Poised for Innovation
Published on 27 July 2018
Community pharmacists are a patient's most accessible health care provider, and as medication experts, they are critical to maintaining and improving patients' health. While this truth has long been understood by pharmacists and the patients who rely on them, the larger health care industry has been slow to fully leverage community pharmacists as the invaluable resource they are.
Rapid changes in the profession have created a challenging environment for many pharmacies, but community pharmacy has long been an incubator of innovation. Today, there is a growing movement to shift focus from filling prescriptions to a model that recognizes the contributions of community pharmacists and their ability to utilize close relationships with patients to serve as key providers of clinical services. With the entrepreneurial spirit that defines them, community pharmacists are poised to usher in a new paradigm of community pharmacy care.
"Clinical pharmacy is going to materialize in a community setting in a way that will illustrate the value of pharmacy and the pharmacist's role in population health outcomes, cost avoidance, individual critical outcomes and preventative care initiatives," said Christian Tadrus, B.S. '96, Pharm.D. '97, northern Missouri community pharmacist and second vice president of the National Community Pharmacists Association. "Community pharmacy is experiencing something of a new awakening. These initiatives are the realization of the promise that we have been working toward for the last 25 years."
As health care costs climb, insurers are desperately looking for ways to reduce costs, and they see opportunity in utilizing community pharmacies to do so. By providing enhanced and expanded clinical services that meet local needs, community pharmacies are reasserting themselves as a linchpin connecting patients to health care systems.
While this renewed focus on community pharmacy is creating opportunities for pharmacists to grow their services and practices, there are obstacles prolonging the evolution.
From shrinking margins to implementing new systems for documentation of activities and services to simply finding time to implement these initiatives, the barriers to providing enhanced services can seem insurmountable. However, as more community pharmacies commit to this practice and new metrics are established that focus on quality of care, the momentum of this evolution will propel community pharmacy above and beyond the obstacles that lay in its path.
An Emerging Pathway
Over the last few decades, the health care industry has come to increasingly recognize pharmacists as practitioners supporting positive patient outcomes. To fully realize the benefits of leveraging pharmacist-delivered care, initiatives have been cultivated across the U.S. that have captured payers' attention, while providing community pharmacy with the support and resources to expand their scope of services and be reimbursed for them. An emerging pathway that has gained the most attention in the last five years is the Community Pharmacy Enhanced Services Network (CPESN).
When Community Care of North Carolina (CCNC) launched in the early 2000s, the need for pharmacists to be key players in improving quality of care and cost effectiveness, particularly for patients with chronic illness, was recognized by program developers. As the medication experts, pharmacists bridged the gap in a network primarily focused on networking primary care physicians. This led to embedding pharmacists into primary care offices, long-term care facilities and hospitals, placing an emphasis on clinical pharmacy.
Moreover, 2013 Medicaid claims data reported that high-risk patients visited their community pharmacy, on average, 35 times a year, compared to 3.5 visits to their primary care provider. To leverage those 35 touch points, CCNC looked for opportunities to incorporate community pharmacy into their program.
Recognizing the success and positive outcomes of CCNC, community pharmacy worked to develop its own care network, focusing on providing enhanced services to their local communities.
Modeled after, and in collaboration with, the CCNC initiative, North Carolina CPESN was developed and has been expanded nationwide as CPESN USA, along with the formation of other local CPESN initiatives in individual states.
"Historically, dispensing prescriptions has been the endpoint in conversations with health care providers," said Tripp Logan, Pharm.D., southeast Missouri community pharmacist and CPESN USA national luminary. "A patient would see the doctor, get a prescription, go to the pharmacy and go home. The pharmacy typically did not communicate back with anybody. This new model establishes community pharmacy as a communication piece in the larger health care puzzle and also includes two-way conversations with providers and health systems."
Initiatives like CPESN also encourage a shift in focus from filling prescriptions to providing patient-centered service. This shift will require a revision of the metrics currently in place that encourage competition in cost and not quality of care.
