Everyone on the “buy side” wants lower cost medicines. But at what cost? As Congress and other Administration officials attempt to make medications more affordable, patient safety must not be sacrificed.

In January, two federal importation bills were introduced, along with a slew of state-based bills, signaling policymaker’s prioritization of this policy.  The federal bills would allow for the personal importation of prescription drugs from Canada as well as wholesale drug importation, in certain instances. Already this year the U.S. House and Senate have held several drug pricing hearings during the first few weeks of the 116th Congress that have included importation. State legislatures are also considering importation proposals, mostly on the wholesale side. Importation bills were introduced in 10 states in 2018; more are expected in 2019.

Efforts to allow for importation belie real issues in drug pricing, and instead, offer a politically popular but unworkable option. Foreign sellers can already increase competition by working with authorities to export FDA-approved products to the U.S. via the legitimate supply chain. Further, the proposed importation policies do not directly address the core issue of domestic prices and overlook the significant risks to patient safety associated with sourcing drugs from outside the closed U.S. supply chain.


	Pharmacists are willing to consider novel approaches to lower the cost of medications but are concerned the recent legislative proposals will result in patients sourcing and relying upon non-FDA approved medicines, including potential counterfeit products outside of the secure supply chain we work so hard to maintain. Consequently, patients purchasing these medications will unknowingly bear the greatest risks.

Current laws protect patients. When FDA-approved medications are purchased, patients do not question their quality. Make no mistake, the burden of ensuring safety and effectiveness of medicines would become “caveat emptor” or let the buyer beware and thus unwittingly place patients in peril from counterfeits or, diverted products should current importation legislation advance.

Demand for convenient, lower-cost medications has created a new economic incentive for criminals to manufacture and sell dangerous-sometimes deadly-counterfeit drugs. Counterfeits are often manufactured in unsafe conditions; contain too much, too little, or no active ingredients; and/or may be made using dangerous or deadly substances, including fentanyl, floor wax, and other harmful substances. Congress aimed to secure the U.S. supply chain from these risks in passing the 

; a robust 2013 law which the U.S. pharmaceutical supply chain is currently implementing.  We should be cautious to not undermine the safety processes this law put in place.

As rational economic actors, drug counterfeiters regularly trade in the highest-cost, hardest-to-get, and most sought-after products based on American demand. Whenever there is a drug shortage, public health crisis, or price spike, counterfeiters and criminals swoop in, and target patients by offering access, “deals,” and even “cures.” The following are just a few of the headlines highlighting FDA’s recent efforts to address this problem: FDA crackdown on fake “Ebola cures” sold online; FDA warns of fraudulent/unapproved flu products;  FDA warns against fake cancer treatments.  

Should lawmakers and other health authorities authorize importation of prescription drugs, we should expect criminals to similarly flock to that new market, placing patient safety and public health at substantial risk.


	Officials struggle to stop dangerous fakes from entering the country. Counterfeit pills laced with fentanyl and other synthetic opioids are shipped into the U.S. in mass quantities from foreign sources, killing Americans. In July, the U.S. Attorney for the Southern District of New York announced the arrest of two individuals for advertising and selling controlled substances through an illegal online pharmacy.  In August 2018, two Chinese nationals were charged in a global opioid and drug manufacturing conspiracy that involved the manufacture and distribution of synthetic opioids that spanned more than 25 countries, hundreds of drug analogues and resulted in at least two confirmed deaths. Expanding mechanisms available to import foreign-sourced medicines to the U.S. would exacerbate an already overwhelming and unmanageable safety situation. FDA Commissioner Gottlieb has noted  it is estimated that FDA is able to physically inspect less than 0.06% of all packages entering international mail facilities thought to contain drug products. 


	Legislators’ actions could also have the unintended consequence of suggesting to Americans that it’s safe to buy any medicine from foreign sources. Messaging matters. We must guard against the risk that Americans might misinterpret the efforts of Congressional leaders and Administration officials to suggest it’s safe to purchase medicine from foreign sources anytime.

U.S. consumers buying medications from Canadian online pharmacies rarely, if ever, receive the same regulator-approved products provided to Canadian consumers. Indeed, the FDA has found that 85% of drugs promoted as “Canadian” came from 27 other countries, including India, Costa Rica, and Vanuatu. Just as online criminals currently pass themselves off as “Canadian,” allowing even a limited legal means of importation would cause criminals to likewise pass themselves off as meeting the requirements of a new restricted importation policy.

