Pharmacy’s biggest problem in the outpatient space: the retail prescription

There’s a very interesting article at the Pharmacy Times that talks about the how the “retail prescription” has created a lot of problems for outpatient pharmacies, and it’s not what you think. At least it wasn’t for me.

“The real problem is more fundamental, emanating from the most basic elements of pharmacy practice…How ironic that a factor which is such an integral part of the profession—the retail prescription—also functions as an internal deleterious force.

The prescription is pharmacy’s direct connection to the population at large. If the patient care services associated with prescriptions were fully optimized, pharmacists could collectively achieve improvements in the health and well-being of countless individuals that would be clinically and economically awe-inspiring. One only need review the findings of the Asheville Project to appreciate what can be accomplished by community pharmacists who provide comprehensive clinical services in concert with prescription processing.

There should be a baseline of direct patient care associated with EVERY prescription, with appropriate follow-up intervention as warranted. Imagine what pharmacy practice would be like if that were the norm, with medication therapy management (MTM) offered as a routine service for all prescriptions, not just those relating to select drugs or disease states.

Unfortunately, the reality of the typical community pharmacy work environment tells a different story. All the talk about shifting focus from product to patient has been largely just that—talk. Rather than building on the patient care potentials of the retail prescription, current pharmacy trends seem more intent on expediting the process as much as possible by employing strategies that range from automation to centralization.”

The article goes on to lay out a compelling argument as to why processing prescriptions is a problem. I’ll give you a hint, it has to do with the willingness to accept low reimbursement from insurance companies. The author, Daniel Brown, PharmD, lays out an interesting strategy to bring pharmacists out from behind the counter and put them in front of the patient. It’s a good plan, and you should all go read it. Unfortunately reality is standing in the way.

You see, retail pharmacies have no desire to provide direct patient care unless it helps them turn a profit. They are the ones that continually accept lower and lower reimbursement from insurance companies, which in turn force independents to do the same to stay in business. It’s a never ending race to the bottom. The problem is that retail pharmacies like Walgreens, CVS, Rite Aid, among others have deep pockets and great lobbies. Independent pharmacies find it difficult to compete. Oh sure, the retail pharmacies are “getting into integrated health”, but the plan isn’t to provide better healthcare. No, the plan is to increase their reach. Putting a retail store inside a hospital is a way to increase your script volume and customer base. Think about it. Ugh, Walgreens has even managed to put a retail store on the UCSF Medical Center campus. As a UCSF alumnus I find it disturbing.*

There are three things that must happen before pharmacists will be able to truly engage patients in the outpatient space:

  1. Use technology as much as possible to minimize the time pharmacists spend filling and checking prescriptions. The technology is there, but not used appropriately. Should a human hand ever “fill” a prescription? Seems ridiculous in this day and age, but it happens millions of times a day. This is where I think pharmacy as a profession could learn a lot from logistic geniuses like Amazon. Seriously, when you boil it down to the nuts and bolts of it, pharmacy distribution is a logistics problem.
  2. Work with Boards of Pharmacy (BOPs) to better define what pharmacists and technicians can do; see item #1. The time for pharmacists to physically touch prescriptions is over, but BOPs have been slow to respond.
  3. Hospitals and healthcare systems need to partner with independent, i.e. community pharmacies to provide outpatient services for hospitalized patients upon discharge. Using national chains isn’t the answer because they don’t care about your local community, independents do. This should include delivering medications to the beside and providing patient education before discharge, follow-up after discharge, and thorough medication therapy management throughout the patient’s care. Difficult to get started for sure, but it would be worth it in the long run. Using local, community-based pharmacies is better for the patient, it’s better for the hospital, it’s better for the community, and it’s better for pharmacy.

Perhaps when the profession has accomplished the three goals above will Dr. Brown’s vision become a reality.

*UCSF and Walgreens “reimagining pharmacy care”. Yeah, not so much…

2 thoughts on “Pharmacy’s biggest problem in the outpatient space: the retail prescription”

  1. Interesting post. A few thoughts:

    I don’t think the chains wanted lower reimbursements, but instead may have traded lower reimbursements for increased volume to remain competitive in the marketplace look at what happened to Wags when they didn’t give in to ES). This is a feature of economies of scale and in the end reduces healthcare costs and probably benefits patients in their wallets.

    I am not sure how much of the reduced reimbursements were driven by the pharmacy-side so much as the payer side anyway, especially when you look at the history of medicaid programs and how PBMs came about.

    With that being said, I think that a move towards greater direct patient care, etc. still requires some sort of financial incentive to remain sustainable- if people don’t get paid for it, they are less likely to do it or to invest in the technologies needed to move towards that model- this is true for independents and chains alike. If the proper financial incentives are there, even the chains support it- after all, that means more billables for them too. One of the concerns with chains is whether they abuse that power to bill and provide a high quantity of low quality services just to make more money, which given their recent history is easily possible, but in my opinion is another issue altogether.

    I think in this climate convincing stakeholders that we should be paid for more professional services comes down to showing that pharmacists can generate long-term cost savings and improve outcomes via the interventions that we can make.

  2. Great article Jerry. What some folks fail to take notice of are the THOUSANDS of clinical interactions, decisions, changes, phone calls, and interventions that constantly go on as retail pharmacists interact with DUR screens and insurance rejects. These happen ALL the time and are almost entirely INVISIBLE to the public and to other professionals.

    The idea that technology could replace a pharmacist’s involvement in dispensing sounds great. But it is like the idea of having a robot drive your car. In theory…it could work. But the degree of technology needed is well beyond where we are at today.

    I think we’ve hit rock bottom. The race is over. Now we need to start climbing again…1 patient interaction at a time.

    Keep up the great writing! I’m a fan.

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