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Commentary

Potential Solutions and the Future of Community Pharmacy in This Era of Pharmacy Benefit Managers


September 19, 2019

mungerThroughout America, community pharmacies are closing. Since 2003, about 16% of independent rural pharmacies–or roughly 1230 stores–have closed, with fewer than 6400 remaining, according to figures released in July 2019.1,2 Community pharmacy closures are not unique to independent pharmacies as Walgreens recently announced that they will close 200 stores this year.3 These store closings are in addition to the chain closing 200 stores in the United Kingdom.4 Earlier this year, CVS stated the company was closing 46 stores.5   Many persons have written about the potential demise of community pharmacy over the years, including me.6-7  These posts are no long the “Boy Who Cried Wolf”—one of Aesop’s fables—community pharmacy is slowly dying.    

This third part of the three part series will provide potential solutions and insights into the future of community pharmacy in this era of pharmacy benefit managers (PBMs).

First, all community pharmacies must understand direct and indirect their own reimbursement fee structures as well as network pharmacy manuals during contractual negotiations.  Getting a corporate or personal attorney involved with the contract to make sure that community pharmacies interests are being expressly represented is paramount. 8-9 Another alternative is to make sure that the pharmacy services administration organizations, which act as intermediaries, explain all contractual terms in real world terminology, in other words getting transparency into negotiations.  PBMs are not your friend in these negotiations. 

Second, the pharmacy profession has to fully implement integration of clinical knowledge, skills, and expertise into the clinical theater.  Most importantly, every patient must be counseled on their medications.  The 2017 NABP Survey of Law shows all but 6 states require counseling personally, face-to-face, by a pharmacist.10 However, we all know that counseling is done at best, infrequently, because there are multiple exceptions to each statute in rule.  Knowing your patients is paramount to understanding your community pharmacy practice.  Increasing metrics will be imposed based on quality measures.  The ability to impact these measures requires a personal interaction with each patient.  If we want the public to be on the community pharmacy side to act against the PBM problem, we must ensure that a personal relationship exists first.   

Third, pharmacists are usually quiet and timid.  It is long past time to publically advocate not just by pharmacy organizations, but by grass root pharmacists and by our patients, that PBMs are a detriment to the public welfare. Call your senator and representative and provide documentation that PBMs are eliminating community pharmacies in their districts.  Have patients call on your behalf.  We are either going to have a seat at the healthcare transformation table, or we will be on the menu.  Where would you prefer to be?   

The community pharmacy profession is in grave jeopardy. PBMs are contributing to this decline. Can the trajectory be changed?  The answer is yes. Historical roots and current professional research supports pharmacists should be involved with compassionate, dedicated, patient engagement.   We must get involved with movements like the “Flip the Pharmacy” intended to move the profession beyond filling prescriptions to greater caring for patients have begun, but are moving slowly. 11   The very essence of the profession as we know it, the very reason we went into the profession of pharmacy--to care for the public, is being stripped away insidiously by many different initiatives (i.e., physician dispensing), businesses (i.e., PBMs, health plans) and consolidation of the drug distribution process. 

The pharmacist is quickly being left out of the equation because we are allowing it to occur.  Make no doubt, the time to stop blaming others, to stop crying wolf, and to act ourselves to save the community pharmacy profession is now.  There is still time, but precious little!

Dr Munger welcomes feedback on his commentary pieces. Please email jgould@hmpglobal.com to coordinate a discussion with Dr Munger.

References:

  1. Rural Pharmacies are closing: Where does that leave patients? https://health.usnews.com/health-care/patient-advice/articles/2018-10-17/rural-pharmacies-are-closing-where-does-that-leave-patients   Accessed 08/2019
  2. Lunds & Byerlys quits pharmacy business, closing 14 locations. https://www.bizjournals.com/twincities/news/2019/07/11/lunds-byerlys-quits-pharmacy-business-closing-14.html   Accessed 08/2019
  3. Walgreens to close 200 US stores. https://www.cnbc.com/2019/08/06/walgreens-to-close-200-stores-in-us.html Accessed 08/2019
  4. Walgreens posts quarterly earnings beat as prescription drug sales rise. https://www.cnbc.com/2019/06/27/walgreens-boots-alliance-q3-earnings-2019.html   Accessed 08/2019.
  5. CVS closing 46 stores: See the list of struggling locations that are going away. https://www.usatoday.com/story/money/2019/05/02/cvs-health-cvs-pharmacy-store-closing-list/3649440002/  Accessed 08/2019
  6. The Noble Community Pharmacy Profession: Is it in Jeopardy? https://www.managedhealthcareconnect.com/content/noble-community-pharmacy-profession-it-jeopardy   Accessed 08/2019
  7. 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
  8. A Payer’s Gide to Managing Pharmacy Benefits: Understanding the Complexity of DIR Fees. http://blog.transparentrx.com/2019/03/understanding-complexity-of-dir-fees_30.html   Accessed 08/2019
  9. Frequently Asked Questions (FAQs) About Pharmacy DIR Fees.  http://www.ncpa.co/pdf/dir-faq.pdf  Accessed 08/2019
  10. National Association of Boards of Pharmacy. 2017 Survey of Pharmacy Law. Copyright 2016. National Association of Boards of Pharmacy, Mount Prospect, IL.
  11. Flip the Pharmacy.  https://communitypharmacyfoundation.org/insider/email_details.asp?uid=7009FC82-21D7-4D01-96A1-52D1EC7050F2 Accessed 08/2019
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