While the government and healthcare community look for comprehensive policy solutions for drug pricing, resources from websites like www.BuySafeRx.pharmacy and www.safe.pharmacy are available now to help consumers stay safe and verify the legitimacy of websites before they buy medicine online. Pharmacists in all practice settings can play an important role in educating patients about their buying options, including ways to identify and coordinate cost-effective treatments that consider individualized needs as well as payer policies. Pharmacists can help optimize the impact of patients’ medications but cannot do this effectively when patients’ medications are not safe or effective.

While we share the goal of increasing patient access to safe, affordable medicine, the potential cost-saving benefits of importation policies must be sufficiently weighed to account for the considerable risks to patients. We urge Congress and the Administration to carefully consider pharmacists and pharmacists’ perspective in policy decisions that impact patient access to safe and effective medications.

Thomas Menighan, BSPharm, MBA, is CEO of American Pharmacists Association.

Libby Baney is a partner with Faegre Baker Daniels and a senior advisor to the Alliance for Safe Online Pharmacies (ASOP Global) and the ASOP Global Foundation. 

Articles

How HHS efforts to increase competition could hurt patients.

Lower Drug Prices Aren’t Worth Higher Health Risks

Have you ever been asked to write an elevator speech?  In other words, what you would say if you had 30 seconds (about the time it takes for a ride in an elevator) to describe your business or to sell a project to a perfect stranger?

I’ve written an elevator speech a couple times as a brainstorming exercise when I’ve participated in strategic planning processes with organizations that I’ve been involved with. More recently, I did it as part of a marketing seminar that was meant to be specifically for my pharmacy.

It’s not easy to describe an organization’s mission or purpose, or in the more recent case, what makes my pharmacy unique, in about three or four sentences.

I live in a somewhat rural part of Wisconsin, so the idea of riding in an elevator with a stranger is somewhat foreign, due to the fact that (a) there is only one elevator in my town, and (b) everyone knows everyone, so the idea of somehow ending up in an elevator with a stranger just isn’t very likely. 

I like to think that instead of an elevator speech, I’m writing a “get to know the other parents at the ballgame a little better conversation.” At this point in my life, my kids’ ballgames are where most of my interactions with others are taking place. I use the word “conversation,” because it’s not likely anyone wants to listen to a prerehearsed 30-second speech anyway.

At the ballgame, when another parent inevitably asks me, “So, what do you do for a living?” I’ve found it helpful to be prepared with more than, “I’m a pharmacist.”

I’ve noticed that very few people have a good idea of what a pharmacist actually does. Maybe it’s because pharmacists do so many different things, or maybe it’s because every time there’s a pharmacy-related story on the news, the one and only video shot is of the counting tray and someone (by assumption, it must be the pharmacist) counting pills by fives and pushing them to the side.

So as part of the conversation (again not a speech), I like to point out the services we offer and say things like, “I spend time with patients who take a lot of medications and look for ways to simplify their regimen to make it easier for them” or, “Have you ever picked up an antibiotic for your child and wanted to know for sure it was the right dose? Well I make sure it is.” 

I’m proud of the many things we, as pharmacists, do every day. And it’s so important for people to know what we do and how it applies to their everyday life.

The cover story this month revolves around even more activities that pharmacists are doing these days, specifically as part of the primary healthcare team in primary care settings like medical clinics and physician’s offices. How great is that! Our profession is continually evolving, and we need to keep finding ways to use our knowledge and skill set to improve patient care.

I’d encourage you to think about how you spend your day and how you describe our profession to others. We need to make sure people outside our profession know how we spend our days so that, someday, the video of the pill-counting pharmacist looks as odd as someone using a pay phone or typewriter.

And just like someday, when we all have jet packs attached to the back of our white coats, the idea of using an elevator will be very odd too.  

When someone asks about your job, how do you answer?

How to Talk About Being a Pharmacist

 that will be diagnosed in the United States this year, the most fortunate patients will have a board certified oncology pharmacist (BCOP) ontheir care team to help them. In addition to being cancer medication experts, BCOPs deliver a broad range of expertise and unique levels of practice, skills, and responsibilities to their patients.

