
  9. The exploration of establishing laws in additional states that are similar to the one in North Dakota that requires pharmacists to hold majority ownership in community pharmacies. Currently operating chain or other corporately-owned pharmacies would be exempted with a "grandfather" provision.
Limitation: At the proposed conference there would be NO discussion of mergers, acquisitions, or federations involving the participating organizations/groups. Although I am a strong advocate for such discussions and actions, those are decisions that can only be made by the individual organizations/groups, and this is not the forum in which they should be considered.

3. Chain Pharmacists

This initiative is for the primary purpose of supporting and strengthening independent pharmacists/pharmacies. However, chain pharmacists are, by far, the largest group of pharmacists in any area of employment/responsibility in pharmacy and their welfare and interests must be included in the interest of protecting and advancing the role and reputation of pharmacy as a healthcare profession and for other reasons that include the following:
  1. Tens of thousands of chain pharmacists are currently experiencing deplorable, understaffed, metrics-dominated, stressful, and error-prone working conditions that have resulted in anger, burnout, mental health issues, and many decisions to leave their position, and sometimes the profession, even before they have confirmed a new position.
  2. Most medication/dispensing errors that harm/kill patients are made in chain pharmacies. Most of these errors are unknown to the media and the public, and often to even state boards of pharmacy, but the few that do reach the awareness of the public severely damage the reputation of community pharmacists and the entire profession of pharmacy.
  3. Disillusioned chain pharmacists who are no longer willing to tolerate management harassment and terrible working conditions are the pharmacists who are best positioned to establish an independent pharmacy in which they are "their own boss." They represent an excellent pool of candidates for recruitment into opportunities to open a new independent pharmacy or join an existing one.
  4. There are no pharmacy organizations that have a goal of advocacy for chain pharmacists and. therefore, there is a need for a new "organization" for chain pharmacists in a profession that already has far too many organizations.
"Organization" of chain pharmacists: The steering committee or a group/structure into which it will grow, in consultation with chain pharmacists and their advocates, will initially plan the structure and priorities for the new organization. The new organization would not be a union and would not address salaries and benefits. For this discussion I will use the designation "organization," the priorities for which could include, but are not limited to, the following:
  1. The guiding theme for the new organization should emphasize "Patient Safety."
  2. A primary goal would be the establishment of a communications system that will reach all chain pharmacists for whom contact information can be obtained with important, pertinent, and timely messages.
  3. Membership would be primarily comprised of in-store chain pharmacists, including pharmacists in grocery stores and "big-box" stores (e.g., Walmart). Although the organization would not be expected to provide in-person membership meetings, continuing education programs, credentials, or other services, the costs of an office, staffing, and a communications network to serve a very large number of members will be considerable, and a nominal financial "contribution" would be expected from members.
  4. The organization could maintain a listing of experienced employment attorneys and other legal services which may be accessed by pharmacists who are victims of discipline/termination that may be illegal, unethical, or otherwise inappropriate. The organization itself would not be involved in the provision of legal services.
Like independent pharmacists, chain pharmacists also need strong support from our profession but needed support has not been forthcoming. Tens of thousands of chain pharmacists are increasingly desperate for recognition of patient safety risks and support for their concerns, and it can be anticipated that the new organization will soon become the largest pharmacist membership organization of all.

4. Colleges of pharmacy

Deans of colleges of pharmacy should be requested to have the required community pharmacy APPE rotation provided in an independent pharmacy, and for which honoraria for the pharmacist/pharmacy preceptor should be provided. Some will respond that there are not enough independent pharmacies in their geographical area to make this feasible or convenient for students. However, to an important extent, colleges of pharmacy contributed to that consequence by failing to support independent pharmacy practice when more were available, many of which were owned by the college's alumni. Students who also wish to participate in an APPE rotation in a chain store or grocery store can do so on an elective basis and I encourage this.

