EDITORIAL:
How Will Pharmacy Recover from 2024?
The following are among the most important issues that dominated the attention of pharmacists and our associations in 2024.
HUNDREDS OF COMMUNITY PHARMACIES CLOSED; MORE PHARMACY DESERTS DEVELOPED.
PBM REFORM HAS NOT BEEN ACCOMPLISHED.
SHORT-STAFFING AND WORKPLACE CONDITIONS IN LARGE CHAIN PHARMACIES HAVE BECOME EVEN WORSE.
SERIOUS/FATAL MEDICATION ERRORS HAVE NOT DECLINED.
MAIL-ORDER PHARMACIES CONTRADICT THE PROFESSION'S POSITION THAT PERSONAL COMMUNICATION OF THE PHARMACIST AND PATIENT IS IMPORTANT.
PROVIDER STATUS FOR PHARMACISTS HAS NOT BEEN ATTAINED.
MOST PHARMACY ASSOCIATIONS ARE NOT EFFECTIVE IN ADDRESSING CHALLENGES.
MOST BOARDS OF PHARMACY ARE NOT EFFECTIVE IN REQUIRING HIGH PHARMACY PRACTICE STANDARDS AND PROTECTING THE PUBLIC.
COLLEGES OF PHARMACY APPLICATIONS AND ENROLLMENTS HAVE DECLINED.
PHARMACY'S RELATIONSHIP WITH MEDICINE AND SOME OTHER HEALTH PROFESSIONS IS ADVERSARIAL.
THE CYBERATTACK ON CHANGE HEALTHCARE/UNITEDHEALTH CRIPPLED THE PROVISION OF PHARMACY SERVICES AND STOLE SENSITIVE INFORMATION OF ABOUT 190 MILLION PEOPLE.
Some will criticize me for focusing on negative issues and not identifying successes that have occurred. I make no apology! Our pharmacy associations prominently identify their programs and accomplishments, and I consider it very important that they provide and promote the best possible image and roles for pharmacists. However, I would contend that if our profession can't effectively address the challenges in the above list, we are not in a position to identify, implement, and sustain positive and successful initiatives.
I acknowledge the limitations of my awareness of the scope and specifics of activities and innovations in which pharmacists are involved, as well as the priorities, policies, and commentaries of the pharmacy organizations. I welcome comments, different opinions, and criticisms in response to this and all issues of The Pharmacist Activist. For those who consider my list of the most important pharmacy-related issues of 2024 (that carry over into 2025) to be excessively negative, please identify the advances/successes you consider important to include.
It is not sufficient to identify problems facing our profession and fault those who have caused and exacerbated them. We must identify recommendations, strategies, and solutions that will resolve the problems or enable us to effectively respond to them. I have not been successful in identifying solutions or even recommendations that have been supported by pharmacy leaders. However, I am confident that there are pharmacists and others with healthcare expertise and experience who have the vision, wisdom, and leadership abilities to identify and implement strategies and plans that will enable our profession to move forward in 2025 and beyond. How do we identify these individuals and how do we focus their collective involvement and deliberations to advance our profession and improve drug therapy outcomes for patients?
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EDITORIAL:
A New Year – An Old Theme: Pharmacy Needs a More Effective National Organizational Structure!
There were a number of years in which I used the above title as the theme for my commentary in the January issue of The Pharmacist Activist and some other periodicals in which I was involved. The last time I did that was in January 2016 when I proposed an outline for a single, unified, and stronger organizational structure for pharmacy – The United Pharmacists of America (www.pharmacistactivist.com: January 2016).
I have commented on occasions since then about our national pharmacy organizational structure and what I consider to be its important limitations. However, pharmacists who are in a position to actively explore alternatives do not share my concerns. But there is a more important question to consider for pharmacists who received their degree prior to 2016:
"Is the profession of pharmacy in a stronger position in 2025 that it was 10 years ago?"
My response to this question is "NO.' For those who would respond "YES," I welcome your reasons for your response. For those who respond "NO," how should the profession respond to address our concerns?
In the list of issues I identified in the preceding editorial, I consider the first five to be the most threatening for our entire profession, and also inter-related (i.e., pharmacy closures/deserts, PBM reform, short-staffing/workplace conditions, medication errors, mail-order pharmacies).
How did we arrive in this situation?
Although there were a number of community apothecaries and some hospital apothecaries already established in the U.S., it was during the early 1800s when the numerical growth in community apothecaries/pharmacies accelerated, as did the recognition of the healthcare role of pharmacists. This growth and momentum resulted from the activities, services, determination, and bold initiatives of community pharmacists. They established the foundation of the profession that has enabled the impressive development of expanded practice areas/sites and responsibilities, specialties, and services. During the mid-to-late 1900s, chain pharmacies (e.g., CVS, Rite Aid, Walgreens) grew rapidly, big-box stores and grocery stores established pharmacy departments, and mail-order pharmacies became huge prescription mills in which pharmacists had no personal communication with patients. These changes started the serious erosion of decision-making authority and professional autonomy of pharmacists in determining the type and scope of professional services to be provided for patients. These decisions are now made primarily by corporate executives who are not pharmacists and for whom the highest priorities are profits and stock value.
