EDITORIAL:
Rescuing Independent Pharmacy: Part 4The Inspiration of Independents
Earlier this month I attended the annual convention of the National Community Pharmacists Association (NCPA). The practice innovations, professionalism, and resilience of these independent pharmacists are inspiring. Their commitment to their patients and communities, in the context of increasing challenges and adversity, are exemplary. If they are not giving in to the financial and other pressures that threaten the survival of their pharmacies and, in my opinion, the future of our entire profession, the very least that I and other pharmacists can do is to support their front-line services and their battle with adversaries.
The American Pharmacists Association (APhA) is the "umbrella" organization for the profession of pharmacy with a membership that includes pharmacists practicing/employed in all areas. It is a formidable challenge to represent the entire profession because, for certain issues, there will be differing opinions among the diverse membership based on their specific type of practice/employment (e.g., community, health-system, long-term care, faculty, pharmaceutical companies). In addition, most pharmacists would identify the national organization that has a mission and programs that address their specific area of practice as their "primary" association and advocate, rather than APhA. As with NCPA annual meetings, I have regularly participated in the annual meetings of APhA and, until I retired as a faculty member, the annual meetings of the American Association of Colleges of Pharmacy. I urge every pharmacist to be a member of APhA as a responsibility of our professional citizenship, and in at least one other national organization that provides advocacy and programs for one specific area of responsibility. This focus on "national" organizations does not overlook the importance of regional/state/local pharmacy organizations as action on some important issues can best be mobilized at the local level and some issues may be of particular importance in a state or other regional area.
The NCPA meeting
In addition to the educational benefits of the plenary sessions and other programming, as well as the exhibits, I greatly value the opportunity to speak with and learn from my discussions with individual and small groups of pharmacists. Their commitment to, pride in, and enthusiasm for the advancement of independent pharmacy and our profession are contagious. They travel to and participate in the meeting at their own expense, and commit their time, expertise, and resources for the benefit of others, in addition to themselves. They are the entrepreneurs and risk-takers whose confidence in themselves and their communities result in their investment that is essential for the future of our profession. I can't help but wonder how many pharmacists would attend national meetings of other pharmacy organizations if their expenses were not covered by their employer, a grant, or some other source. The commitment and spirit of independent pharmacists should be valued and emulated but, very unfortunately, many within our profession have ignored, abandoned, or even demeaned independent pharmacy to an extent that imperils the future of our profession.
A featured component of the NCPA meeting was the participation of Lina Kahn, the Chair of the Federal Trade Commission (FTC). In a discussion with NCPA CEO Doug Hoey, Ms. Kahn demonstrated a clear understanding and concern about the policies and actions of PBMs and health insurance companies that have had such a devastating impact on community pharmacy and the health care of consumers. Her comments and the recent actions of the FTC to require the largest PBMs to provide records of their practices that are of greatest concern are very encouraging. Although this is a very important step to address practices that many view as monopolistic and anticompetitive, the investigation and subsequent actions will require considerable time which may be further extended if FTC takes actions against the PBMs that the latter challenge in the courts.
The business plan competition involving student pharmacists has been a positive initiative of the NCPA to connect with colleges of pharmacy, and a team of students from the University of Arkansas for Medical Sciences College of Pharmacy was announced as the winner of the 19th annual competition. Students from 25 colleges of pharmacy participated in this event and the three finalists competed at the annual meeting. These students and their team advisers at 25 colleges of pharmacy are to be commended for their participation. However, this statistic is also disconcerting in that more than 115 colleges of pharmacy did not participate in the competition. With the exception of some NCPA student chapter faculty advisers, deans and faculty were conspicuous by their absence from the meeting. Their absence strongly suggests that the leadership of most colleges of pharmacy continues to be oblivious to or ignores the very important and positive influence independent pharmacists have had in the decisions of young people to study and pursue a career in pharmacy. However, this influence is diminishing, as are applications to colleges of pharmacy, as a result of the reduction in the number of independent pharmacists/pharmacies.
