Community pharmacies today are much more than places to pick up medications. Pharmacists and other health-care workers increasingly are taking on additional roles and working to improve patient health.
In a recent article in Pharmacy, Jean-Venable “Kelly” Goode, Pharm.D., examines the evolution of community pharmacy in the United States. We spoke to her about what these shifts might mean for the profession and for patients.
Goode, who holds a B.S. and doctorate in pharmacy from VCU, is a professor and director of the community pharmacy practice and residency program at VCU School of Pharmacy. She also is president of the Virginia Pharmacists Association and a recent past president of the American Pharmacists Association. Co-authors for the article include Sharon Gatewood, Pharm.D., associate professor in the VCU School of Pharmacy.
VCU School of Pharmacy: Why is it important for community pharmacy to evolve?
Jean-Venable “Kelly” Goode, Pharm.D.: When we look at the margins and the pressures on just the product, it’s causing pharmacies to not really be able to stay in business. There are lots of pressures on drug cost, as well as insurance companies and pharmacy benefit managers taking money from community pharmacies, money that they don’t really know if it’s going to be taken. We’re losing a lot of smaller pharmacies, but it’s also hitting some of our larger chain pharmacies as well.
There’s not necessarily the ability to support the business based on just the product. And pharmacists are trained to do much more, right? We are taking care of patients and really taking more responsibility for medication outcomes.
[Community pharmacies are] a natural fit to be an access point because you’re seeing community pharmacies visited by patients and consumers much more than other healthcare providers. That access point, sometimes the first entry into the healthcare system, is done in a community pharmacy.
Why haven’t more pharmacists and pharmacies already evolved into something like that?
Again, it’s financial a little bit. Pharmacists have traditionally been associated with that product, and payment is attached to the product. And so when we look at expanding services beyond the product, there has to be some sort of way to maintain that as well. It can’t always be value added or given in complement to a product. And there are not very many good mechanisms in most states for pharmacists to get paid for those other services, because they may or may not be recognized as a healthcare provider.
Even if they’re recognized as a healthcare provider, [that] doesn’t mean that people who are paying for services — third-party payers, insurance companies — are recognizing them for payment.
There are a couple of states that have been able to get pharmacists paid by passing legislation that requires payers to pay pharmacists for any services that they would pay another healthcare provider for if it is in the pharmacist’s scope of practice. We don’t have that law here in Virginia or have legislation for that in Virginia. So it’s really either relying upon the patient to pay for the service, or a third-party payer to pay for the service. …
If you look at the long list in the Social Security Act for payment for service [under Medicare], pharmacists are not listed there. And that’s what the profession’s has been fighting for at Capitol Hill for years, trying to get legislation so pharmacists can be inserted into that Social Security Act as a provider.
How crucial is that to achieving the goals that you lay out in your article?
It’s a piece of it. Many pharmacists are also doing workarounds. When you look at some of the structure, there are pharmacists who have been able to work on teams and collaborate with physicians, helping physicians meet quality measures. There are a lot of quality measures in primary care that are related to medication use. Having that collaboration with the pharmacist partner can help the physician meet quality measures, which increases physician payment in primary-care practice.
Some pharmacists have been able to work with primary care practices and get their pharmacists involved in those practices. They send a pharmacist to the practice to see patients, or those patients come to the community pharmacy, and the physician pays a piece of what they’re getting paid to take care of that patient to the pharmacist who’s doing the actual work.
That’s a workaround, because the pharmacist isn’t getting directly paid from the third-party payer; the physician is, and then it comes back to the pharmacist.
Patients can pay out-of-pocket if they see value. Many times they’re using a flexible spending account, and they can pay the pharmacist and some of the services out of a medical flex spending account. So there are other ways sort of to do it. You can also direct contract with payers — some pharmacies are doing that. Medicaid is stepping up in some states to pay pharmacists to manage medications as well.