The pharmacist’s critical role in the care of oncology patients was underscored in a recent 

 of transitional care management (TCM) conducted at Boston Medical Center. The study concluded that pharmacist intervention reduced the average 30-day unplanned readmission rate among patients who had an inpatient oncology service. The readmission rate was 18.7% among patients who completed the TCM process; it was 37% for patients who did not. Pharmacists in the study were credited with identifying errors in more than half the discharge medication reconciliations completed by physicians. The authors concluded that pharmacists’ subsequent intervention with patients helped to reduce harm and optimize patient care.

“The oncology pharmacist is often one of the few team members who fully understands the safety, efficacy, pharmacologic, and financial components of patient care,” says Michael Bourisaw, executive director of the Hematology/Oncology Pharmacy Association. “The changing landscape of healthcare and evolving approach to cancer care-including oral therapies, targeted therapies, and personalized medicine-emphasizes the need for the oncology healthcare team to include an oncology pharmacist.”

 in Kentucky sees about 100 patients each day. On-staff clinical oncology pharmacy specialists Megan May and Jeannie Patrick-who are both PharmD and BCOP-consider education to be one of their primary roles there.

They provide in-services and up-to-date information to their fellow interdisciplinary team members in addition to counseling every new oral chemotherapy patient. They also facilitate drug acquisition and patient management, working off treatment plans to help streamline the way products are ordered and treatment plans are entered.

May and Patrick are the only two clinical specialists in the Baptist Health Lexington Cancer Care Center; two to three other pharmacists compound IV chemotherapies, and two pharmacists are responsible for oral chemotherapy dispensing.

May says her work begins before a new patient starts chemotherapy. Once the oncologist has made a diagnosis and recommended treatment with her assistance, she sits down with the patient to do a medication reconciliation. She reviews their list of at-home medications and double checks it for accuracy with their local pharmacy to ensure there will be no interactions with the patient’s chemotherapy.

“Then we go over with the patient what we’re prescribing, what it’s for, how to take it, how long they’re going to take it, any side effects they might have from that, and we also touch on adherence,” she explains. This step includes drawing up a meticulously detailed schedule that shows precisely when the patient should take the various medications.

Almost all of the oral chemotherapy medications prescribed at the cancer center are considered specialty drugs, and most are available from the in-house pharmacy. When medications are in limited distribution, or when drug manufacturers require the use of a specific specialty pharmacy, they are ordered from outside.

May and Patrick help the cancer center’s financial navigator find ways to reduce high out-of-pocket costs for the specialty medications. One recent case involved a 71-year-old with prostate cancer whose oncologist wanted to start on abiraterone (Zytiga). The insurance company approved the prescription, but the copay was $2,196 per month. “Obviously, there was some sticker shock,” recalls Patrick.

The financial navigator started a search, and two days later found a $6,500 grant that the patient was qualified for and received. After the patient’s first copay, Patrick estimates that his monthly cost dropped to about $500.

“We keep a running log, and as that grant money starts to trickle down and run out we start the same process all over, looking at grants to see if anything has opened up that we can apply for. If not, we’ll reach out to the manufacturer for assistance,” Patrick explains.

 at Yale New Haven in Connecticut, Darren Luon, PharmD, BCOP, clinical pharmacy specialist in medical oncology, still recalls a case he handled as a P4 student that led to his decision to specialize in oncology. It involved a young patient who only spoke Cambodian, which Luon had learned as a child.

“She and her family had no idea what was going on because there was such a language and cultural barrier,” he says. “The team let me sit down with [the patient’s family] and talk about everything to see how they were doing. It really affected me greatly, and after that I wanted to go into oncology 100%.”

Today, counseling patients is a major part of Luon’s role at Smilow. While the oncologist talks to patients about their cancer diagnosis, prognosis, and the treatments that are available, his role is to explain the drugs. “We have the most experience in being able to guide our patients in terms of how to manage side effects and supportive care in general,” he says.

Luon’s colleague, Kristen Rychalsky, PharmD, BCOP, BCPS, oncology clinical pharmacist II, also relishes the role of counselor, which she first experienced while working at a VA hospital. She recalls one patient who was suffering from a medication-related rash on his hands and feet. His physician hadn’t talked to him yet about side effects, so Rychalsky addressed the issue by holding the medication until the rash resolved and reducing the dose.