As the largest and strongest advocate for independent pharmacists/pharmacies, the NCPA is best positioned to unite, coordinate, and mobilize initiatives to strengthen and rescue this essential core of our profession. However, notwithstanding the extended reach of its programs and services via online communications and publications, only a small minority of its membership attend the annual meeting and experience the benefit and personal communication with peers and Association leadership. It is also noteworthy that, in addition to the three major pharmaceutical wholesalers, there were approximately 20 organizations/networks comprised of independent pharmacists that are identified as NCPA corporate members and which participated as exhibitors. As much as I would like to think that all of these organizations are committed to working collegially to establish a professionally and financially viable future for independent pharmacy, differences of opinion and the competitive relationships that exist among some of these organizations compromise the attainment of goals that might be possible if their resources and programs could be coordinated/united to achieve synergistic outcomes. The similarities of the goals and programs of these organizations are far more important than the differences that exist. If the leaders of these groups fail to take appropriate actions to achieve the common goals, their associations will experience the same consequences that have resulted in the closure/sale of many independent pharmacies.
The rescue
At the NCPA meeting I met individually with several independent pharmacy leaders, some of whom have also served in leadership positions in other national pharmacy organizations, for the purpose of learning from their experiences and opinions. These individuals, as well as pharmacists who have responded to the last 3 issues of The Pharmacist Activist, are in complete agreement in identifying the factors that threaten the survival of the independent practice of pharmacy and which are described in my last several editorials. However, there is not a consensus or even strategies voiced with strong conviction, regarding a best course of action to respond to the threats. To the extent there was agreement regarding strategy, it was something that the profession should not do, and that is to not "reinvent the wheel" (i.e., not establish another organization or initiative that would compete with or dilute programs or actions of NCPA). There was general agreement that the NCPA "wheels" are on the right track and have some momentum, and that CPESN provides a practice model that many more pharmacies should adopt as soon as possible. There was also agreement that the need to effectively respond to the threats is urgent and that the NCPA/CPESN "wheels" need to roll much faster on the most direct track to the destination in which independent pharmacists/pharmacies will survive and thrive. To summarize: a) we can specifically identify the sources and impact of the threats and the need to urgently act to avoid more destructive consequences; b) we recognize that some of the actions needed are outside of the control of our profession (e.g., actions of the FTC to require divestiture of components of the monopolistic and anticompetitive healthcare behemoths), and it is not possible to predict whether such actions will occur or, if they do, whether they will occur quickly enough to rescue independent pharmacy; and c) the profession of pharmacy including the strongest advocates for independent pharmacy do not currently have plans/strategies for a "rescue" or consensus on what actions to take.
Dan Hoffman, President of PBRA Consulting, is not a pharmacist himself but is very supportive of the role and need for independent pharmacists. He often comments on my editorials and his most recent message includes the following advice:
"I think your September Pharmacist Activist issue takes a definite step forward. I like that you named specific pharmacists who have embarked on various ventures which may be instructive. You also raise other useful ideas but I have to say that it still appears you are putting forward organizational process instead of substantive, business model planning.
Now if you want to start with committees, boards, planning groups, caucuses, and congresses, I suggest you should first task them with developing a business model for independent pharmacies that can attract hard-pressed pharmacists currently working at chains and people soon to graduate from pharmacy schools. Everything else should follow and depend upon that.
I am attaching an article that may be useful for your deliberations. Mark Cuban's Cost Plus Drugs has teamed up with Rightway, a small established PBM. As the article points out, Cuban originally said he would avoid PBMs and sell drugs directly online. Apparently Rightway found a way to work with Cuban's approach by taking a cut of Cost Plus's 15% markup without gouging end-users for their own profit and that of their payer clients. I bring this to your attention only for the purpose of suggesting that Cuban appears sufficiently flexible to modify elements of his business model – e.g., bypassing PBMs – as long as he can maintain his goal of selling medications at a fixed 15% markup. I suspect that once someone advises him of the value added by independent pharmacists (compliance, cost saving, reduction of adverse events), he can work out a way of including them in his model.