Many independent pharmacists were able to continue to practice professionally, in spite of an increasingly complex and competitive marketplace. However, when the huge PBMs (CVS Caremark, Express Scripts, United Health/Optum) seized control of the selection, distribution, use, and costs of prescription medications (i.e., the drug distribution system), the disastrous financial impact on independent pharmacies and some chain pharmacies resulted in many closures.
How should pharmacy respond?
Of the many pharmacy practice areas and specialties, community pharmacies/pharmacists are, by far, the largest segment, the most visible, and the identity of our profession for the public. Community pharmacies are also the most threatened area of our profession. The policies and abysmal compensation imposed by PBMs, as well as the understaffing and egregious policies of the management at the largest chains, have made it almost impossible for pharmacists to devote time to counseling and providing professional services.
If the community pharmacy foundation of our profession collapses, I believe that our entire profession will collapse.
Our associations
The National Community Pharmacists Association (NCPA) is the largest pharmacy association that represents the interests of independent pharmacists. As anticipated, the NCPA has been the most active, boldest, and critical in challenging the programs, companies, and agencies that threaten the professional and financial survival of its members. However, its efforts have fallen short as is evident from the issues identified at the beginning of this issue. The NCPA needs strong support from the entire profession but is not receiving it.
In addition to the closures of many independent pharmacies, hundreds of chain pharmacies have closed in the last several years. Rite Aid declared bankruptcy and Walgreens is experiencing another crisis. The National Association of Chain Drug Stores (NACDS) may be viewed by some as representing the interests of chain pharmacists. However, the NACDS is not a pharmacist membership association, but rather represents the interests of the corporate chain organizations and their executives. With respect to some issues such as the threats imposed by PBMs, the priorities and actions of the NACDS may coincide with those of NCPA and the profession of pharmacy. However, with some other issues, the positions of NACDS correspond to those of its corporate members and may be contradictory to those advocated by the profession of pharmacy.
The American Pharmacists Association (APhA) represents pharmacists in all areas of responsibility and has the primary role of promoting and advancing the interests of the entire profession of pharmacy. I consider it essential that such an organization exists to assume the broadest role in representing pharmacists in all areas of professional pharmacy practice. But this, in and of itself, is a formidable challenge given the broad range of opportunities in which pharmacists participate. APhA and NCPA have worked closely and effectively together in addressing the current threats, but even their combined efforts have fallen short.
The American Society of Health-system Pharmacists (ASHP) has a large membership that approximates that of APhA. Its primary purpose is to represent the interests of pharmacists practicing in hospitals although it has extended its initiatives to "health-systems," that may include affiliated practice sites that serve ambulatory patients. The ASHP represents its membership very effectively, but at the present time does not experience the situations that threaten independent community pharmacies. However, many small hospitals have closed and others are fighting to survive. Many hospital pharmacists have no personal communication with patients, and do not have decision-making authority for the type and scope of the pharmacy's professional services. Rather they must operate according to the directives of hospital administrators who are usually not pharmacists or other health professionals, and whose decisions are usually driven by economics and not by the quality of patient care and services. Hospital pharmacists are at risk of being the next large group of pharmacists to encounter the short-staffing. workplace conditions, and suppression of patient communication and professional services that many chain pharmacists now experience.
The other national pharmacy associations have been established for the primary purpose of representing pharmacists in a particular area/specialty of practice or affinity group. However, their development has been possible only because there is a foundation for our profession established primarily by independent community pharmacists on which additional/expanded practice roles, services, and locations can be constructed. The priorities of these associations typically focus exclusively on the needs and interest of their memberships. Their memberships are relatively small. Although they provide an important role and services for their members, their priorities have a limited focus and, even collectively, they can't provide an identity for the profession with the public.
Hundreds of dedicated pharmacy leaders and our pharmacy associations have been successful in establishing new pharmacy practice roles and services. This commentary is not intended to be critical of the associations and these leaders. Indeed, with the challenges in increasing membership and resources, the number of successful programs they have established is noteworthy. However, the successes are largely in the professional areas of responsibility and have no or limited economic support to sustain their growth and widespread implementation.