“The next time I was able to talk to him, the patient simply expressed his gratitude in such a touching way,” she recalls. “I was not only working to the top of my ability, but I knew the appreciation that the patient felt for me and my role. It was an amazing experience to have as any type of healthcare professional.”

Luon admits that a cancer clinic is not the easiest or happiest place to work. With many patients moving towards the end of life, conversations often center on difficult topics. Still, he appreciates all the hard work and experience that got him to this point. That, and a large dose of compassion, keeps him going day to day.

“We’re basically fighting an uphill battle a lot of times. We want to make patients get better, but there’s only so much you can do sometimes,” he says. “In order to keep doing this, you need to have that drive and love this field.” 

Oncology pharmacists have a challenging job caring for cancer patients.

What it’s Like to Be an Oncology Pharmacist

Over the last several years, pharmacists have embraced information technology, software, automation, and hardware to support their daily work load and help them better manage an increasing number of patients. But more innovations are coming. Advances in predictive modeling, robotics, mobile apps, and diagnostics are opening new horizons for pharmacists, which can vastly improve their ability to dispense medication, minimize errors, and monitor patient adherence. 

Improving patient engagement and encouraging medication adherence after discharge is a top priority for pharmacists, especially as more focus on supporting value-based care, says Ken Perez, vice president of healthcare policy at 

, a supplier of medication management solutions based in Mountain View, CA. He says pharmacy information systems can help by offering medication synchronization and medication therapy management, for instance.

Related article: Prescription Drug Monitoring Programs Benefit Pharmacists

They can also help pharmacists flag patients who are abusing or selling opioid medications, if those systems are integrated with prescription drug monitoring programs (PDMPs), says Perez. PDMP databases are maintained by almost every state, and pharmacy information systems are beginning to integrate with them.

Rebecca Chater, RPh, MPH, FAPhA, director of clinical healthcare strategy at Omnicell, adds that more systems are also integrating with electronic health records (EHR). Newer systems will access actionable data, such as lab values and diagnoses codes. This will help pharmacists efficiently document their tasks and share data with the broader healthcare team, Chater says. “These emerging information systems will help break down silos. These new age systems are all about supporting patient care as it relates to medication usage.”

, a medication automation consultancy based in Bellevue, WA, says pharmacy information systems and automated dispensing systems are already helping pharmacists more efficiently view patient medication histories, fill subscriptions, and avoid medication errors. “These systems are pretty sophisticated and are helping pharmacists do a better job of monitoring because of the vast amounts of data they contain,” he says. Neuenschwander is a member of the 

Perez considers automated drug dispensing an essential standard of care in hospitals. These systems facilitate patient safety and also cut down theft. “The information that is flowing through these dispensing systems has to be mined more extensively to gain insights,” he says. “For example, artificial intelligence, predictive modeling, and algorithms could be used to predict drug shortages, price increases, waste, and theft based on dispensing patterns.”

In the community pharmacy setting, Neuenschwander thinks most dispensing systems will remain semiautomated, depending on whether the pharmacy wants to invest in more expensive sophisticated automation. But Amazon’s purchase of PillPack will influence pharmacies to check out more automated dispensing options, he says. “To stay competitive, the smart retail pharmacy might consider establishing a competing dispensing system that combines smartphone apps and barcode scanning to prompt patients to take their medications,” he says. 

Chater agrees there is room for growth for automated dispensing in community pharmacies. “They are not ubiquitous in community pharmacies, although they’ve gained significant traction,” she says.

One way to improve patient adherence and produce better health outcomes is to provide medications in multimedication packaging. But this is arduous when it’s done manually, says Chater. “Having automation in place helps pharmacists provide this service to patients without consuming too much time.”

This is where medication synchronization in the pharmacy comes into play, she says, noting that the software and algorithms needed to make it work is generally available, but not widely used. Such is also the case for the robotic automation needed for multimedication packaging. These systems will appear in the future as more pharmacies become more patient-centric, she says. 

The number of mobile apps that can be used in pharmacy practice is growing, and helping pharmacists better care for patients and their business, says Timothy Aungst, PharmD, an assistant professor of pharmacy practice at 

Massachusetts College of Pharmacy and Health Sciences

Related article: The 10 Apps Pharmacists Should Be Using

“Mobile apps are finding greater use for reference purposes,” he says. “Drug information contained in the apps is an important practical resource in pharmacy practice.”

