I recently read a book, If You Can Keep It: The Forgotten Promise of American Liberty, by Eric Metaxas. The book title is part of a quote from Benjamin Franklin in 1787, the year the Constitution was drafted. A woman asked Franklin what the founders had given the American people. “A republic,” he responded, “if you can keep it.”1 Metaxas’ book examines the freedoms and liberties provided by the Constitution, and the unprecedented system of governance by the people of the United States, as distinct from a dictatorship or monarchy. But he voices concern about the erosion of some of these freedoms over the years and warns that if we as individuals and a society do not demonstrate a stronger commitment to protect and promote what the founders entrusted to us, we are at risk of losing the greatness and exceptionalism that has characterized our country.
As I read this book, I was struck by the parallels to what has been occurring in the pharmacy profession. The founders of the pharmacy profession in the United States were independent pharmacists/apothecaries. They founded the Philadelphia College of Pharmacy in 1821 as the first college of pharmacy in the United States and provided leadership in the formation of the American Pharmaceutical Association in 1852. Over many years, independent pharmacists have been the face of our profession. They usually live in the communities in which their pharmacies are located, become trusted health professionals and friends and establish lasting relationships with their patients. It is not uncommon for them to have served several generations of many families. They are also often very involved in and provide civic leadership for their communities. When surveys of the public consistently rank pharmacists so highly with respect to qualities such as integrity and ethics, it is most likely independent pharmacists participants are thinking of when responding so positively. The annual Honesty/Ethics in Professions poll performed by Gallup® shows that pharmacists are rated second in regards to honesty and ethical standards.2 Independent pharmacists are the ones who have earned the respect and excellent reputation for our entire profession, and from which all of us benefit.
During the last several decades, the number of independent pharmacies has significantly declined, while the number of chain pharmacies has greatly increased. There are tens of thousands of very capable chain pharmacists who would enjoy getting to know their patients. However, the management-imposed policies and metrics of many chain pharmacies often result in high prescription volumes and understaffing that allow very little time for speaking with patients. In addition, many chain pharmacists may “float” among several stores within the chain or be transferred to another store which, combined with the high turnover rate many chains experience, results in much less opportunity for pharmacists to get to know patients.
The financial pressures that both independent and chain pharmacies face also compromise the amount of time that pharmacists can spend with patients. Pharmacy benefit managers (PBMs), insurance companies and government programs provide inadequate compensation for medications and pharmacy services. Some of these organizations are reducing the size of their networks of pharmacies, and independent pharmacies are at greatest risk of being excluded from these networks, thereby losing patients and their prescriptions and other purchases. The above factors are colliding during a period of time when Baby Boomers are the second-fastest growing segment of the population, next to Millennials.3 Baby Boomers and the Silent Generation are taking more medications and have the greatest need for the expertise, time, counseling and monitoring that can be provided by pharmacists. The major need in the provision of healthcare is for physicians and other prescribers, and pharmacists, to spend more time with patients. More comprehensive and personalized communication will result in patients better understanding their medical problems and the medications prescribed, better compliance and adherence to medication regimens, improved comprehension of instructions and a reduction in adverse drug events, drug-drug interactions and physician/ER visits and hospitalizations.
Independent pharmacists are strategically positioned and are the most readily accessible health professionals to provide counseling and monitoring regarding prescriptions. They are highly valued by their patients and communities and are, by far, the most visible representatives/ambassadors of our profession. However, their survival is being threatened!
In previous editorials, I have voiced my strong opinion that the future success of the entire pharmacy profession is inextricably entwined with the extent to which independent pharmacists can not only survive, but thrive (see my editorial “Pharmacy’s National Treasure – Community Pharmacists” [April 2014 issue of The Pharmacist Activist]).
The independent pharmacy profession must not be extinguished. We must keep the fire burning! Consider the following recommendations.
- Support – The entire pharmacy profession must strongly support the role and services of independent pharmacists.
- Relationships among independent pharmacists – Independent pharmacists must make a stronger commitment to communicate and work together. When the number of independent pharmacies was much larger, they often viewed each other as competitors. Today, independent pharmacies seldom view each other as competitors. Often, independent pharmacies are very confident that they can effectively compete with chain pharmacies. Rather, it is the mail-order pharmacies owned by PBMs that unfairly compete by stealing patients from independent and chain pharmacies with program restrictions and mandates and/or financial incentives to use their mail-order pharmacies. In efforts to improve their purchasing power and efficiency, most independent pharmacists have established working relationships with one or more major wholesalers, are investors/participants in wholesaler collaborative companies and/or are members of buying groups. However, an irony exists. Although independent pharmacies may not be competing against each other, the organizations with which they are affiliated compete to increase the number of independent pharmacies they represent. Efforts must be strengthened to have all of these organizations work more closely together for the benefit of all independent pharmacists.
- Association support – All independent pharmacy owners and their pharmacists must be members of the National Community Pharmacists Association (NCPA), the American Pharmacists Association (APhA) and their state and local associations. We must have stronger professional organizations, and that requires increased and involved membership. We must revive organizations that have been inactive and identify strategies through which the collective voice and importance of the role of independent pharmacists can be communicated. The associations provide the forum and influence through which pharmacists can unite and effectively address legislative issues.
- Appointment of task force – The NCPA and APhA should appoint and provide the necessary resources for a Task Force on Independent Pharmacy (TFIP) comprised of independent pharmacy leaders and appropriate consultants whose single priority will be the development of strategies for the promotion of advancement and growth of independent pharmacy.
- Advocacy for small businesses – Our profession must be aggressive in revising federal and state laws, policies and tax structures that favor big businesses but place small businesses at a disadvantage or represent disincentives for individuals to start small businesses. It is important for communities to provide the necessary opportunities and incentives to enable both small and large businesses to thrive. If a large business considers relocating its corporate headquarters from one state to another, its current home state will often offer tax relief and other incentives worth millions of dollars to keep it in its present location. However, when a small business experiences financial challenges that may force it to close, there is no relief or support.
