Breaking Out of the Bubble

Groupthink

Groupthink is a formal psychological theory, first introduced by Irving Janis,1 that describes the problematic effects of limited conversation and consideration of ideas within like-minded groups of individuals with similar backgrounds, training, and life experience. In casual lexicon, this phenomena can be referred to as “living inside a bubble,” and in political parlance, “speaking within the echo chamber.”

Groupthink can lead to decisions and actions within, and by, a group that are curious, seemingly disconnected, and often misunderstood from the perspective of stakeholders outside the group. The consequences of groupthink are amplified when forces external to the group’s environment can influence or disrupt the group’s internal environment.

As I write my first Editor’s Note for Pharmacy Times, I’d like to draw upon my own life experience and multidisciplinary training in the fields of public health and health economics to encourage all of us within the pharmacy bubble to avoid groupthink and take a look at the big picture from time to time. The commonly held axiom that “change rarely occurs from within” may be more apt now than at any point in the history of our industry. The fundamentals of the business of health care are changing and pharmacy is a subset of that industry, so it cannot disconnect itself from the larger forces at play. It is entirely feasible that pharmacy will be changed by higher-level reorganizations and reorientations of the health system, and not by changes emanating from within our “pharmacy bubble.”

Historically, the pharmacy industry has operated, for the most part, within its own regulatory, financing, and practice-model framework—within a silo—somewhat insulated from other components of the health care industry. Examples are plenty. We have yet to have a coherent policy and statutory framework in place acknowledging that pharmacists are health care providers who are complementary to other providers of care.

We have an electronic system of remuneration based on selling a product and not a service, with information technology systems that are recalcitrant to the needed modifications that would exchange clinical information and allow for billing for a service at the patient level. This is the result of a legacy health information technology infrastructure that was designed around selling and reimbursing for individual drug products; it never contemplated exchanging clinical information from a pharmacy provider to a non-pharmacy provider and vice versa.

Legacy systems, legacy thinking, and the impenetrable status quo live on. In today’s modern integrated delivery networks, where pharmacy divisions are making great strides in expanding and advancing practice models, most directors of pharmacy are still not located in the C-suite with other decision makers, and an increasing (not decreasing) portion of our clinical activities are funded by 340B strategies (the latest, greatest strategy to sell a product at a good margin). And while our educational and training infrastructure(s) have migrated slowly toward assimilation with other health care professionals, the business models in which students find themselves upon graduation are completely disconnected from their training. Moreover, new graduates are all too often insulated from, and unaware of, the regulatory and financial changes that are rapidly taking place on the other side of the “fence” that separates pharmacy from the rest of the system.

Breaking Down Walls

It is altogether understandable how we arrived at this place, given our upbringing. As drug development efforts bore more and more fruit in the 1960s and 1970s, cost controls for drug use were essential to ensuring premium risk stability. The pharmacy benefit management (PBM) industry was born and developed over the 1980s and early 1990s. At the time of this PBM model buildout and maturation, clinical services provided by a pharmacist weren’t much more than a theory with a cottage industry of practice, too immature and not with enough scale to have a meaningful effect on regulatory and financing frameworks developed during the formative stages of the system as we know it today.

So we remain in the financing and regulatory legacy that the PBM industry set forth when separating the pharmacy benefit—with all of its pharmacy-related activities, financing, and incentives—from the medical benefit (Figure). This has largely resulted in the perception among the public and policymaking world that our singular purpose is to fill medications fast, accurately, and cheaply.

Breaking out of the status quo has proven difficult. I’m fond of the phrase, “Don’t hate the player, hate the game,” and the reality is, the game won’t change until a set of external forces surrounding the game are strong enough to upend the status quo and break down the walls that have caged us in our designated corner of the system for so many decades. Payment reform, consumerism, practice reform, consolidation, and health information, as well as other technological advances, are some of the tectonic plates shifting below our feet that will undoubtedly influence pharmacy practice over the next decade(s).

I’m committed to the persistent exploration and development of Pharmacy Times content that helps us better understand, anticipate, and react to these external forces that will no doubt set the stage for the next life cycle of pharmacy practice. Doing so requires (1) bringing voices and experience into Pharmacy Times from outside our bubble and (2) our readership to be receptive to new perspectives and new worldviews when attempting to identify emerging opportunities and threats to our desired practice, business, and sustainability models.

I’d like to close with a final nod to Fred Eckel, who served for many years as the author of this Editor’s Note. I’ve had the privilege of knowing Fred for quite a while now, and the best advice I’ve ever received from him was never spoken by him, but learned by observation.

Being genuine is best practice.

Thank you, Fred.

Troy Trygstad, PharmD, PhD, MBA, is vice president of Pharmacy Programs for Community Care of North Carolina (CCNC), which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina.

Reference

• Janis IL. Groupthink. Psychol Today. 1971;5(6):43-46, 74-76.