My suggestion is that you can make faster progress through an entrepreneurial approach than you can in the manner of an academic. That is, get no more than several other people committed to your efforts and get a grant to pay their salaries while they draft a business plan, talk to pharmacists practicing in various venues and organize a planning process. Then, once they've got something rolling on a plan, your starter team can hand it off to those who are in the best position to implement it."
I very much appreciate Dan Hoffman's interest in supporting the role and rescue of independent pharmacy, as well as his sage counsel. Several months ago, I had tried to send a message to Mark Cuban, but either it did not reach him or he was not interested in my suggestion that potentially synergistic opportunities exist in collaborating with independent pharmacies. I will attempt to contact him again and if any readers have access to reliable contact information for him, please provide it to me.
In the September issue of The Pharmacist Activist I recommended that our profession compile detailed reviews/case studies complete with business/marketing plans of innovative and professionally and financially successful practice models, and I provided summaries regarding four successful independent, but very different, practices. At the NCPA annual meeting additional types of successful healthcare practice innovations were identified and it is my belief that there are excellent independent practice models available now to provide a range of diverse opportunities that could be of value in extending the services/programs of existing pharmacies and provide the motivation for entrepreneurial pharmacists to establish new pharmacies. As a starting point for considering such opportunities, independent pharmacists who have not yet done so should learn about the CPESN practice model which has been widely adopted in a relatively short period of time.
The best ideas and the best patient-centered pharmacy practice models can not be implemented and maintained unless they are also financially sustainable (including external sources of funding such as grants, consultant services for community programs, and practice-based research). A business/marketing plan is essential but, because of the diversity of practice opportunities for independent pharmacies, the initial plan would need to be a "generic" template that can be adapted/extended to incorporate planning for the specific services to be included in the practice.
I have not been an entrepreneur and do not have experience in developing business/marketing plans and, therefore, can't provide leadership in these areas. However, I do have ideas and opinions that I hope would serve as a catalyst to stimulate and facilitate connections of ideas, pharmacists, and pharmacy organizations that would result in progressive actions. We know our services can be of much greater value for our patients and communities, we know the threats and barriers that so greatly limit the utilization of our expertise, we know the status quo is not sufficient for independent pharmacy and the profession of pharmacy, and many feel that our need for action is urgent, but we do not have adequate plans and strategies to effectively respond and move forward. I will continue brainstorming but your ideas and recommendations are needed.
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EDITORIAL:
Politics, Platforms, and Polls
If the number and frequency of political polls are indicators, many Americans must view them as credible and reliable. I am a skeptic. We don't have to be anytime close to elections to begin seeing polls that assess opinions of different groups with respect to politicians and myriad issues. Early on, there may be large differences (e.g., 10-20% or more) in the polls of public opinion to the delight or disappointment of those who eagerly await the results. However, after observing the results of many polls over many years, I have observed a trend. As election day approaches, the percentages of those who support each candidate are sufficiently similar that the outcome of the election is described as a "toss-up" or "too close to call." Were any of those earlier polls really of any value?
An even more predictable characteristic of most elections is that almost all of the campaign advertisements on behalf of a candidate are actually critical attacks against their opponent. Are we expected to assume that the positions of the candidates are the opposite of those for which they are criticizing their opponent? It would be refreshing to hear candidates state what they stand for, their positions on the issues they consider most important, and their reasons that support those positions.
If I was a candidate for an elected office next month…
I would conduct my campaign with integrity and transparency, and identify my positions on the following issues that I consider most important:
1. Violence, crime, vandalism, and fraud:
A society without laws and standards and enforcement of such will collapse, and violence, crime, and breaking laws must not be tolerated. Those who do so must be promptly identified, prosecuted, appropriately penalized, and provided opportunities for reform, repayment as appropriate, and reduction of penalties.
