Who will provide clinical pharmacy services in the community?

Recent legislation and new products have resulted in a number of new clinical service opportunities for pharmacists in community settings.  These include providing naloxone to patients who may be at risk for opioid overdose and their family members; providing counseling, education and monitoring for patients taking specialty drugs (biologics); collaborative drug therapy management with physicians; and providing oral contraceptives without a prescription.

A big reason for these opportunities is the wide spread availability of community pharmacies. Community pharmacists are available in geographic areas and at times that physicians and other prescribers are not.  And, consumers visit community pharmacies a lot more frequently than they visit other health care providers or sites.

But it seems to me there is an unfortunate disconnect. A few pharmacies (such as Towncrest Pharmacy or Osterhaus Pharmacy) have implemented clinical services, but most community pharmacies have not.

Lots of factors deter community pharmacies from providing clinical services.  Reimbursement for many services is not commensurate with the amount of work required.  There is a lack of consumer awareness and demand for these services.  One of the big problems with medication therapy management (MTM) is that many consumers don’t want the service even when it’s offered at no charge.  Lack of demand keeps pharmacies from developing high service volumes which might make services more profitable.  Collaborative practice acts have been passed in most states but specific requirements of some of the laws inhibit their widespread use. Also, many pharmacists are reluctant, or not sure how, to give up their roles as dispensers and adopt new roles as service providers.

The community pharmacy model may not be suitable for providing services

Or it could be that providing services requires a different model than the community pharmacy dispensing model.  This model is characterized by focus on high volume, moving products, minimal personal service, and lack of privacy.  Dispensing is a vital function that pharmacists perform and one that works well in the current community pharmacy model.  But will the model allow community pharmacies to evolve into clinical service providers? Or will other organizations arise to meet the need?

Here are some examples to illustrate my concerns.  Providing naloxone to consumers who don’t have a prescription for it (as is now allowed in Kentucky, California, and Virginia) requires teaching consumers how to safely use injectable or inhaled products.  The inhaled products must be assembled at the time of use.   I don’t see this occurring as a 5-minute conversation at the prescription counter.  Dispensing oral contraceptives to women who don’t have a prescription is allowed in Oregon and California.   Doing so requires the pharmacist (at least in California) to have the patient complete an eligibility screening tool (United States Medical Eligibility Criteria for Contraceptive Use), to review it, and to counsel the patient on the appropriate use of the product selected.  Again, it’s hard to see this happening in 5-minutes at the prescription counter.

Clinical services are best provided in private areas, by professionals who are not preoccupied with meeting dispensing quotas, and who can devote significant amounts of time and attention to each patient receiving the service. Community pharmacists are certainly educated and capable of providing these services.  But is the community pharmacy dispensing model going to change enough, and fast enough, to allow them to do so?

To date (and from what I can see) the evidence does not look promising.  For example:

– Getting optimal results from specialty drugs requires adherent patients, who have been educated about how to use the products, and who are carefully monitored by pharmacists for adverse and therapeutic effects.  This is exactly what community pharmacists are trained to do and it seems to me that it would best be done face-to-face.  However, community pharmacies aren’t the major players in this area.  Instead, specialty pharmacies have developed to meet this need.  Most of these deliver drugs by mail and clinical services by phone.

–  Medicare-mandated MTM looked like a service that was made to order for community pharmacies.  But according to the 2014 Medicare Part D Medication Therapy Management (MTM) Programs Factsheet, most MTM is provided by telephone through organizations that are not community pharmacies

–  Most states have collaborative practice acts that allow pharmacists to prescribe, change dosages, or approve refills under protocol.  To the best of my knowledge, these are primarily used by clinic and institutional pharmacists.  Few community pharmacies have taken advantage of these laws.

The one service that has been widely adopted by community pharmacies is immunizations.  But more than most services, immunization fits into the traditional dispensing model.  Most pharmacies process a request for an immunization in much the same way as a prescription.  In fact, I suspect that pharmacies’ success with immunizations has been due to their ability to distribute large volumes of vaccine efficiently.

Can community pharmacies maintain the high volume, low service dispensing model while simultaneously developing a professional services dispensing model?  That seems like a hard thing to pull off.  Or will community pharmacies change from a dispensing to a service model.  That also seems like a difficult proposition, but as prescription reimbursement continues to decline, switching to services seems like a better and better idea.  Or, will other organizations continue to develop to provide clinical services in the community?  It’s not that far-fetched to imagine a mail service pharmacy (like a specialty pharmacy) that screens and educates patients by phone, then ships them oral contraceptives or naloxone.

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