EDITORIAL:
Rescuing Independent Pharmacy: Part 3
Although they were not designated as such, the editorials in the July and August issues of The Pharmacist Activist could have the titles Rescuing Independent Pharmacy: Parts 1 and 2, respectively. If you have not had the occasion to read those, I encourage you to access them at www.pharmacistactivist.com before reading this Part 3. The "expanded" titles and the revisions of strategies/recommendations in this commentary have resulted from the advice that has been provided by many pharmacists and others who have responded. They have communicated strong support for most of the concepts I have voiced and have also proposed wise revisions and suggestions with respect to the goals/strategies and the timing/sequence in addressing them.
Basic challenges
For many within the profession of pharmacy, there is little or no identity with or understanding of the day-to-day experiences in an independent pharmacy or chain pharmacy, as well as the implications of these experiences for the entire profession. There may be a general awareness of growing financial challenges in an increasingly complex healthcare system, but not of the closely related events that contribute to the downward financial spiral. The size, wealth, and influence of government agencies and prescription programs, pharmaceutical companies, health insurance companies, and pharmacy benefit managers (PBMs) that have resulted in their almost complete control of the terms of programs and compensation for prescription medications and accompanying services are the dominant factors that start the negative cascade of events.
Independent pharmacists/pharmacies are most vulnerable to the consequences of non-negotiable and inequitable contracts of mandated prescription programs. Although corporate owners of chain pharmacies also have some vulnerability, they are in a stronger position to negotiate terms and achieve economies and efficiencies because of their much larger number of stores. As independent pharmacists attempt to cope with a quickly worsening financial dilemma, they often make hasty decisions that may include working longer hours, reducing services, and spending less time with patients. However, such a response will usually be self-defeating by substantially reducing the services, as well as the personal communication and relationships with patients. Providing personal, time, "touch," and counseling in assuring the effective and safe use of medications are the services of greatest value that pharmacists can provide. BUT, our profession has failed in convincing the public and payers of the value of these services, and the prospect of doing so is further compromised if independent pharmacies reduce communications and services in a manner that results in their being indistinguishable from chain pharmacies.
The negative cascade of events for many independent pharmacists accelerates as, in addition to having less time for patients, they have less time to be involved with professional associations, speak with other pharmacists with similar challenges, and to think about and plan positive, creative strategies that would better position them to professionally and financially survive.
Revising strategies
Considering the Concepts and Strategies identified in Part 2 as the starting point to identify revisions, the following course of action is proposed.
1. Steering Committee: Although a steering committee will need to be established, its formation should be preceded by brainstorming sessions involving a smaller number of pharmacists who are committed to the rescue of independent pharmacy. My friend Dan Hoffman, President of PBRA Consulting, is not a pharmacist but has extensive expertise and experience in assessing what works and what doesn't work in healthcare systems and delivery. He recognizes that almost all of my pharmacy experience has been in academia and wisely cautions that there are steps that must precede "the academic's reflex of establishing committees, boards, panels, and meetings whose results will consist of more panels, papers, and meetings."
Brainstorming has started with several pharmacy leaders who quickly and enthusiastically responded to the concepts identified in Parts 1 and 2 of this series of editorials. I will be attending the annual meeting of the National Community Pharmacists Association (NCPA) in early October and will be speaking with additional pharmacy leaders during that event.
2. Independent pharmacist organizations/groups/allies: The NCPA is the largest and strongest organization that advocates for the interests, welfare, and services of independent pharmacists. Other national organizations with similar interests include the American College of Apothecaries (ACA), Community Pharmacy Enhanced Services Network (CPESN), Alliance for Pharmacy Compounding, and Pharmacists United for Truth and Transparency (PUTT). In addition to some state/local/city organizations of independent pharmacists, other regional groups include wholesaler collaborative (e.g., Value Drug) and buying groups of independent pharmacists. All of these organizations/groups have their own current priorities, agendas, programs, and working relationships. Therefore, they may be reluctant to commit to participate in another initiative that does not yet have defined and specific goals and strategies. For this reason, priorities of the small group of brainstorming pharmacists (and friends) will be to clearly describe the professional and essential roles of independent pharmacists/pharmacies, and propose a business/marketing plan that will enable their establishment and promote sustained growth.
