Reforms to the way that Ontario community pharmacies are compensated for professional services, combined with an expanded scope of practice for pharmacists, are presenting major adjustment and implementation challenges for the profession.
The changes are part of a culture change ushered in by a general shift in health care towards a push for greater inter-professional collaboration, with all healthcare professionals working at full scope of practice.
Denis Darby, CEO of the Ontario Pharmacists’ Association, says the role of retail pharmacists is evolving from being “the goalies of health care” (i.e., the last defense against medication errors) to one of medication experts. The OPA represents 7,600 of the province’s 13,400 pharmacists who work retail pharmacies (independents and chains), hospitals, long-term care facilities, family health teams, businesses and government.
Clinical services can be “counted and measured”
Dispensing fees and rebates from generic drug companies—sometimes referred to by the Ministry of Health and Long Term Care as “professional allowances”— were a mainstay of retail pharmacy revenues for many years until 2006, when the MOHLTC began to significantly reduce the amount it paid for generic drugs.
Rebates were payments made by generic companies to pharmacies—the amount was typically a percentage of the amount charged to the province, private drug plans and individuals who pay out of pocket, for generic drugs. At the beginning of this month, the MOHLTC eliminated the last “allowable” rebate, which was for drugs dispensed to individuals not covered by Ontario’s drug plan.
Rebates were “an amorphous” way for pharmacists to be compensated for services, while more recent changes introduced by the province allow for pharmacists’ clinical services to be “counted and measured,” says Darby. These include a suite of payments for clinical services that retail pharmacists provide.
The uptake of the new, individually remunerated services has been gradual and in some cases uneven.
MedsCheck, a program in which the province pays pharmacists to provide an individualized review of medications with eligible patients, was introduced in 2007 for individuals taking three or more prescription medications.
Pharmacists review with the patient their medications (prescription and over the counter), and make recommendations, for example about the best time to take medications. Patients leave with a print out of their medications and notes added by the pharmacist.
New program created “workflow challenges”
The MedsCheck program initially created “workflow challenges” to busy community pharmacists, who typically had no formal appointment system for clients, and no separate private consultation room, says Lisa Dolovich, pharmacist and professor with the department of family medicine at McMaster University. (Dolovich authored a study of the program early in its existence).
In 2010, the program was expanded to include consults for long-term care residents, persons with diabetes, and home visits for homebound and chronically ill individuals on multiple medications. The annual number of claims under the MedsCheck program more than doubled between 2008/9 and 2011/12 (from 216,678 to 549,212) with the province paying $67-million for those services during the latest year, according to the MOHLTC. Payments differ for the various types of consultations—for example, pharmacists are paid $60 for a standard in-office consultation, $75 for an annual diabetes check, $90 for a consult for a long-term care resident and $150 for a home visit.
Jim Semchism, who owns an independent pharmacy in London, says one of the most valuable uses of MedsCheck is a consultation that takes place when a patient is discharged from hospital, since it is at such transition points that medication errors may occur (see for example, this examination of the risk of unintentional discontinuation of medications on admission to hospital.)
Semchism says he does between five and ten MedsChecks at day, typically for patients over 50 years old who are on between five and ten different medications.
While there has been no formal evaluation of the program, there have been reports that the program is under-utilized because pharmacists are too busy to perform MedsCheck reviews.
Health ministry is funding a study of outcomes of MedsCheck program
The ministry says it is funding a research study to look at outcomes of the program and is working with other provinces that are doing similar reviews “to leverage results wherever possible.”
In an attempt to ensure the quality of MedsChecks that are billed to the province, the province does spot audits.
The MOHLTC has not made it a requirement for the MedsCheck results to be forwarded to the patient’s physician/health care provider, however, in 2011 the province introduced the “pharmaceutical opinion program”. If, in the course of doing a MedsCheck, a pharmacist identifies an issue such as “suboptimal” prescribing, he or she can document this, for a payment, in a “professional opinion” which is shared with the prescriber.
Communication between community pharmacists and physicians/primary care providers can be sometimes be problematic, which is a function of the fact that they are rarely “co-located”, and information is often shared by fax, or through assistants, instead of directly, says Dolovich.
Ontario Medical Association president Dr. Doug Weir says that as health care professionals take on expanded roles and responsibilities, it’s important that “we also improve lines of communication between providers to ensure that the quality of care, patient safety and continuity of care are all enhanced.”
