Michael J. Schuh is a clinical MTM pharmacist in Jacksonville, Fla. Contact him at mschuhrx1@gmail.com.

Michael J. Schuh, BS, PharmD, MBA

Let's address the safety issue first. Compared to other healthcare professionals, pharmacists answer and make more telephone calls, give more FREE professional advice, and ring more cash registers. They personally re-bill and adjudicate insurance claims, and they may deal with more drug abuse/law enforcement issues.  

They do all this while supervising cashiers/technicians dealing with client/patient ("customer" in retail lingo) complaints, putting up orders, making orders, performing corporate paperwork according to company policies and procedures, waiting on "customers" at the drive-through, and ... oh, I forgot ... reading, interpreting, and checking the accuracy of prescriptions.  

As evidenced by the above, any of these distractions can individually or collectively lead to a misfill error. However, there's another factor to consider: the fishbowl issue. In many instances, all these things take place in an open physical environment filled with background noise: telephones ringing, overhead intercoms sounding, and cash registers ringing, as well as the constant distractions of interacting with others, whether staff or pharmacy patrons, further interrupting the prescription filling process and leading to an increased chance of error. 

Some operations are addressing these issues by designing pharmacies that physically set the pharmacist apart from many of these distractions, providing some control over their work environment that still allows for the counseling of patients and more efficient processing of prescriptions, a necessity in light of the workload.  

But what about the others? How many retail pharmacists deal with prescription fraud and abuse on a daily basis? Prescription drug abuse is common and growing. Does your pharmacy have narcotics and other abused drugs in plain sight of potential drug abusers or criminals who could come back later and rob you at gunpoint? How many of us know of pharmacies that have been robbed at gunpoint or burglarized? In Jacksonville, Florida, my hometown, a pharmacist was shot a few years back because a patient had to wait too long for a prescription. Safety is a real issue for both patients and pharmacy staff in many current retail models.  

Walk into many local pharmacies. What do you see in the prescription department? Staff unseen from the shoulders down, looking down, seemingly doing nothing! At least that's what it looks like to a pharmacy patron. In other professions, staff may be stationary much of the time, usually seated, but clients assume they are professionally engaged. What gives? They are not in a fishbowl! Access to them is limited and privacy is preserved, for both staff and clientele.  

Yes, pharmacies have "privacy" areas for consultations. But are these really private and professional-looking, compared to other professional environments? No. 

And what about communications between pharmacy staff members? How many of us have received a complaint from a pharmacy patron about an overheard conversation between pharmacy staff that had nothing to do with the patron or which the patron misheard?  

I remember an incident that took place many years ago during a slow spell in a busy pharmacy where I was interning. I was talking to my preceptor about Phil Niekro, one of the great knuckle-ball pitchers of our time, and a person near the pharmacy misinterpreted the conversation and complained to the corporate office that racial slurs against customers were being used in the pharmacy.  

How will changing the model help retail practice? How will it serve a retail chain executive making corporate decisions? For one thing, future pharmacy students may be attracted to the company when they graduate, instead of running as fast as they can from retail because of the professional environment.When staffing is better in the stores, the pharmacist will be able to spend more time in one location, dispensing professional services, which will create a more loyal clientele. And happier professional employees will stay with the job longer, so turnover and therefore personnel costs will be lower. As for safety, the company will be more protected from misfill lawsuits and employees more protected from the occasional deranged or criminal individual seeking to cause harm.  

, is a clinical pharmacist in Jacksonville, Florida. He can be reached at 

Articles

Doctors don't do it. Attorneys don't do it. Physical therapists, insurance agents, title agents, audiologist, and nurse practitioners don't do it. Who came up with the fishbowl model of retail pharmacy anyway?

A retail pharmacist examines the consequences of working in a fishbowl

You bet they are! Our facility, a major health system, has been performing comprehensive ambulatory MTM services since 2003. Although we have contracted with pharmacy benefit managers to perform MTM functions and we have a retail pharmacy, we have not, however, modeled our practice after a chain or PBM. 

We are fortunate to have in-house physicians who support our practice with referrals, but many of our patients evolve from self-referred requests to their physician. They want to talk about their medication with a pharmacist. There is a public demand for these services! It is up to enterprising pharmacists to step outside the pharmacy box, educate the public and the medical profession, and market their services! 

To be professionals who are respected for what we know and NOT for what we sell, a few things must take place. First, access must be limited. Patients have to make appointments in order to see a doctor, attorney, dentist, or chiropractor. Why shouldn't they for comprehensive pharmacy services?  

Second, physicians must understand that you are partnering with them to improve outcomes for their patients and not to get into their wallets. We can, in fact, become an important referral source for physicians! How many of us in the community pharmacy triage patients on weekends or evenings, when physicians are not available, to help patients decide to use an OTC product for their condition, see the doctor, or in some cases go to an emergency room? 

Third, we cannot as a profession let others define what we are and what we do. The PBM model defines MTM as keeping patients adherent to their medication schedules, keeping them on medications that match their formulary, and generally performing services that are favorable to the PBM at the lowest cost possible to the PBM. It is not that these services are not valuable to the patient. They are. But the services are defined from the PBM point of view. This business model is not necessarily the best business model for pharmacy practice, because compensation for these services, like compensation for services in filling prescriptions, is inadequate to cover the true costs in delivering these services to patients. 

Many will say MTM cannot be done because reimbursement levels are not enough to cover costs, which is a valid point. But, since one must crawl before one can walk, I would suggest a phase-in of the services into practice. In the current structure we have, we are able to cover 60%-80% of our labor costs depending on time spent with the patient and use of non-pharmacist leverage. With projected adjustments soon to be made, we can be breaking even or making money in as little as six to 12 months on a per-consult basis. We have been aggressively marketing the service for less than a year. 

If potential patients are turned off by non-coverage by insurance and out-of-pocket costs, start at lower fees, then work your way up over time after the practice is established. One must tailor one's practice to the population one serves. If the local family-medicine group has mostly working-poor patients, offer a practice "membership" to your services of a few hundred dollars a year to offset the service costs to see these patients and throw in an in-service quarterly to the clinical staff or perform drug information services for them. Be creative! 

If pharmacy as a profession continues to take a backseat to physician assistants, physical therapists, occupational therapists, speech pathologists, audiologists, and the like and remains politically inert on the subject of rendering professional services, we as a profession will become irrelevant.  

Current procedural terminology (CPT) codes for MTM services are the key to unlocking the product ball and chain from the pharmacy profession's ankle in both institutional and community practice. It is incumbent upon pharmacists to unlock and remove the ball and chain. We all know what happens when we do nothing... Nothing! 

THE AUTHOR is an ambulatory/community pharmacist who practices in Jacksonville, Fla. You can reach him at 

Pharmacists must find creative ways to offer medication therapy management services and get paid for them.