The provision of prescription medications in a system that assures the most appropriate selection, effective, and cost-efficient use at the least risk represents an important and continuing unmet need of the public. The scope of this need is expanded further when the extensive and often inappropriate use of nonprescription medications, dietary supplements, vitamins, and other "health-promoting" products are also considered. Pharmacists and our organizations repeatedly insist that pharmacists are the best positioned of all health professionals to address and resolve these needs. We further contend that pharmacists can improve patient compliance in using their medications and substantially reduce the risk of adverse events, drug interactions, and other drug-related problems in a manner that will reduce the costs of health care (e.g., hospitalizations) to an extent that will not only more than offset the increased financial commitment for expanded pharmacy services but will also achieve a net reduction in costs for the entire healthcare system. With few exceptions, we have not convinced the public and government officials of the need for and value of our services, but relevant questions also exist. Have we even convinced our profession of pharmacy of the validity of these claims? If we are convinced, why have we not been successful in achieving public and governmental support for our proposed solutions for numerous drug therapy problems? If our profession does not have enough internal support and strength to clearly, comprehensively, and convincingly communicate our messages of hope and value, we can't expect the public to understand or even be aware of them!
Existing organizations/programs/pharmacies: New strategies and plans should support and build on the existing foundation of initiatives with a similar vision, goals, and commitment to improve therapeutic outcomes for patients by increasing the utilization of the expertise and services of pharmacists. The NCPA is the largest and most experienced advocacy organization for independent pharmacists and all pharmacist owners should be members. The CPESN (www.cpesn.com) is a national clinically integrated network of hundreds of community pharmacies that coordinates patient care with other care teams to provide medication optimization activities and enhanced services for high-risk patients. Independent pharmacists who are not participants in or aware of this network and its services should evaluate the potential benefits of joining.
In addition to the programs and services provided by organizations that are advocates for independent pharmacists, there are individual pharmacists who have demonstrated entrepreneurism in establishing innovative practices that are both professionally and financially successful. Their vision and success are inspiring but they are the exceptions for which there is limited awareness even within our profession. The following are examples that come quickly to mind.
Pharmacist Amina Abubakar's pharmacy experience began in a large chain but she quickly recognized that important patient needs were not being met. She communicated with physicians whose patients had special medication needs and these working relationships resulted in her establishing an independent practice in Charlotte, NC. Her innovative practice and services (e.g., using pharmacogenomic information for the selection and appropriate dosing of certain medications) grew quickly and to the point that she needed expanded facilities. She purchased and extensively renovated a chain store that had closed, and the remodeled pharmacy practice area, laboratories, and offices are a "showplace" that reflects her commitment to her patients and pride in our profession. Her Avant Pharmacy has now extended to three locations in the Charlotte area.
Pharmacist Mayank (Mac) Amin has multiple abilities and interests but his passion is independent pharmacy and serving his patients and community. He would often ride past what had been the neighborhood, but now closed and vacated, independent pharmacy that had served his community well. As soon as he was in a position to do so he bought the property and renovated and reopened Skippack Pharmacy in a Philadelphia suburb. Many of his patients and community civic and business leaders gathered for the ribbon-cutting to celebrate the reopening. Mac and his pharmacy colleagues and community volunteers have been national leaders in providing tens of thousands COVID-19 and other immunizations. His COVID-19 immunization program began on a snowy Sunday morning in February, 2021, from which a video showing Mac in a Superman outfit carrying boxes of vaccine has received extensive media publicity, as have his subsequent programs.
Pharmacist John Sykora developed and pioneered the concept of medication synchronization in his Abrams and Clark Pharmacy in Long Beach, California. This concept has been adopted nationally and not only has improved therapeutic outcomes for tens of thousands of patients, but has also enabled business and inventory financial efficiencies for pharmacists. His vision has become a "gift" to patients and the profession of pharmacy.
Pharmacist Lucy Malmberg and her late husband George, also a pharmacist, bought a small independent pharmacy that was on the brink of closing for financial reasons. Their vision was to recognize the continuing benefit and potential of a practice that had essentially been abandoned by many within the profession of pharmacy – Pharmacy Compounding. Commercially manufactured pharmaceutical products dominated pharmacy practice, but Lucy and George understood that the "one size/potency/dose fits all" concept was a fallacy. Collaborating with prescribers, they customized and personalized compounded prescriptions that provided the best balance of effectiveness and safety for individual patients. They restored the image of compounding as the original "personalized medicine" and their Wedgewood Pharmacy (New Jersey) quickly grew to the point that the FDA erroneously alleged that they were a "manufacturer" rather than a pharmacy. They battled the FDA challenge at huge personal expense all the way to the Supreme Court of the U.S. where they prevailed in a victory for their pharmacy and for our profession. Through continued rapid growth and acquisitions, Wedgewood Pharmacy became the largest compounding pharmacy in the country, as well as the largest compounder of products for veterinary patients (pets, zoo animals, wildlife).
Pharmacist Nate Hux has owned Pickerington Pharmacy (Ohio) and, in 2020, opened Freedom Pharmacy right next door. The original pharmacy takes almost all insurances but Freedom Pharmacy takes no insurance and dispenses generic medications at wholesale prices plus a markup. Based on the particular medications patients are taking, Nate advises them as to which of his two pharmacies will be the best and less costly to obtain their medications. His practice was recently featured in comprehensive media coverage titled, "Frustrated pharmacists are opting out of the insurance system, saving some customers hundreds of dollars a month."