There also has been a push in communication apps, trying to make more concise platforms for patient-pharmacist communications, he says. “Pharmacists would be able to communicate better with patients and their providers.” 

Aungst predicts that apps will soon be integrated with EHRs, and patients will be able to share lab information with their pharmacists, who will then work with physicians to determine the best medication for them. He expects HIPAA-compliant secure texting communication platforms to grow.

Apps are already helping patients access their medical information. They send reminders for appointments, laboratory tests, and test results, Aungst says. They also improve remind patients to take their medications as prescribed.

Testing blood sugar several times daily is burdensome for diabetic patients. Many don’t test as frequently as they should, which can result in poor control of blood glucose levels.

Several technology companies are working to create noninvasive glucose monitoring technologies. For instance, 

, in Seattle, WA, is developing a noninvasive arm band-like device that would use radio spectroscopy, machine learning, and complex algorithms to monitor glucose levels. Joshua Welborn, PharmD, who has consulted with Know Labs, says hospital pharmacists may have limited data from only a few blood tests. “The longer a patient is in the hospital the more data we have which, usually, leads to better glucose control.  A noninvasive device that scans in real time would be extremely helpful.”

Related article: Diabetes Management and the Promise of Telemedicine

Welborn says that a device that measures glucose levels noninvasively at 15-minute intervals without bothering the patient would be ideal. “The entire healthcare team needs to know when glucose levels might be high or low as soon as possible so that the physician and pharmacist can adjust the treatment plan,” he says. 

A closer look at how recent innovations are shaping how pharmacists and patients interact-for the better.

The 4 Tech Advances Benefitting Pharmacies and Patients

Two transformational multibillion-dollar deals in the healthcare and pharmacy industries have been in the works for months-the $69 billion CVS-Aetna merger and the $52 billion Cigna-Express Scripts merger-despite concerns that more consolidation will mean higher costs and fewer choices for patients. Pharmacists, particularly independents, could also be affected, experts say. 

The Cigna-Express Scripts merger has gotten a go-ahead from the Department of Justice, but DOJ has not ruled on the CVS-Aetna merger at press time. However, Reg Blackburn, managing director of The Braff Group, a leading mergers and acquisitions firm specializing in healthcare services, expects the CVS-Aetna merger to go through. Both deals have shareholder backing.

“I think it’s part of an overall trend,” Blackburn says. “There used to be really large, medium, and small players with a lot of gray in between. What has evolved throughout healthcare is this gap where there are really larger players getting larger and very few players in the middle, and if they are in the middle, they are getting acquired or struggling.”

Frederick S. Mayer, RPh, MPH, FACA, and CEO of Pharmacists Planning Services Inc., is no fan of mergers. He fears that they could result in loss of pharmacy jobs due to closures of independent pharmacies that can no longer compete. Chain pharmacists could also have less job security as locations may close. Mayer also says consolidation could lead to higher prices, lower quality, and less choice for consumers.

“Pharmacists know how medications react and interact in the body. They are the experts regarding medication choice and side effects. They trained eight years for their PharmD, and now they are counting, pouring, and typing due to mergers,” says Mayer, who adds that pharmacists in larger settings don’t have adequate time for patient counseling.  “Over the past 10 years, mergers have resulted in poorer choices of medication for consumers and patients.”

“[Independent] pharmacies are getting less and less, and going out of business,” says Mayer, who notes there used to be 59 independent pharmacies in Marin County, CA, where he ran his pharmacy for decades before retiring. “Today there are three independent pharmacies. The chains are buying up all the pharmacies. [Independents] can’t stay in business.”

Stephen Schondelmeyer, PharmD, PhD, a professor of pharmaceutical economics and head of the Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, agrees. “Chains that are in one of these vertically integrated systems have guaranteed volume without competition on price,” he says. “The independents in those systems may have seen an even faster loss of volume out there. They could be shut out.”

Perry Cohen, CEO of The Pharmacy Group, says the potential merger of CVS-Aetna and the potential merger of Cigna-Express Scripts are examples of a growing trend: Companies responding to the need for new care models for healthcare services. “The marketplace needs new care models and wants to embrace these companies that get ahead of the curve,” says Cohen.