What are some of the most encouraging or positive signs that you’ve seen as far as the future of the profession in this direction?
We’re seeing pharmacists out in the community taking care of patients and being able to go beyond just being tied to those four walls of the pharmacy. They’re in patients’ homes, they’re in community centers, they’re in shopping malls, they’re in work places providing care to patients. And that’s really that access piece — putting the pharmacist front and foremost as a patient care provider.
As part of that, what we’re seeing with these enhanced services is the creation of networks. For example, Community Pharmacy Enhanced Services Networks. They started out in North Carolina. We’re seeing many states begin to develop their own networks, which put those pharmacies that are offering these enhanced services together so that they can then perhaps contract with payers to take better care of patients within those communities.
Is there some reluctance to move in this direction among some people in the profession?
Are you hearing reluctance?
There’s a lot of talk about workplace well-being. And as we look at the payment stream — which is typically now just for the product — that requires pharmacists to push out more product, push it out faster and push out more during the day or the hours. And we’re not the only healthcare profession getting squeezed that way, right? Physicians are getting squeezed to see more patients per hour as well because they’re paid based on the patients they see.
So there’s a lot of, perhaps, workplace conditions that are not the best for pharmacists. As a result, sometimes they see extra services as “something extra I have to do within this workplace day.” So it’s based on depending upon where you are and the practice that you’re in, whether or not you’re able to do this.
I think most people when they step back from sort of that day-to-day grind and what’s happening, they see this as where the profession needs to go. And I think from schools and colleges of pharmacy, this is definitely where we’re teaching our student pharmacists to go in the future. I think we’re going to see lots more innovation and sort of stepping outside of what we see as the traditional role.A quote: "There is going to be so much opportunity. If you look at where pharmacists are, pharmacists are everywhere, right?" [View Image]
What would you tell somebody who’s interested in possibly going into pharmacy but they don’t know what to expect with all this change?
There’s going to be so much opportunity. If you look at where pharmacists are, pharmacists are everywhere, right?
If you want to make a difference in patient care, pharmacy is probably a great place to be because it gives you lots of opportunities. We see pharmacists in the FDA. We’re seeing pharmacists who are pharmacist lawyers, doing policy. We see associations, pharmacists within that changing practice.
It’s really wide open to what you can do with a pharmacy degree, but it’s probably going to look a little different. It also right now might be painful for a little while as we sort of readjust, and healthcare readjusts. I think that there’s got to be a balance back.
I think all healthcare is going through sort of a readjustment, because you hear some of the same conversations within medicine about wellbeing and what’s happening to physicians.
It’s not just pharmacy that’s feeling this, it’s everybody. And I think if we look at team-based practice, the pharmacist is key to that. Then we can all help each other.
If somebody were to take one takeaway from this article, what would you point to?
This role of the community-based pharmacist practitioner and really taking care of patients. I hear it from student pharmacists: They say they don’t want to do community-based practice because they want to be clinical. But every single pharmacist is clinical. Community-based pharmacists are clinical every day. Even when they’re “just” dispensing medications, they’re making clinical decisions.
I think it’s this role of this community-based practitioner that’s doing more beyond than the clinical activities attached to the product, but really taking care of patients. And there’s lots of opportunity for community-based pharmacists.
Goode has received awards and recognition including the Virginia Pharmacists Association’s 2014 Ed D. Spearbeck Virginia Pharmacist Service Award, APhA’s Daniel B. Smith Practice Excellence Award in 2011, the inaugural National Association of Chain Drug Stores Foundation Community Pharmacy Faculty Award in 2009, the APhA Community Pharmacy Residency Excellence in Precepting Award in 2008, the VCU Distinguished Service Award in 2005, the APhA-APPM Distinguished Achievement Award in Clinical/Pharmacotherapeutic Practice in 2004, the VCU School of Pharmacy Teaching Excellence Award in 2003 and the Virginia Society of Health-System Pharmacists Practice Innovation Award in 1997.