Society, Patients, and our Profession Need Independent Pharmacists!
CHALLENGES AND STRATEGIES

The challenges

1. Our profession and our associations (with the exception of those with a primary mission of advocacy for independent pharmacy) do not provide support for the role and autonomy of independent pharmacists at a level that corresponds to their importance for the entire profession.
   
   
2. Most colleges of pharmacy provide very little instruction, or even visibility/participation, related to independent pharmacy that would result in more students actively considering entrepreneurial/ownership opportunities.
   
   
3. Many independent pharmacists are apathetic (not that this characteristic is unique to this group), and do not take actions that would contribute to progress in addressing threatening challenges. Some may be satisfied with the status quo and do not feel that changes/threats will occur with a timing that will affect them personally. Many are not members of the National Community Pharmacists Association (NCPA) and regional/local associations that are advocates for their role and survival, have not written a single letter to their legislators or the employers, government agencies, and others who are paying for prescription benefit programs with inadequate services and compensation, and do not financially contribute to initiatives that offer hope for effectiveness in addressing the challenges.
   
   
4. There is too much competition among those who should be the strongest advocates for independent pharmacy. Yes, the decline in the number of independent pharmacies results in a situation in which they are seldom competing with each other. However, the professional associations, wholesalers with whom independent pharmacists affiliate, buying groups, and others are often in intense competition that precludes attainment of results and progress that would be possible with unified and strong collaboration. What might be accomplished if every independent pharmacist was a member of NCPA, and if wholesalers and buying groups functioned collaboratively, rather than competitively?
   
   
5. Some independent pharmacists have fallen into the trap of "filling more prescriptions faster' to respond to the challenges of metrics-driven chain pharmacies and the policies and inadequate compensation from PBMs. The consequences are a reduction in services for and communication with patients. But these are the very activities that distinguish independent pharmacies from mail-order and chain pharmacies, and provide the added value that is claimed. A "more prescriptions faster' response is self-destructive because, if services and counseling/communication are not provided at any of the pharmacies that patients use, they will conclude that it doesn't matter where they obtain their prescriptions.

Strategies

1. Prescription medications and services would be available for all patients. However, older adults are the patient population to whom the services of the pharmacy would be primarily promoted. These are the individuals who take more medications for chronic conditions and who have the greatest needs for which pharmacist counseling will be valuable.
   
   
2. The regular inventory of prescription medications would consist almost entirely of drugs that are available generically. Between 80% and 90% of prescriptions dispensed in community pharmacies are for medications for which generic equivalent formulations are available. Most, but not all, of these generic medications can be purchased at low cost. Many of these medications are ones that patients would be taking for many years for chronic conditions like hypertension and hypercholesterolemia. The focus on generic medications will permit low inventory costs.
   
   
3. The pharmacy would not participate in prescription benefit plans administered by PBMs and/or health insurance companies. Provision would be made for exceptions to include selected prescription plans that assure professional services for patients, and policies and equitable compensation that are consistent with the professional and financial operation of the pharmacy. The cost of a generic medication plus an equitable professional fee will often be less than what a patient would be charged as a co-pay for a prescription in current PBM prescription plans. Because many generic medications used for chronic conditions may be dispensed in 90-day supplies, the pharmacist would have increased flexibility to establish a professional fee that will support and build the financial viability of the pharmacy. This concept would be promoted to patients and local employers as one that would have lower costs than the programs provided by PBMs and health insurance companies. Patients/consumers would be encouraged to make an appointment for a free consultation to review their medications and costs, and the possibility of contacting their prescriber if medications of equivalent benefit and risk can be provided at a lower cost.
   
   
4. Medications that are not included in inventory but may be obtained and provided at a cost (including professional fee) that patients are willing to pay, can be ordered and provided on a timely basis. For medications that are costly and would require the use of a prescription benefit plan, the pharmacy would identify another pharmacy to which the patient can be referred. As an alternative, the pharmacy could establish a working relationship with another pharmacy at which prescription plans are accepted, and the medication could be provided to the primary pharmacy for dispensing to the patient for an appropriate professional fee.
   
   
5. The pharmacist/pharmacy would assume the primary responsibility for maintaining records and for the review, monitoring, and recommendation for all medications used by its patients, including medications that are more expensive and are obtained from another pharmacy.
   
   
6. The pharmacist would coordinate/synchronize the provision of medications for chronic conditions in a manner that would permit convenient and time-efficient visits/consultations of patients with the pharmacist (e.g., once a month, once every 3 months for maintenance medications).
   
   
7. The visits of patients to the pharmacy to obtain refills of prescriptions would be on an appointment basis to enable greater convenience, time efficiencies, and schedule planning/staffing, as well as the avoidance of long waits for patients. Patients with new prescriptions for medications that do not have to be started immediately would also make appointments. Provision would be made for prompt dispensing and consultation for medications for which starting treatment quickly is necessary (e.g., antibiotics, analgesics).
   
   The schedule that is primarily appointment-based will permit hours of operation and staffing of the pharmacy to be established for the convenience of both patients and pharmacists. Procedures would be identified for obtaining medications needed for emergency, "after-hours' situations.
   
   
8. Depending on the scope and interests of the pharmacist and the patients, products and services could be extended, and might include immunizations, compounded prescriptions, medical supplies/equipment, and nonprescription medications and selected dietary supplements recommended by the pharmacist for common minor problems/symptoms.
   
   
9. The location of the pharmacy is important and should be convenient and readily accessible (e.g., parking) for patients. The needed real estate and the size of the pharmacy will be relatively small. Close proximity to a chain pharmacy could be advantageous because of its research regarding location and the likelihood that patients using the chain pharmacy may often experience waits/delays, have little or no discussion with the pharmacist, and be interested in changing pharmacies. Indeed, pharmacists currently working in a chain pharmacy might consider opening their own pharmacy in a nearby location in which they are already known to many members of the community.
   
   
10. In addition to the prescription department and area for nonprescription medications and healthcare products, the pharmacy would include an attractive reception area and an area for private consultation with the pharmacist.
    
    
11. Local physicians and senior citizen centers would be personally visited to acquaint them with the pharmacy and its services.
    
    
12. House calls would be made (for a fee, as appropriate) to patients who are unable to come to the pharmacy and would benefit from personal consultation.

Elagolix sodium
(Orilissa – AbbVie)
Agent for Endometriosis

• Is administered orally (whereas leuprolide is administered intramuscularly and nafarelin is administered intranasally);
  
• Does not cause initial flare of symptoms;
  
• Labeled dosage recommendations permit use (150 mg once a day) for up to 24 months (whereas, when used for treating endometriosis, leuprolide should not be used for longer than 12 months and nafarelin should not be used for more than 6 months).
  

• Interacts with more medications;
  
• Has not been directly compared with other therapies in clinical studies;
  
• Labeled indications are more limited (leuprolide and nafarelin are indicated for use in children with central precocious puberty, and leuprolide is also indicated for the treatment of uterine fibroids and prostate cancer);
  
• Is administered once a day (compared with leuprolide depot 11.25 mg that is administered every 3 months).