The pharmacists identified above have integrated innovation, professionalism, and entrepreneurism with personal care for their patients. Their accomplishments are inspiring, as are the practices of many other pharmacists. But to what extent are they communicated and known to those within our own profession who could be motivated to adopt similar or extended practice models for the benefit of their patients and themselves?
Our profession should compile detailed reviews/case studies complete with business/marketing plans of innovative and professionally and financially successful practice models that could be widely distributed. This could be an excellent research project for a graduate student in pharmacy administration. The case studies could be published in a text that also would be used in an elective course that colleges of pharmacy could offer as part of efforts to encourage entrepreneurism and ownership of independent pharmacies.
Patient advocate allies: The profession of pharmacy has an unfulfilled opportunity to collaborate with individuals and organizations who are not health professionals but who are advocates for more effective and safer health care and medication use by patients. Our profession is fortunate in that initiatives that would best achieve those goals for patients would be mutually beneficial for the goals of pharmacists.
Loretta Boesing is the Founder of Unite for Safe Medications ( www.uniteforsafemeds.com). Based on her son's experience, she became an activist, primarily against mail-order pharmacies and the unacceptably high temperatures to which medications they send are often exposed. At an early age, her son was identified as needing an organ transplant. The transplantation surgery was considered successful and he was prescribed several immunosuppressive anti-rejection medications. The family was informed that the medications had to be obtained from a mail-order pharmacy if most of the substantial costs were to be covered. The medications were shipped in the southern U.S. during a summer in which heat and humidity were oppressive in standard bags/packages in the cargo areas of trucks that were not air conditioned. At least one of the medications that were exposed to extremely high temperatures during shipment apparently lost potency and was considered a factor in the rejection of the organ transplant her son received. Fortunately, subsequent surgery and other interventions have restored health for her son, but Loretta was baffled as to how medications could be shipped under conditions that could endanger patients. However, her questions to regulators whom she expected to act on her concerns were dismissed or ignored, with the result that she started her advocacy organization. In late August, Loretta had the opportunity to give a presentation regarding her experiences and concerns at a district meeting of boards and colleges of pharmacy. She was very encouraged by the interest and support of student pharmacists of the Southwestern Oklahoma State University College of Pharmacy and some of the pharmacists who attended the meeting. However, she was shocked that some representatives of mail-order pharmacies, as well as some members of boards of pharmacy minimized her concerns and/or did not consider further action necessary.
Loretta and other "consumers" are important allies for our profession whose advocacy for patient safety and safe working conditions for pharmacists are synergistic with ours. Indeed their advocacy is stronger than that of many pharmacists and we must collaborate more extensively and effectively.
PBMs and health insurance companies: The non-negotiable and egregious prescription "benefit" programs of PBMs and health insurance companies have had a devastatingly destructive impact on independent pharmacies and the profession of pharmacy. The NCPA and several other national and state pharmacy associations have committed extensive effort and resources against these companies and their anticompetitive and deceptive programs over several decades, but with very limited success. However, these are battles that must continue to be fought and supported by the entire profession of pharmacy. And following decades of frustration, there are now some encouraging actions and responses.
On December 10, 2020 the Supreme Court of the United States (SCOTUS) with a unanimous vote restored/upheld the Arkansas law that would regulate certain provisions of prescription plans administered by PBMs, and in doing so emphatically rejected the challenges of PBMs. Substantial progress has also been made in discussions with the Federal Trade Commission (FTC) and the Department of Justice (DOJ). On February 24, 2022 the DOJ announced that it was initiating litigation to block UnitedHealth Group's acquisition of Change Healthcare, a large health data company. Unfortunately, a federal court ruling in mid-September has allowed this acquisition to proceed. However, there have been positive steps on other fronts in this battle.
On June 7, 2022, the FTC announced that it would launch an inquiry into the prescription drug middlemen industry and required the six largest PBMs (CVS Caremark, Express Scripts, OptumRx, Humana, Prime Therapeutics, and MedImpact Healthcare Systems) to provide information and records regarding their business practices. The press release states that "this inquiry is aimed at shedding light on several practices that have drawn scrutiny in recent years including:
- fees and clawbacks charged to unaffiliated pharmacies;
- methods to steer patients toward pharmacy benefit manager-owned pharmacies;
- potentially unfair audits of independent pharmacies;
- complicated and opaque methods to determine pharmacy reimbursement;
- the prevalence of prior authorizations and other administrative restrictions;
- the use of specialty drug lists and surrounding specialty drug policies;
- the impact of rebates and fees from drug manufacturers on formulary design and the costs of prescription drugs to payers and patients."