Cohen says current care models are “healthcare professional driven, expensive, and inefficient,” adding they are “not a sustainable model going forward.” That’s why some of the biggest players are changing their strategies, and he gave the following examples:

CVS is trying to become a total healthcare provider with the Aetna merger.

United Healthcare is using numerous strategies, including buying a large physician practice, DaVita Medical Group, for $4.9 billion through its OptumCare direct-to-patient healthcare subsidiary.

Amazon is acquiring PillPack, an online pharmacy that delivers medications in premade dose packaging. “Amazon has 100 million users in the United States. They are trying to get those 100 million to buy their prescription drugs through Amazon,” he says. 

New care models will leverage technology to allow most care to happen in the patient’s home with the aid of telehealth, mail, Amazon deliveries of dose packages, or small in-home dispensing kiosks that combine the medication with patient engagement through a WiFi connection to the pharmacy, Cohen predicts. He says when he talks about pharmacy careers with students, he explains there are now jobs that didn’t exist in the business 20 years ago, particularly involving managed care and mail order.

Blackburn expects to see more vertical mergers and acquisitions, like the CVS-Aetna and Cigna-Express Scripts deals, and horizontal mergers and acquisitions, like the failed attempt by supermarket chain Albertsons to buy Rite Aid and its EnvisionRX PBM business. That proposed $24 billion deal collapsed in August because it was opposed by shareholders.

“The horizontal is being driven a lot by the reimbursement pressure,” Blackburn said. “The vertical is much more strategic around the control of the overall person’s healthcare.”

While the Rite Aid and Albertsons deal may have fallen apart, Blackburn expects that what is left of Rite Aid may eventually be absorbed by another chain. After attempts to sell its stores to Walgreens were stopped in June 2017 by federal antitrust issues, Rite Aid later transferred 1,932 stores and three distribution centers to Walgreens in March for about $4.4 billion

“From a government perspective, there are many, many pharmacies out there. Every Walmart, Target, Kroger’s, they all have pharmacies,” Blackburn says.

Other companies are making deals as well, like Fred’s Inc., which operates approximately 600 general merchandise and pharmacy stores, including 13 franchised locations. The company scrambled after its plan to become the third-largest drug store chain by buying 865 Rite-Aid stores, as part of the original Walgreens-Rite Aid deal that was scrapped.

Since then, Fred’s has been selling off pieces of the company. In June, it closed on a $40 million deal to sell assets from its specialty pharmacy unit to Advanced Care Scripts Inc. an affiliate of CVS Health. On September 10, Fred’s agreed to sell patient prescription files and pharmacy inventory of 185 stores in 10 Southeastern states to Walgreens for $165 million plus an amount equal to the value of the related pharmacy inventory.

Fred’s will continue to operate 162 pharmacies, but the company announced 80 layoffs and it’s unclear how many pharmacy jobs Walgreens will pick up.

Mayer, Cohen, and Schondelmeyer are members of the 

How Mergers Will Affect Pharmacists

Work hours can be long for pharmacists working in a retail or hospital setting. As an employee, a pharmacist may feel that he or she is stuck with whatever hours or shifts that management gives them. But it doesn’t need to be that way.

Pharmacists need to realize that they hold the power when negotiating for better hours, says Alex Barker, PharmD, founder of 

, which provides motivational career counseling to pharmacists in all practice settings. “The more indispensable you are, the more likely you are to have a major bargaining chip when negotiating,” says Barker.

Related article: The Drug Topics 2017 Pharmacist Salary Survey

Whether a pharmacist is looking to reduce long days and overtime, or to realign their current hours to meet personal needs, they must justify their request by providing information that will demonstrate how the requested revision will benefit the organization, he says.  “Simply going to a manager or director and asking for a change in hours is a poor approach.”

Take for example, a pharmacist who works five days a week, and on three of those days he spends an extra two hours earning overtime, says Barker. That pharmacist can ask to officially be assigned those extra working hours on those three days, and in return, eliminate one day from his workweek.

One argument should be: The pharmacist would be saving the retail store-or hospital-a significant amount of money by absorbing those extra hours at the overtime rate into their regular pay scale.

Another argument that can be made: “In some cases, the extra hours could be a justification for letting a store or a clinic remain open later in the evening,” says Barker.

Barker describes a pharmacy client who wanted to work more days, but fewer hours each day. “She positioned the negotiation in such a way that if she worked more days, she could provide coverage during the busy hours of the store.” In the end, she didn’t get the exact arrangement she wanted, but it was close enough to satisfy both parties, he says.

