Disruption Is Ongoing and Inevitable

For most of our professional history, health-system pharmacists have focused heavily on providing high-quality, safe care for acutely ill patients admitted to hospitals.

Pharmacies have spent small fortunes on developing medication use systems to ensure the right drugs and dosages are administered to the right patients, often within minutes of the scheduled times. We use all types of sophisticated technology, including automated cabinets, bar code scanners, electronic health records, robotics, and smart pumps to make this process as error proof as possible, at least for the average 6 or 7 days that patients are admitted. As hospitals increased ambulatory services, health-system pharmacies expanded medication use systems and clinical services into outpatient clinics and other ambulatory settings. Over the past decade, many centers also developed more traditional outpatient and specialty pharmacy services to capture internal prescription volume and revenue. However, reimbursement systems and sheer volume have kept this a mostly traditional, transactional relationship with patients, not a transition to the medication use systems in communities.

The medication use system in the community is a poor model of health care delivery. Most community pharmacists are isolated from the balance of the patient care team, operate in an environment of minimal patient data, and, by design, have little accountability for patient outcomes. The system is mostly a retail transaction in a mercantile model, which has become an unfortunate so-called bloody red ocean, brought about by racing to the lowest cost. Although often discussed as a system that is ripe for disruption, serious disruption has been occurring for years. The vertical alignment of the industry has increasingly restricted access and created razor-thin margins at the community pharmacy level and as specialty pharmacy has grown, local pharmacies have been left on the sidelines. The fallacy of performance metrics has dramatically increased the clawing back of revenue by pharmacy benefit managers (PBMs). These disruptions are driving independent pharmacies out of business and further consolidating volume to the major chains and their vertically aligned systems. There have been some attempts to improve focusing on patients, including adherence packaging, medication synchronization, and medication therapy management services, but evidence of improved overall outcomes is limited.

Unfortunately, there is a lopsided focus on cost. Although I agree that the cost of pharmaceuticals must be controlled, efforts are misguided and may result in dismantling the profession, leading to even higher costs and poor outcomes. For years, we have seen cost-reduction strategies by payers and PBMs that fractionate patient care, increase medication safety concerns, and make it more difficult for patients to adhere to prescribed treatments, all in pursuit of the lowest net cost of drugs and not the overall care. Such strategies have included mail-order pharmacy restrictions, restricted specialty pharmacy provider networks, site-of-care policies, and “white bagging.” This leads to pharmacy care from multiple providers who have no real relationships with the medical team or the patient. In addition, new potential players are entering the market to further carve up the pharmacy benefit landscape to chase the lowest net cost. For example, Civica, Inc, is introducing low-cost insulin products that will only be available through limited partners; GoodRx is expanding its discounting pricing model; and billionaire investor Mark Cuban has announced his cost-plus pricing model for a limited selection of high-cost generic drugs. Expect others to come forward to disrupt the system and carve out niches in the pharmacy landscape.

However, although lowering the cost of pharmaceuticals is laudable, will all this splintering of care reduce costs? Forcing patients to use multiple “vendors” to acquire their prescriptions means no one will be accountable for patient outcomes. We already know we spend as much money on the bad outcomes of drug therapy as we do on the cost of the drugs. Does this inevitable continued disruption of pharmacy care have any chance of improving the situation?

One of the promises of the elusive value-based models of health care delivery is the creation of aligned incentives within provider networks to be accountable for improved patient outcomes. Unfortunately, for most systems, fee for service remains the predominant source of revenue, and the fraction tied to value-based performance is having a limited effect on aligning incentives. As this fraction grows, pharmacy leadership must keep organizations focused on high-quality pharmacy care, especially for chronic diseases.

Pharmacists have 2 choices: do nothing and watch the rapid evolution of the disruption of the medication use system in the community or disrupt the medication use system for patients. Pharmacists must leverage the fact that they have the data, patients, and providers. Pharmacists can implement a medication use system that is highly patient centered and relational vs transactional. They can become integrated into patient care teams, working with care managers, nurses, providers, and social workers to address the many challenges of delivering effective drug therapy. No other potential vendors can do that. To be successful, pharmacists must harness technology, have a digital presence, and incorporate other nontraditional models to deliver highly efficient care that is not dependent on brick-and-mortar pharmacies on every corner. Pharmacists must efficiently shift resources from prescription counters to clinics to develop those patient and provider team relationships and fuse clinical care and medication use systems.

Pharmacists must convince providers that pharmacy care is just as important to keep in system as any other referral for care, as most interventions for chronic diseases concern drug therapies. The team should care where patients receive their pharmacy care. This will be challenging to implement, given reimbursement models, but it can be done using efficient systems and leveraging value-based performance metrics. Pharmacists probably have 3 to 5 years to disrupt the model, so time is of the essence. If they can align the clinical accountability with the financial incentives, health-system pharmacies can have a huge impact on improving medication-related outcomes. It is up to all of us.

ABOUT THE EDITOR

Curtis E. Haas, PharmD, FCCP, is director of pharmacy for the University of Rochester Medical Center in New York.