"Currently, pharmacies are networked by cost," Logan commented. "They really should be networked by quality. What current metrics fail to do is take into account the overall impact on the health care system. Do lower prescription costs keep people out of the hospital? What we are seeing is an overall 'No.' Over time, community pharmacies have been focused on pharmacy reimbursement on prescription drug products, which is completely unrelated to how well a pharmacy does in keeping a person healthy."
Swimming in the Crosscurrent
CPESN initiatives are gaining traction across the country, but community pharmacy finds itself caught in the crosscurrent of providing enhanced and expanded services while grappling with shrinking margins, limited resources and lingering misperceptions about the role of the community pharmacist.
"The revenue lines from dispensing services are what support the expansion of clinical services," Tadrus said. "With reimbursement continuing to decrease, it obstructs community pharmacies as they try to grow from where they are to where they want to be and operate."
Another obstacle faced by community pharmacies is time. Providers are ready and willing to partner with community pharmacies to help lower out-of-pocket costs and improve their metrics, but engaging in new initiatives requires time and resources. While many pharmacists are doing their best to stay ahead of trends, many find themselves under-resourced when faced with the undertaking.
"Having the time to develop enhanced services and knowing that you may not get immediate payoff for that is one of the main obstacles community pharmacists are faced with," said Roxane Took, Pharm.D., assistant professor of pharmacy practice at the College and community pharmacist at Shop 'n Save. "The paperwork necessary to apply to things like Direct Care Pro and accreditations to provide services like diabetes self-management education (DSME) all take time and resources."
Engaging in new care models will require most community pharmacies to invest in new systems and approaches in order to support robust documentation and outcomes measurement.
"We are seeing payers move to a more clinical outcome reimbursement methodology, which means documentation of activities is absolutely necessary for community pharmacists. It's how we prove to payers that we are the ones improving outcomes," Tadrus said. "Pharmacists will increasingly document their activities using electronic care plans, a form of a continuity of care document commonly used in health care. This standardized method of electronic documentation developed by the National Council on Prescription Drug Plans facilitates the rapid exchange of clinical information between community and other settings. It is rapidly being adopted by technology vendors and should provide a more efficient means for community pharmacists to participate in patient care activities."
For community pharmacists on the leading edge of these trends, lingering perception gaps can be problematic.
"It's hard in the community setting to be recognized as a health care provider," Took explained. "Community pharmacists go through the same schooling and have the same capabilities as other pharmacists. The difference is the community pharmacist is not working side-by-side with the primary care provider, which is a barrier."
The Next Generation
With the impending retirement of the baby boomer generation, community pharmacy anticipates a wave of business transitions that, compounded with shrinking margins, may result in a wave of consolidation and investment partnerships, rather than new independent pharmacies. This very real possibility may appear as a decline in community pharmacy, but these transitions are full of opportunity.
As new pharmacists enter into community pharmacy, they often provide a fresh perspective when looking for other revenue streams and opportunities. To be successful, it is critical that student pharmacists pursuing community pharmacy are prepared to embrace new opportunities.
"Sometimes students who are not health-system driven go into community settings," Took said. "They get used to a model of pharmacy that is dispensing focused, which can create hesitation when they get the call to start providing more clinical services."
Exposing students to a model of community pharmacy where pharmacists are directly providing patient care may also attract students that have a passion for more clinical work, but may have overlooked community pharmacy initially. When fully leveraged as health care providers, pharmacists can exercise the full range of their skills in clinical and community practice settings.
Although obstacles remain, there is hope rooted in the potential of community pharmacy, wherein pharmacists engage through an expanded scope of services, and they are recognized for their ability to make improvements in outcomes and quality of care. Within a health care industry ripe for innovation, community pharmacy is, in many ways, positioned as the way forward. Armed with an innovative spirit, community pharmacists are poised to usher in changes that bring together providers and payers to create meaningful benefit for patients.
This story was first published in the spring 2018 issue of Script. Visit stlcop.edu/script to read more and access previous issues.