Beyond the benefits of reduced overtime pay or better hours, pharmacists should look for a correlation between patient safety and the requested work schedule, as that is always an issue that weighs on managers’ minds, Barker says.

For example, the pharmacist in the previous scenario could have argued that having more pharmacists on hand during busy hours would reduce the likelihood of dispensing errors.

Anna Legreid Dopp, PharmD, director of clinical guidelines and quality improvement at 

, agrees that pointing to patient safety and patient care is important when discussing work hours. She suggests providing data that validates the positive effects on patient care and patient safety that such a change would provide.

But, where pharmacy hours are concerned, she noted that some pharmacists thrive on the extra hours and aren’t necessarily looking for a reduction.

Barker notes that unions representing pharmacists can be a resource for pharmacists in negotiating hours. In dealing through a union, pharmacists should remember that unions generally want things to be fair, so if you’re part of a large organization, look around and see what other pharmacists may have that you don’t. “For example, how are other hospitals handling pharmacists’ schedules?” he offers.

But it’s important to consider that “every union rep is going to be different and some may fight harder than others,” Barker added.

Related article: The 25 Cities with the Highest Pharmacist Salaries

Safety is an issue among the 700 pharmacy staff members represented by Illinois-based 

. The membership includes retail pharmacists, chain pharmacists, students, interns, and graduate students.

“A chain pharmacist may be forced to work at least one 12-hour shift a week, and pharmacists find it difficult, if not impossible, with their current work flow to take a break,” says a spokesperson for the union, noting that this raises safety concerns.

"In any bargaining situation, having members stand strong and demand a change is important,” says the spokesperson. Beyond that, “Legislative intervention would even the playing field by requiring all retailers to do the same thing and impose penalties [for noncompliance].”

, which represents healthcare workers in Florida, New Jersey, New York, Massachusetts, and Washington, DC, representative Lauren Vallone is involved in collective bargaining negotiations with the more than 2,000 hospital and retail pharmacists represented in the union. Vallone agrees with Barker in that negotiating may often involve reducing a workweek or, in some cases, adding days to a workweek.

“It can be an issue of age,” Vallone says. Longer 12-hour days may be more difficult for the older worker, whereas a younger member of the pharmacy workforce may find such a schedule to be good.

Vallone has found that in most of the collective bargaining sessions in which she has participated, “the members get what they need.” In addition to negotiating hours, the union has negotiated issues such as how many flu shots a pharmacist can administer and still be expected to safely fill the required number of prescriptions.

ASHP has recently made a commitment to supporting the well-being of the pharmacy workforce and reducing burnout, which can stem from working long hours.

The organization is leading the pharmacy effort associated with the National Academy of Medicine’s 

Action Collaborative on Clinician Well-Being and Resilience

, which addresses the serious consequences of burnout among healthcare providers.

“We feel it can benefit both pharmacists and patients and can help pharmacists to feel their best and do their best,” says Aretha Hankinson, director of advocacy communications at ASHP.

Related article: Balancing Act: Dealing with Stress in the Pharmacy

For hospital pharmacists, stress and burnout on the job can be caused by internal and external factors, says Christina Martin, PharmD, MS, director of membership forums at ASHP. External factors can include personal elements such as family issues or personal financial situations. Internal factors can include long hours leading to stress, onerous rules and regulations, increased oversight, inspections, audits, high employee turnover, and drug shortages.

 “The goal of the initiative is to raise awareness of these issues, provide the education, and get the discussion going on the organizational level,” says Dopp.

Overall, pharmacists should never be afraid to ask for different work hours, says Barker. “The worst thing that could happen is a manager will say “No’. There is little or no consequence that comes from asking, and if you’re rejected, it doesn’t mean you’ll be rejected the next time.”  

What does and doesn’t work for pharmacists trying to improve their working conditions.

Negotiating Better Hours: A Guide for Pharmacists

I’ve been precepting students for the past 10 years, and #61 and #62 are currently staying with my wife Denise and me in our home, about two hours from the University of Pittsburgh. This Rural Pharmacy Rotation is sought after by the serious community pharmacy students because of our involvement in working in physicians’ clinics, where we provide pharmacy consultation to the providers.