2. Freedom of speech, exercise of conscience, and integrity/objectivity of the media:
- Freedom to voice one's opinion must be assured and protected, but not permitted to reduce the rights, safety, and/or convenience of others;
- The right of individuals to exercise conscience for ethical, moral, or religious reasons must be respected and assured;
- When reporting "news" there should be integrity, objectivity, and completeness (i.e., avoiding omission of information that may not coincide with the opinion/bias of the reporter or media source);
- "Opinions" are of great value but should be identified as such, and not misrepresented as facts or news;
- Allegations of lies and misinformation must be supported with documentation/reasoning;
- "Fact-checkers" and individuals/organizations that make critical and/or damaging allegations regarding the statements, opinions, and/or actions of others must be held to the highest level of accountability.
3. Immigration:
Immigration laws and policies must be strictly enforced, and opportunities should be provided for legal immigrants that will facilitate their transition into their new society and workforce.
4. Drug overdoses and addictions:
- Educational and other programs that will reduce the "demand" for and recreational use of drugs that are often abused/misused (including marijuana) must be strengthened;
- Sources/supplies of illegally developed and distributed drugs must be reduced and penalties for perpetrators increased;
- Health professionals and others involved in the legal manufacturing, distribution, prescribing, and therapeutic use of controlled substances must be more accountable for avoiding inappropriate use and diversion;
- The utilization of the most effective existing approaches for treating/rehabilitating those with addictions should be encouraged, and more effective strategies developed.
5. Health care: The healthcare system is broken and must be reconstructed.
- Wellness and disease prevention programs should be emphasized;
- Patients should have freedom of choice in selecting the physicians and pharmacists in whom they have trust and confidence;
- Priorities of health professionals must include effective communication with and listening to patients, attainment of positive healthcare outcomes, and protecting patient safety;
- The rights of health professionals to exercise professional judgment and conscience must be protected;
- Healthcare insurance coverage and programs must be transparent, simplified, and concise;
- The costs of healthcare services and products must be reduced and specifically identified.
6. Education:
- Instruction in the K-12 public school system should focus on the development and enhancement of basic knowledge and skills, and must be significantly strengthened;
- Excellence in teaching should be recognized and rewarded;
- Communication with and involvement of parents in the educational process should be increased;
- School choice options for families should be facilitated. A portion of the taxes paid to support the educational system should be provided to families that choose to have their children educated in options other than the public school system (e.g., charter, private, religious, trade, special needs schools);
- Career guidance programs for high school students must be strengthened, with the recognition that going to college is not in the best interests of many graduates whose interests and abilities would be better served by participating in a skilled trade program/apprenticeship or entry into the workforce or military service;
- A "gap year(s)" should be considered by high school graduates who are undecided on a career direction.
7. Economy and environment:
- Employment opportunities should be increased, appropriately compensated, and include provisions for personal growth and advancement;
- The Medicaid/welfare system should be reformed and improved, and opportunities and incentives for those able to be employed should be increased;
- The economic system should be stabilized with priority given to supplying products and services essential for daily living and well-being available at affordable costs;
- Measures should be taken to protect the environment but resources for potential future benefits must not be at the expense of meeting immediate current needs.
8. Communities and local businesses:
Planning, financial support, and other measures should be strengthened to preserve/restore the legacy, character, vitality, and financial viability of communities and local businesses. The establishment of additional needed small businesses, healthcare practices, and community services should be promoted and supported, and residents should be urged to patronize ('buy local") these businesses and services.
9. Abortion:
I am opposed to abortion, with limited exceptions. Regardless of whether the result of conception is designated as an embryo, a fetus, the contents of the womb, an unborn child, or a baby, there is life, and abortion will terminate it. I support the SCOTUS decision that enables the citizens of individual states to establish laws/policies with respect to limiting/permitting abortion. When unplanned and unwanted pregnancies occur, placing a newborn child with an adopting family should be emphasized as a positive alternative to abortion.
10. Veterans:
Those who serve in the military and police and fire departments place their lives and abilities at risk to protect individuals, society, and our country. Some die and others are severely disabled in fulfilling their responsibilities. The highest-quality health care and services should be provided for those who are injured and/or experience physical or mental harm, and the immediate families of those who have died or experienced disabling harm in the line of duty should be assured of continuing resources and support.
Now that I am prepared for a debate, maybe I should be a candidate. Ask any question!
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