With the expansion of pharmacists’ scope of practice, the province began to reimburse pharmacists for providing services such as flu vaccinations, prescribing smoking cessation products, renewing existing prescriptions and “pharmaceutical opinions” —for example, when a pharmacist identifies and corrects a prescribing error, or refuses to fill a prescription for a customer who appears to be under the influence of alcohol or drugs.
Pharmacy technology hasn’t yet caught up with paperwork requirements
But to provide flu shots (pay for each is $7.50), pharmacists need three qualifications (first aid, CPR and completion of a course on providing vaccinations), a requirement which has deterred some from participation. By the beginning of February this year, about 2500 pharmacists had been qualified to administer the shots, according to the OPA.
Pharmaceutical opinions are clinical interventions by a pharmacist in consultation with the prescriber where the prescription may not be dispensed, may be dispensed as prescribed or a prescription therapy may be adjusted. The pharmacy is reimbursed $15 for these interventions. However, technology is not yet in place to ease the time-consuming documentation and paperwork involved in obtaining the $15 compensation for pharmaceutical opinions.
Many of the ongoing changes in pharmacy were called for in the 2008 document Blueprint for Pharmacy (and, later, its implementation plan) which aimed to “strategically align pharmacy practice with the health care needs of Canadians to ensure . . . optimal drug therapy outcomes through patient-centred care.”
The Canadian Association of Chain Drug Stores supports pharmacists’ expanded scope of practice, and will soon release a white paper with its own proposals for change. (While a CACDS spokesperson mentioned the upcoming white paper, the association declined an interview request and provided no information about the white paper proposals.)
At the same time, pharmacy education is also changing with the shift to a Doctor of Pharmacy (PharmD) as an entry level degree to practice at the pharmacy schools at the University of Toronto and the University of Waterloo. The revised program provides student with more clinical experience to prepare them for the full scope of practice.
There is growing support to have community pharmacists more integrated into the healthcare system by both reimbursing and having them accountable for drug related outcomes of their patients. However, there is a lack of evaluation of the impact of these changes on health outcomes and these changes are likely to be disruptive for both pharmacists and physicians.
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A very thoughtful and timely article. %featured%I totally support a new program with new accountabilities and new payment model – optimally salaried approach to pharmacists as part of an integrated primary care team.%featured% I am worried about a few things:
– one “side effect” of the absolutely necessary regulation of generic pricing is its unequal impact on small self opened community pharmacies and the loss of this infrastructure. As well I am concerned with public dollars going into private for profit businesses that employee pharmacists or have some sort of contract agreements with them (think Walmart or the various makeup/food/drug companies, (think Shoppers or safeway) where pharmacies are seen as loss leaders, not necessary component of the care team. I like pharmacists who question the necessity of drugs and who can reenforce other parts of a patient’s care plan and who understand the social determinants of health. They need to know and have a working relationship with the drug “prescription generators” as much as the clients to have impact.
– professional preparation requirements – we need to think about apprenticeship models were students can work, escalating up their responsibility, pay as their competencies increase. To think that a health care program can run on a masters or PHd prepared provider as its base is very horrifying.
Pharmacists need to promote ourselves by innovation, example, and some risk taking.%featured% The overwhelming focus for us to need promotion and coaxing of the public by the health system to justify our cut from the budget is a losing battle.%featured% We should be taking a proactive approach to solidify and expand our presence in the private sector rather than focusing exclusively on the public which is about to have fiscal problems of its own.
These ideas for fully reimbursed services at an equitable rate is merely a pipe dream. We have from experience seen that when services are reimbursed, they are often reimbursed at an arbitrary rate that has major flaws such as value differentiation, reduced patient expectations from subsidized services, pricing that reflects real demand, and fraudulent activity from poor provincial oversight (those these cases are realistically few and far between).
If we amount the effort as a profession we have paid for lobbying, excessive pandering to public officials who truly do not understand healthcare outside of a snap shot chart, and most of all time costs, are our efforts being reflected in legislative output. Many pharmacists still struggle with diversifying reimbursement because the real fact is most income is still tied to dispensing. With competitors like costco and walmart offering lower than ODB rates already, the next logical progression is a cut in dispensing fees which will yet again throw a wrench in the whole operation of providing expanded services.
We need advocacy groups that look at the broader picture rather than focus on the status quo which is what they are doing. Expanded services are a great start but the main focus should be to empower the patient and if pharmacy is what it claims to be, we should not have an issue competing so long as patients spend their money where they see fit, not the province. Until we come to the realization and shift in ideological culture, there is little hope for dramatic improvement to come proactively from pharmacy as we shift ever closer to an OHIP model of physicians.