A Fork in the Road: The Community Pharmacy Perspective

The particular skill set of the pharmacist is more fully utilized when the quality of care provided is valued over the quantity of prescriptions filled.

Traditionally, a community pharmacy’s success has been defined by the sheer volume of prescriptions it can fill on a day-to-day basis with little regard for the level of patient care or health services it can offer. A pharmacy is deemed successful simply for processing a large quantity of prescriptions, and so far, community pharmacy has been rewarded financially for doing so.

This “quantity over quality” model has put today’s pharmacist in a difficult position in a role of quality control rather than as a valuable and participatory member of a health care team. Pharmacies have been operating in this specific fashion for a very long time and making major operational challenges can be difficult. However, a new approach could provide the pharmacist with opportunities that will better utilize their unique skill set to improve each patient’s outcomes.

Showing Value

A community pharmacist’s role is unique when compared to other members of the health care team, and due to the uniqueness of this position it can be very valuable in providing a distinct form of patient care. Community pharmacists are easily accessible, often interacting with patients more than once every 30 days. A community pharmacist will see changes made by various providers for a single patient faster than a primary care provider. Community pharmacists are also the first provider a patient will see after a transition of care, for example, a hospital discharge. These distinct scenarios for a community pharmacist are an opportunity to provide a higher level of patient care that is advantageous from a population health management perspective and differs from what a patient has been traditionally provided.

As community pharmacy has grown we have already seen some opportunities arise. The accessibility and medical knowledge of pharmacists has already persuaded many state legislators to allow them to provide vaccinations that go well beyond the simple flu vaccine. Medicare Part D plans as well as private insurance plans are being incentivized to reduce hospital admissions and improve patient outcomes, and they have turned to community pharmacists to expand their health care role.

Many insurance providers have set up medication therapy management (MTM) programs that pave the way for pharmacist-led care to reconcile the common errors that can be created by a patient seeing multiple providers or from a patient misunderstanding a provider’s instructions given at an office visit. These MTM programs are utilizing the community pharmacist as the central hub of a patient-based health care team. A pharmacy has the ability to see all of a patient’s medication and fill history and this can be used not only to identify common problems, such as drug interactions or therapeutic duplications, but also as a reference to measure a patient’s adherence to therapy.

Why Value over Volume?

When asked why pharmacists who devoted themselves to gathering the knowledge and experience necessary to provide a high level of medical care have instead devoted their expertise to simply finding ways of cutting costs and increasing revenues, the answer is simple: money. However, due to factors such as increased competition and decreasing reimbursements a simple volume-based model may not be enough for a community pharmacy to stay viable. Community pharmacy is a retail business, and within that setting, customer service is the key to success.

The difference between pharmacy and a typical retail setting is that insurance companies can incentivize a patient to use 1 particular pharmacy, regardless of customer satisfaction. As important as customer service is in every facet of business, a patient may not be willing to spend $5 more at a particular pharmacy simply because the cashier was polite.

We believe that making a difference in a patient’s quality of life can be the deciding factor in where they choose to have their prescriptions filled. Furthermore, with the expansion of the star rating program for Medicare Part D and preferred pharmacy programs by private insurance companies, we feel it is necessary to set ourselves apart from our competitors by providing services that some may continue to ignore.

A Changed Business Model

At our pharmacy, we have implemented a variety of patient care—centered services. Our first step was to utilize the information that was readily available, and we began a medication compliance program. Prior to this, we worked within a system that had a patient requesting their medication refills—typically on a monthly basis—and only then would we look through the patient’s record to identify any potential health risks or improvements. Our compliance program involves a pharmacy staff member reaching out to a patient when their medication is due and refilling if necessary; this is not unique and many pharmacies have done this in the past.

Proactive Patient Care

Where our system differs is when the patient claims they do not need the medication. At this point, our staff will inquire as to why the medication is not needed. There can be a variety of reasons ranging from simply forgetting to a lengthy hospitalization that has left a surplus. By utilizing data that were already available to us, along with taking the time to personally speak with a patient, we have been able to identify and solve problems that were previously left unnoticed and unresolved.