This comprehensive listing of practices to be examined reflects understanding of the concerns that NCPA and other organizations have continued to communicate, and individual pharmacists must continue to provide documentation of situations that demonstrate these egregious practices.
On June 16, 2022 the FTC issued a press release with the title: "FTC to Ramp Up Enforcement Against Any Illegal Rebate Schemes, Bribes to Prescription Drug Middlemen That Block Cheaper Drugs," further suggesting its awareness of the deceptive and anticompetitive practices of the middlemen and pharmaceutical companies. The NCPA has just announced that FTC Chair Lina M. Khan will be speaking and responding to questions at its 2022 Annual Convention from Oct. 1-4 in Kansas City. The wealth, lobbying, and influence of the PBMs and health insurance and pharmaceutical companies must never be underestimated, but recent events are more encouraging than at any previous time.
3. Chain Pharmacists: In the August issue of The Pharmacist Activist, I included a discussion of the deplorable working conditions of chain pharmacists and the increased risk of errors and harm to patients. These issues continue to be extremely important but are so different from the challenges of independent pharmacists that they are best considered separately. A plan is under development to establish an effective communications system and strong "voice" for these pharmacists, and it is anticipated that more specifics regarding this initiative will be announced before the end of this year.
4. Colleges of pharmacy: A substantial decline in applications and enrollment is being experienced by most colleges of pharmacy, and some will close as a consequence. A review of the actions approved by the House of Delegates at the recent annual meeting of the American Association of Colleges of Pharmacy does not provide even a clue to the importance of these issues that some attendees describe as "the elephant in the room." In many respects, the challenges faced by the colleges of pharmacy are parallel and related to those faced by independent pharmacies.
To my knowledge, not even one college of pharmacy requires students to complete their APPE community pharmacy rotation in an independent pharmacy. Before my "retirement" as a faculty member, I was not successful in convincing my own faculty colleagues of the value in doing this. There are many excellent chain pharmacists, but it is much more likely that independent pharmacists have a stronger professional role in knowing and serving their patients, being involved in their communities, participating in the activities of pharmacy organizations, and applying entrepreneurial and management skills in the operations/services of their pharmacies. Wonderful opportunities that would be of mutual benefit for the students, colleges, and independent pharmacists are being missed.
To continue to ignore such arrangements further increases the risks to colleges of pharmacy in maintaining sufficient enrollments and financial stability. Young people who are now or soon will be making career and college decisions, and who are working part-time in a chain pharmacy, are not likely to be encouraged to study pharmacy as they observe the working conditions and the stress and negativity of the pharmacists. A part-time employment experience in an independent pharmacy is much more likely to have a positive influence that could encourage young people to study and pursue a career in pharmacy, as has been the experience of many thousands of pharmacists over the years. However, not only have many colleges of pharmacy abandoned independent pharmacy and relegated it to obscurity, they have failed to recognize they are damaging and reducing the pool of potential applicants they will need to maintain enrollments and vitality.
As within every profession and vocation, there are stronger, but also weaker, independent pharmacists/pharmacies. To date my position has been that pharmacy students fulfill their APPE community pharmacy rotation requirement in an independent pharmacy. I am now revising my position and recommending that every pharmacy student fulfill this requirement in a CPESN-participating pharmacy or another independent pharmacy with a strong commitment to provide optimum therapeutic outcomes. The excuses for not doing so will be the immediate response – e.g., there are no CPESN pharmacies within convenient traveling distance from our college (that conveys a message that convenience of location is more important than value for the students). There are some states with no or few CPESN pharmacies. This situation must not be viewed as a limitation/restriction but rather as an opportunity. Colleges of pharmacy could identify local independent pharmacies (or start one) that would have the best potential to affiliate with CPESN, and provide part-time faculty support and other resources.
Independent pharmacies, colleges of pharmacy, and the entire profession of pharmacy must be PROACTIVE. Contemplation of the alternatives is not encouraging. The collegial relationship that colleges of pharmacy have claimed is already being replaced by sometimes intense and negative competition to recruit from a smaller pool of applicants for whom admission standards are being reduced. Colleges of pharmacy were oblivious to or just stood by during the closure or sale of many independent pharmacies and the disappearance of many local pharmacy organizations. Now that colleges of pharmacy are facing related challenges, will their experience be any different? Can they expect support from pharmacy organizations or even their own alumni, many of whom perceive their alma mater to only be interested in how much they will contribute? To what extent are current graduates proud of, enthusiastic, and supportive of their alma mater? Or are their primary concerns the burden of substantial college debt and difficulty in identifying a professionally fulfilling employment opportunity for which their alma mater may be providing no or little assistance? The questions continue at a faster pace than answers can be identified. Your comments and recommendations are always welcomed!
To be continued…
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