At the same time, the PBMs and health insurance companies have increased their dominant control of the drug distribution system that has resulted in a highly destructive impact on the provision of pharmacists' services for patients, as well as threatening the financial survival of pharmacies. In my opinion, consequences of these threats far exceed the value and importance of the successes our profession can claim. In 2024, NCPA and APhA committed extensive time and resources to obtain bipartisan legislative support and approval of PBM reform and provider status for pharmacists in what was considered the best opportunity to attain these goals. Even with these best of circumstances, these proposals were not approved, in large part because, in spite of strong lobbying and support, our profession can influence but does not have authority for decisions and resultant outcomes. The fight to strengthen these efforts must continue to be supported, but we must also identify strategies and programs for which pharmacy has some control. Doing nothing is not acceptable and the threats of the status quo will result in more damage. Let's consider the likely consequences if our profession is not successful in advancing our professional roles and services for patients, and obtaining equitable compensation for pharmacists.
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The closure of independent pharmacies will continue at an even faster rate. The strongest will survive, but their numbers will be small and they will be located so far apart that their existence and services will become invisible to most of the public and decision-makers. Even now, much of the public has never been in an independent community pharmacy. They will no longer be recognized or remembered as the foundation and public identity of the profession that enabled the establishment of so many professional practice opportunities.
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The vast majority of the population are ambulatory residents of their communities. If a large majority of independent pharmacies close, what type and group of pharmacists will become the public identity for our profession?
My answer:
LARGE CHAIN AND MAIL-ORDER PHARMACIES!
No other group or combinations of groups of pharmacists in other practice sites or specialties are in a position to become the public identity of our profession. Although a large number of pharmacists are employed in hospitals, the percentage of the public which is aware of chain and mail-order pharmacies is far greater than the percentage which is aware of the responsibilities and services of pharmacists in hospitals and other practice sites. One consequence of the continuing closures of independent pharmacies is that personal communication of pharmacists and patients will decline to the point that the awareness of its value will be lost. If/when that occurs, can pharmacy continue to justify its valued recognition as a health profession, or will it be viewed, as many already do, as just a link in the drug distribution process?
Recommendations
Multiple strategies can be pursued but I will initially identify one for which the profession has complete control – establish a stronger and more effective national organizational structure that is committed to advance the interests of the entire profession of pharmacy and the professional practice roles of its membership groups. I can agree that every national association of pharmacists provides valued services for its members. However, can these services and professional advocacy not be provided within, rather than separate from, a larger and stronger existing pharmacy association? In my view, the interests and advocacy for a new practice role and the participating pharmacists can be established more effectively and efficiently when it joins a larger, established association (e.g., as a special interest group, specialty, or academy), than if it is established as a new association with the administrative and sustained operational costs needed. Even with capable leadership and valued programs, the existing national pharmacy associations function separately from the others, and too often compete with each other and/or have overlapping/duplicative programs and services. In many situations, this fragmented approach has been successful for individual associations but, in responding to the most important challenges listed earlier, our associations and profession are falling far short of what needs to be accomplished to move pharmacy forward.
In the January 2013 issue of The Pharmacist Activist, I made the recommendation, "The APhA and ASHP Should Merge!" I received supportive comments from some pharmacists but the one association officer who responded rejected the concept. Twelve years later, the national pharmacy organizational structure is essentially unchanged with the exception of the addition of several small organizations. During this period it is my understanding that some of the associations have experienced financial challenges and have reduced staff. In addressing some of the most important issues, communication among associations in the preparation of letters and position statements on the issues has increased, and included listings of dozens and even hundreds of national, state, and local pharmacy and other associations which support the message. These initiatives provide some encouragement that there has been more communication among the associations, and a possible glimmer of recognition that the larger number of supporting associations increases the likelihood of a positive response.
Although these efforts have not provided the desired outcomes, I commend the association leaders who planned this strategy. My hope is that there will now be a greater recognition of the strength and synergies that can be achieved if the national pharmacy associations merged into a much larger association that would take strong unified positions to address important issues, and also use that strength to add support for the professional priorities of the groups of pharmacists in different types and locations of practice.
I recommend consideration of the following actions:
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The NCPA and APhA should merge. These are the two associations with the strongest commitments to protect and strengthen the professional services of community pharmacies provided to the largest segment of the population.
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The ASHP should be included in the deliberations from the beginning with the goal that it will also be part of the merged structure. Its participation will add substantial and important extensions of the scope of professional programs and services, as well as the experience and skills associated with those roles.
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The initial planning should provide for the addition of other national associations of pharmacists with differing primary areas of professional responsibility. When strong progress in merging APhA, ASHP, and NCPA, becomes evident, the other organizations should welcome the opportunity to be part of the stronger and unified organization. The momentum will build!
These actions will require unprecedented commitment and effort, but we should not let that intimidate us. Some will immediately reject the concept as many have done previously; some will support it; some will identify other strategies that have the potential to be more effective and supported by more associations; and some will ignore it.
For those who ignore it or are satisfied with the status quo, consider what I consider to be the likely consequence of inaction:
CHAIN AND MAIL-ORDER PHARMACIES WILL BE THE PUBLIC IDENTITY FOR OUR PROFESSION!
Your opinions and ideas are important and I welcome them!
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