After implementing our medication compliance program we found one major issue was simply patient adherence. A patient forgetting to take their medication was not only a common issue, but one that is very difficult to resolve. As we do not have the resources to verify adherence on a day-to-day basis, we found a need for outside intervention. Working together with another company we were able to provide adherence packaging. We now offer a variety of adherence packages that are useful as short- or long-term solutions to increase a patient’s adherence with their medication regimen.

After finding success increasing the level of care for our general patient population, we identified a specific population that had a greater need for our services. We found that patients who had recently undergone major medical events demonstrated a high need of care that we are in a unique position to provide. We have implemented a transition-of-care program. A major lifestyle change is often necessary as a patient is discharged from a hospital or long-term care facility. By utilizing our established position in that patient’s life, we have been able to ease that transition and identify any potential problems at their onset. We expanded this program by sending a pharmacist to the patient’s home shortly after a transition of care had occurred. The impact this program has had on a patient’s quality of care has been outstanding—we have seen not only improvements in a patient’s medication adherence, but also in their overall quality of life.

Relationships with Prescribers

Increasing our level of patient care has created many areas in which our pharmacy was forced to grow and adapt. One area in which we have seen a large amount of growth is our communication with prescribers. This communication consists of the typical telephone calls and faxes to physicians’ offices for medication changes, but can often go beyond these traditional means. We have found success in forming relationships with direct patient caregivers, such as home health nurses and patient care coordinators.

The pharmacist fits nicely into the patient care team, and we have found that the services provided are very similar to our community pharmacy responsibilities. We identify and assess interactions, analyze gaps in care, and identify medications that are high risk; now we are simply bringing these services to new settings. By increasing the level of communication with other providers it becomes evident that we all share common goals of improving patient outcomes and reducing hospitalizations.

Challenges

Implementing these changes has been exciting for our pharmacy. However, adding a higher level of service without creating a straightforward revenue stream is a challenge. Without being able to directly attribute increased revenues to these programs it can be difficult to justify allocating resources to this area. We have made a commitment as a company to provide these services and we firmly believe that it will provide long-term financial success.

Benefits

Unconventional approaches can produce anxiety for pharmacies, but also great reward. Fortunately, we have seen value in the short term and anticipate growth in our value-based services as purchasers demand more value. As for immediate benefits, we have seen an increase in prescriptions filled at our pharmacies that we can attribute directly to our programs. As for future success, we are relying on the fact that providing a higher level of care will not only increase our customer retention as well as word-of-mouth advertising, but will also put us in a position to become a vital part of the health care home model and preserve or enhance reimbursement for those pharmacies choosing to provide additional value.

Differential Reimbursement: On the Horizon?

The future of expanding the pharmacist role may very well depend on the ability of a pharmacist to be reimbursed based on the level of care they provide. We have already seen some small gains in this area with some insurance providers utilizing MTM platforms to assist with the process. However, to fully utilize the pharmacist skill set to make a real difference in patient outcomes reimbursement on a larger scale will be necessary. Our approach is to expand the services we provide and once we have proved their value, we expect the reimbursement opportunities to follow.

Ashley Abode received her doctor of pharmacy from the UNC Eshelman School of Pharmacy in 2010. Upon graduation, she began working at Realo Discount Drugs, providing medication therapy management services. At the start of 2013, Realo Discount Drug expanded pharmacy services in a clinical direction with their patient-centered services. Abode became the clinical service coordinator for the company and has worked to implement a refill compliance program and a medication reconciliation program.

Joey McLaughlin received his bachelor of science in pharmacy in 1983 from the UNC Eshelman School of Pharmacy. In 1996, he partnered with Rob Bizzell, chief executive officer and president of Realo Discount Drug, and opened Carolina Home Medical. He expanded this partnership in 1998 when he opened his first drugstore in New Bern, North Carolina. McLaughlin currently owns 13 Realo Discount Drugs locations and 8 Carolina Home Medical stores.