- Relief from antitrust laws – Independent pharmacists must be provided relief from antitrust laws. The current system, in which large insurance companies and PBMs are able to exclude pharmacies from their networks and permit participation only under the terms of their “take it or leave it” agreements, is both inequitable and anticompetitive. Independent pharmacists must be granted an exception or the laws should be changed in a manner that will permit pharmacists to work together to negotiate more favorable agreements and equitable compensation. Several large PBMs have recently announced changes in their formularies for 2017 that will result in some widely prescribed medications being excluded or “demoted” from coverage. These changes are being made for the financial benefit of the PBMs and, in theory, their clients. Pharmacists must commit considerable time to explain these changes to patients and provide counseling regarding the drug and dosage changes and other information pertaining to the alternative medication to which they are being switched. Pharmacists should be able to charge a fee for their services that are necessitated by formulary changes made by the PBM.
- Pharmacy’s own PBA – The pharmacy profession should establish its own national prescription benefit administrator (PBA). A national PBA with programs could provide prescriptions and medication therapy management with positive therapeutic outcomes that include greater benefits for patients and equitable compensation for pharmacists. This opportunity has such excellent professional and financial potential that it would quickly attract both support and investment from within and outside of the profession. However, majority ownership must be held within the pharmacy profession to prevent acquisition by others who are not committed to the same goals.
- Advocacy for entrepreneurism – We must do much more to encourage entrepreneurism and provide business and management programs that will help assure success when a pharmacist purchases an existing independent pharmacy or opens a new one. Colleges of pharmacy must make students aware of these opportunities. Many pharmacy students have limited or no awareness of independent pharmacies. There is a great, if not greater, need for highly capable graduates to enter community pharmacy practice as there is for them to enter other areas of practice. Every pharmacy student should participate in an Advanced Pharmacy Practice Experience (APPE) rotation in an independent community pharmacy. This will provide a patient-centered professional practice experience, provide the opportunity to observe and learn about the involvement of the pharmacist owner in their community and demonstrate the benefits of owning a pharmacy and having the personal responsibility of making practice and business decisions.
- Political action – We must increase our legislative influence. Buddy Carter of Georgia is the only pharmacist in Congress, and a small number of pharmacists serve in state legislatures. When pharmacy-related and other healthcare legislative proposals are being considered, these pharmacists are the trusted peers whose opinions are valued by their colleagues. However, additional opportunities exist. Our profession should be doing much more to encourage pharmacists to become active participants in legislative and policy matters and to identify and support pharmacists who are willing to be candidates for civic positions and legislative offices.
- Increase Scope – Numerous opportunities exist to increase the scope and value of services provided in community pharmacies. The provision of immunizations is one excellent example. Immunizations are now provided in most community pharmacies, for the benefit of both the public and our profession, as a much larger number of individuals are being protected against the occurrence of potentially serious illnesses. Another example is the popularity of smoking cessation products. Pharmacists possess the expertise regarding these products and should consider implementing smoking cessation clinics. To further increase scope of services, pharmacists can also designate an area of the pharmacy as a center for health information, such as medical literature and medication information.
Examples of other community pharmacy-based initiatives that have the potential for patient, professional and financial benefit include:
- Collaboration – Working relationships can be established with family practice and internal medicine physicians. Some chain pharmacies have allocated space for clinics staffed by nurse practitioners. An independent pharmacist owner could establish a referral service in which patients could be referred to a practice group or particular physician based on their medical needs, or an arrangement could be made in which a local physician could be available for consultation in the pharmacy during designated times. Over-the-counter (OTC) products – Our role in the recommendation of OTC products (and referrals to physicians as appropriate) can be greatly strengthened. In many pharmacies, patients select OTC products from self-service shelfs or displays and purchase them without speaking to a pharmacist. Pharmacists have an opportunity to be recognized as experts regarding OTC medications and their appropriate use. Products for specific symptoms that a pharmacist has or would personally use or recommend for use by a member of her/his own family could be identified in a section with designations like “The Pharmacist’s Choice” or “The Pharmacist’s Formulary.”
- Natural products – Extending our role with respect to the use of natural products (dietary supplements, herbal products, etc.) and probiotics has excellent potential. For many of these products, there is very little authoritative information regarding effectiveness, safety and dosage. Pharmacists can respond to questions and make recommendations. If we are aware of safety concerns for a product, or question whether it is effective, we should recommend against its use and recommend an appropriate OTC product for which definitive information is available. As with certain OTC medications, certain natural products (e.g., melatonin, St. John’s wort) could be made available only from behind the counter for the purpose of assuring discussion with a pharmacist.
Although it is unlikely that chain pharmacies will take advantage of these types of opportunities, they can be quickly and effectively implemented for the benefit of patients, independent pharmacists and the pharmacy profession.
We must move forward in a strong and urgent manner to protect and promote independent pharmacists as if the future of our profession depends on it. Because it does!
Sources:
1 Metaxas, Eric. “If You Can Keep It: The Forgotten Promise of American Liberty.” New York City, NY: Viking, 2016.
2 “Honesty/Ethics in Professions.” Gallup. Dec. 2-6 2015. Web. 1 Dec. 2016. http://www.gallup.com/poll/1654/Honesty-Ethics-Professions.aspx
3 Fry, Richard. “Millenials overtake Baby Boomers as America’s largest generation.” Pew Research Center. April 25, 2016. Web. 1 Dec. 2016. http://www.pewresearch.org/fact-tank/2016/04/25/millennials-overtake-baby-boomers/
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