Colleges of pharmacy, as well as pharmacy organizations and pharmaceutical companies, that provide prescription benefit plans for their employees that utilize PBMs (e.g., Caremark, Express Scripts, Optum) and health insurance companies that steal patients from and provide abysmal, non-negotiable compensation for independent pharmacies, should terminate these relationships on the next date benefit providers can be changed. There are much better options

How can a college of pharmacy appeal to its alumni, particularly the alumni who own independent pharmacies, to contribute generously to their alma mater when it facilitates and supports companies that have done more than all other entities combined to cause financial devastation and closure of independent pharmacies, and cause the erosion of the professional roles and reputation of all pharmacists and our profession? It is ironic that some colleges of pharmacy are now experiencing sharp declines in enrollment and financial stability to the point of the risk of closing. so soon following the related challenges that independent pharmacists whom they have failed to support continue to face.

To encourage and facilitate much stronger working relationships, independent pharmacists and their advocates should ask deans of colleges of pharmacy to identify a) their faculty members who are most involved with independent pharmacists; b) faculty members who wish to spend a day in an independent pharmacy; c) the number of IPPE and APPE rotations that were provided in independent pharmacies during the most recent academic year and; d) to provide syllabi for required and elective courses that provide the most information for students about independent pharmacy practice. There are synergies to be achieved but, at present, colleges of pharmacy show little awareness of the value of independent pharmacists/pharmacies, and the implications if they would disappear.

5. Pharmaceutical companies

The pharmaceutical industry has a remarkable and well-earned record of success in developing life-saving and health-protecting medications. During much of the 1800s, independent pharmacists compounded most prescriptions and "store-brand" products that generated almost all of the business in the pharmacies of that era. In the latter part of the 1800s, a number of small pharmaceutical companies were started (e.g., Lilly, Merck, McNeil) that were able to prepare larger quantities of pharmaceuticals more quickly and efficiently than they could be compounded in local pharmacies. The establishment of these companies was welcomed by practicing pharmacists and their products were dispensed/sold exclusively in pharmacies. This support of independent pharmacists was an extremely important factor in the initial success of these companies. The companies grew rapidly and established research programs that resulted in the development of many new and more effective medications. Some of those initially small companies are now the giants (or have merged into the giants) of the present pharmaceutical industry that has had phenomenal research and financial success. However, very regrettably, the pharmaceutical industry has essentially ignored and abandoned the independent pharmacists whose ancestors and early counterparts were primarily responsible for the early success of these companies. Now the priority of the pharmaceutical companies is their working relationships with government and other large purchasers of their products, hospital/health systems, and, to their peril, the PBMs.

It is not too late for the pharmaceutical companies to change their priorities, and to re-establish positive working relationships with independent pharmacies. The initiative to rescue and rebuild independent pharmacies provides excellent opportunities for companies to provide substantial financial contributions and take other important actions that will accelerate the achievement of the goals identified.

Pharmacists in these companies can also proactively participate in these efforts. If there is not already a current list of pharmacists employed in all areas of a company, pharmacists can start such a list/directory. This group of employee pharmacists can be a value-added resource for company management in the selection of a benefit program and administrator that values the participation and use of independent pharmacies in a manner that will also enhance the reputation of the pharmaceutical company in the profession of pharmacy.

6. Funding

What monetary value can be placed on the profession of pharmacy in the United States? $Billions? $Trillions? $Quadrillions? a $googol? This proposal includes a broad scope but does not begin to cover the totality of pharmacy activities. The agenda is ambitious and substantial funding will be necessary

From whom will support be requested? The large pharmaceutical companies whose early founding and subsequent success was intertwined with the purchases and support of independent pharmacists are best positioned to provide substantial financial support and will be approached first. Their contributions will not be viewed as reparations, apology gifts, or incentives to buy influence (e.g., preferred placement of their products in the national community pharmacy formulary). Rather, their contributions will be viewed as investments in the rescue and future vitality of the profession of pharmacy.

Examples of additional potential contributors are other pharmaceutical companies, pharmaceutical wholesalers, foundations committed to advances in health care, other philanthropic organizations and individuals, individual pharmacists, many of whose accomplishments have been highly professionally and financially successful. No gift is too small and student pharmacists may wish to invest in their future opportunities.

7. Integrity

The leadership of this initiative and those who are employed participants will be committed to the highest level of integrity and, as applicable, individual (e.g., financial disclosures) and operational transparency.

Next step

Individuals will soon be identified and approached regarding appointment to the steering committee. It is anticipated that the committee will be appointed and hold its first meeting before January 1, 2023.

To be continued……!

Your comments and recommendations are always welcomed.



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