It’s the Business Model, Stupid.

AS JAMES CARVILLE SAID, “IT’S THE ECONOMY, STUPID”

As the often-quoted political strategist famously quipped in 1992 during the presidential campaign, oftentimes overanalysis and casual observation alike can miss the big picture or main driver of a trend, sentiment, system, or problem. This is the case with community pharmacy’s chronic ills, stressors, and symptoms of malaise and poor health. When you strip away all of the complaints, the criticisms, and the looking down on community pharmacy practice and reveal the fundamental cause, it isn’t the pharmacies or the pharmacists. It’s the pharmacy business model, stupid!

Pharmacy Drugstore: Man Chooses Medicine, Comes to the Counter, Talks to Beautiful Pharmacist Cashier, Pays for the Health Care Products at the Checkout Counter Using Contactless Payment Credit Card - Image credit: Gorodenkoff | stock.adobe.com

RECENT ARTICLE BERATING COMMUNITY PHARMACY PRACTICE MISSES THE MARK

Last month, a colleague of mine sent me a link to an online article from a pharmacist in a position of leadership at a health system who railed against the current state of community pharmacy practice. Filled with denigrations and blaming, the short opinion piece claims that community pharmacies have let patients down and intimates that pharmacies and the staff who work themselves to exhaustion put profits ahead of patients. The author charged community pharmacists with, among other activities, health screenings, preventive care, exercise recommendations, patient education, fixing drug shortages, and administrative problem-solving with third-party rejections—none of which are currently reimbursed—and ostensibly to be funded with $0.65 dispensing fees.

SUBSIDIZED PHARMACY PRACTICE MODELS DO LITTLE TO SOLVE THE OVERALL PROBLEM

The inconvenient truth is that all pharmacy practice is stuck in a broken business model. Yes, that includes health systems. A very small percentage of clinical pharmacist positions are funded by the services that are provided. The vast majority are subsidized or outright entirely funded by academic positions and 340B “savings” (gross profits) from—you guessed it—dispensing activities. It just so happens that some pharmacies and systems have gigantic dispensing margins and community pharmacies have anemic margins, barely able to hang on with the available staffing that is supported by paltry reimbursements. It’s a wonder there are not more walkouts and open positions because there is little money to be made and a lot of criticism to be had, mostly by peers in other settings of care.

WE AGREE: COMMUNITY PHARMACY PRACTICE HAS SUPERIOR POTENTIAL FOR FRONTLINE CARE DELIVERY

Despite recent trends in pricing and reimbursement that put immunization care at the same risk as dispensing below cost, administration of vaccines remains economically sustainable. As a result, 90% of all adult immunizations now occur in a community pharmacy.² If there is an economically sustainable business model around care delivery, medication optimization, and gap closure, community pharmacy will surely take it up, scale it, and tell the other settings of care, “Here, hold my beer.”

CHANGING THE BUSINESS MODEL REQUIRES CHANGING PURCHASER EXPECTATIONS

Instead of blaming community pharmacists for not leaping tall buildings with a single bound, all the while being chained to the ground, you can help change the business model. Yes, we all need and benefit from advocating for pharmacy practitioner status and reimbursement for services. But you can also help employers, patients, taxpayers, administrators, and lawmakers understand that we are putting patients’ lives at risk by not reimbursing community pharmacies and pharmacists for care delivery, and doing it sufficiently is a drop in the overall budget. How many of you sit on a committee that selects preferred drugs or the pharmacy benefit manager for your self-funded plan? Poor decisions and lack of demand by these committees for funding patient care delivery on the outside are part of the problem.

TEST-TO-TREAT MODELS OFFER ACUTE CARE EXAMPLE, AND AT-HOME PHARMACY SERVICES OFFER A CHRONIC CARE EXAMPLE

Examples are emerging and hold promise for changing the model from retail transaction–driven to care-driven economics and practice models. Last month, Walmart launched test-to-treat in Montana,¹ following other states and pharmacy groups in offering services at reasonable and sustainable price points to both insurers and patients. Not only are these types of health care services filling critical gaps in our underserved areas of need, but they are safe, effective, convenient, and cost saving, regardless of where you live.

Also emerging are services in the community, with community providers (pharmacies) to help keep patients in their own homes and prevent transition to institutional care. A major driver of transition to long-term care facilities from the home is a caregiver or family member who determines that their patient or relative can no longer self-administer medications. The opportunity for better care and a reduction in overall cost of care is significant. Why are these services growing so quickly? Because reimbursement for these patients is different and more economically sustainable.

LET’S ROW IN THE SAME DIRECTION

It’s high time we stop casting aspersions at community pharmacy and get on board with new models of care and new models of payment. Not only do we owe it to the patients to provide better care in the community, but we also owe it to the community pharmacy workforce and the profession writ large.

REFERENCE

1. Monaco H. Testing and treatment services launch at Walmart pharmacies in Montana. Q2 Billings. Updated August 26, 2024. Accessed August 29, 2024. https://www.ktvq.com/news/local-news/testing-and-treatment-services-launch-at-walmart-pharmacies-inmontana

2. Trends in Adult Vaccination in the US. IQVIA. February 27, 2024. Acessed September 3, 2024. https://www.iqvia.com/insights/theiqvia-institute/reports-and-publications/reports/trends-in-adultvaccination-in-the-us