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Commentary

The Noble Community Pharmacy Profession: Is it in Jeopardy?


June 04, 2019

mungerPharmacy can tie its professional roots to being recognized as a medical practice dating as far back as Sumerian times, around 2,000 to 1,500 BC, from which medications were prescribed.1 Even 4000+ years ago, pharmacists provided patient care which focused on optimizing medication management therapy.

Approximately 750 AD, pharmacy started to evolve into what we call drug stores in ancient Baghdad, during the Islamic Golden Age.1 In the 1200s AD, drug stores, were mostly located in Monasteries through Europe.  In 1729, the first community pharmacy was founded in Philadelphia, PA.1 The industrial revolution of the 1940s produced pharmaceutical manufacturing processes that allowed mass production of drugs, expanding community pharmacy business throughout the U.S. Then, with the passage of the Durham-Humphrey Amendment to the Federal Food, Drug and Cosmetic Act of 1938, in 1941, pharmacists now needed a physician’s prescription to dispense many medications. Thereby, community pharmacists were restricted to recommending over-the-counter remedies and the profession began focusing on dispensing and product safety.2 Resultant professional activity became a product-focused, transaction-based business model, transitioning away from the historical patient-centered health care profession.  However, dramatic changes in pharmacy occurred in the 1960s when pharmacists recognized the human cost of inappropriate medication use.  Were they right?  Yes.  The current cost of prescription drug-related morbidity and mortality is estimated to be $528.4 billion or 16% of total health care expenditures in 2016.3 The development of clinical pharmacy and the patient care practice model was spawned.4 Clinical pharmacy practice became focused on optimizing medication therapy and promoting health, wellness, and disease prevention based on scientifically valid information.  The development and implementation of clinical pharmacy returned pharmacy to its noble roots as a medical practice.

The clinical pharmacy revolution has, however, been very slow to be adopted by community pharmacy.  The focus continues to remain on a transaction-based business model resulting in many pharmacist’s dissatisfaction with their career choices. A recent study has shown the impact of this slow adoption.  In a survey of community pharmacists to model drivers of self-reported occupational satisfaction and stress for possible intervention by the profession, community pharmacists state a high level of dissatisfaction with > 50% stating they wanted to quit their jobs.5 Dissatisfaction was higher among PharmDs, and those employed in pharmacy chains.  Twenty percent stated their mental and physical health and quality of work was adversely affected by their employment.  In contrast, direct patient care activities were associated with higher satisfaction and lower stress.  Interestingly, institutional pharmacists are positive about their job, showing that the more time spent on clinical activities, the greater their satisfaction.6 

The study also calculated a Net Promotor Score (NPS).6 The NPS is an index ranging from -100 to 100 that measures the willingness of customers to recommend a profession’s services to others. The study calculated the NPS as a proxy for gauging community pharmacist’s overall satisfaction with their working environment.  The NPS score was -18.15, an indicator that more pharmacists are detractors than promotors of the profession.  What implications might this have?  If this continues over time, it can be an indicator that the community pharmacy profession is going out of business.7

Is the community profession trying to change?  The answer is yes. Market forces are driving diversification including CVS/Aetna (combining a health plan with a retail clinic), potentially Walgreens-Express Scripts with Cigna, and Walmart with Humana.  Quality and patient satisfaction of retail clinic care of otitis media, pharyngitis, and urinary tract infections have generally been good compared to traditional clinics and emergency departments.8 However, cost savings have not been realized related to increase use, to date.9  Stated benefits for the development of retail clinics have been that primary care physicians can see fewer patients, may be able spend more time with complex patients, and maintain their same level of income.10  The major question is whether these retail clinics can show they can reduce upstream medical events, thereby improving quality of life and reducing healthcare costs?  Conduction of prospectively rigorously controlled studies with the aim to reduce medical event outcomes must be undertaken.   

Is the noble community pharmacy profession in jeopardy?  The answer is yes.  Can the trajectory be changed?  The answer is also yes. Historical roots and current professional research supports pharmacists should be involved with compassionate, dedicated, patient engagement.  Direct retail clinics do deliver quality care, are convenient, but have yet to prove reduction in healthcare costs.  Research is needed to understand whether direct retail clinics can reduce upstream medical events, and in a cost effective manner.  Direct retail clinics continued transformation from a sole transaction-based business to a hybrid model of patient care practice with transactions is imperative for sustaining the community pharmacy profession.  Time is of the essence!

References:

  1. History of Pharmacy. https://www.coynecollege.edu/news-events/history-pharmacy   Accessed 05/2018
  2. History of Pharmacy. https://stlcop.edu/practice/about/ Accessed 05/2018
  3. Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother 2018. Doi: 10.1177/1060028018765159.
  4. Elenbaas RM, Worthen DB. Clinical Pharmacy in the United States. Transformation of a Profession. American College of Clinical Pharmacy. Lenexa, Kansas. 2009.
  5. Munger MA, Gordon E, Hartman J, Vincent K, Feehan M. Community pharmacists’ occupational satisfaction and stress: A profession in jeopardy? J Am Pharm Assoc 2013;53(3):30-44.
  6. Olsen DS, Lawson KA. Relationship between hospital pharmacists’ job satisfaction and involvement in clinical activities. Am J Health-Syst Pharm. 1996;53:281-4.
  7. Detractors Effect on Business. https://www.retently.com/blog/detractors-ruin-business/ Accessed 05/2018
  8. Shrank WH, Krumholz, AA, Tongy AY, et al. Quality of care at retail clinics for 3 common conditions. Am J Manag Care 2014;20(10):794-801.
  9. Ashwood JS, Gaynor M, Setodji CM, Reid RO, Weber E, Mehrotra A. Retail clinic visits for low-acuity conditions increase utilization and spending. Health Aff (Milwood) 2016;35(3):449-55.
  10. Rubin R. Is direct primary care a game changer? JAMA Published online May 2, 2018. doi:10.1001/jama.2018.3173.
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