Related article: Why I Still Recommend the Pharmacist Profession

Denise works at the Centre Volunteers in Medicine (

) in State College, PA, which provides care to the neediest of all patients, the uninsured. Denise does a stellar job getting medications from all kinds of resources such as AmeriCares, Direct Relief, pharmaceutical reps, and MAP programs. She cares for people released from prison and many other patients who have no insurance. Her situation is unique: her patients get brand name drugs that are usually not covered by most insurance plans, thanks to the generosity of the manufacturers. She works with numerous volunteers from an assortment of healthcare careers-physicians, CRNPs, and nurses. State College, home to Pennsylvania State University, is one of the more affluent communities, and their fundraising efforts are most successful in supporting this clinic.

The clinic I work in is a direct-pay family practice clinic. Zane Gates, MD, founder of the 

 clinic, works tirelessly on this model to remove the insurance companies from the examination room. Gates’ clinic is a modern family practice office that caters to the underserved, the Medicaid population, and business groups who buy “memberships” for their employees at a nominal monthly cost. Gates uses his pharmacists and his physician assistants, to provide excellent care at a reasonable cost. The pharmacist sees the patient first, cleans up the med list, verifies adherence, pends refills that are needed, and discusses smoking cessation with the patient, before the provider even walks into the room.

The question every student asks either Denise or me is, “So how did you get a position like this?” The answer can be distilled down to one word: Connections.  I met Gates at a mutual friend’s party about six years ago. He asked me to develop a formulary to help him care for his working poor. Working with my wife, daughter, and son-in law, we developed a usable formulary where the drugs cost less than $10 a month. He was pleased, and when he got funding from the State Health Department for a pharmacist for four hours a week, I came to mind. After the grant expired, he was able to keep me on. Four days a week, he has a pharmacist staffing his clinic. I cover two of those days.

Denise got her position at CVIM when the manager came to her and asked if she knew of a pharmacist who would be interested in covering 12 hours a week. Denise offered two names, who were not interested, so she decided this was an opportunity to practice clinical pharmacy. She works directly with the volunteer physicians and residents from Hershey Medical Center. The position is a dream job for her, allowing her to break away from the “golden handcuffs.”  She has never been happier in her career.

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Nothing pleases me more when I get to share in the success of my past student pharmacists. Student #15, Mike Geishauser, a resident of Altoona who graduated from Duquesne University five years ago, called me and asked if he could shadow me at Gates’ clinic, because he landed a position at Altoona Family Physicians as a full-time clinical pharmacist. How did Mike get his dream job?  He was persistent in showing the supervising physician articles, information, and proof of the value of a pharmacist in a family practice clinic. We had an awesome day together, and I shared my protocols and my experience in the clinic.

I tell every student that you won’t find a job like I have, you have to create a job like I have. Mike is proof of that. 

You probably can’t find your perfect job-you’ll have to make it.

How to Create the Job You Want

Just as hospital pharmacists moved out of the basement and into direct patient care in the 1980s and 1990s, outpatient pharmacists are moving out from behind the counter and into medical practices.

“There is a demand for pharmacists from the physician side in ambulatory care,” says Elizabeth Cuevas, MD, director of the Primary Care Transformation for Residency Clinics at 

, a nonprofit eight-hospital academic medical system with facilities in Western Pennsylvania and Western New York. Allegheny is putting pharmacists into about 250 different practices that are part of its accountable care organization (ACO), a payment model in which the health system receives higher reimbursement if it improves quality and reduces costs.

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“We’ve used our pharmacists for improved medication management, medication reconciliation, patient education and outreach, symptom management, disease management, and making sure patients are actually taking their meds,” says Cuevas. “Pharmacists have a natural role in practices.”

Allegheny isn’t alone in placing pharmacists in physician practices and ambulatory care clinics. Integrated health systems and larger group practices nationwide are moving in the same direction.

In the ideal arrangement, pharmacists are embedded in practices with 5 to 10 physician and nonphysician practitioners, explains John Kennedy, MD, chief medical officer of 

, formerly the American Medical Group Association. “For smaller practices or areas that may be more remote, you can use telemedicine or share remote [pharmacist] support as long as you have a shared electronic health record.”

Allegheny is using embedded pharmacists and shared services, depending on the size and location of the practices. Practices with one or two providers usually can’t support a full-time pharmacist, but they can benefit by sharing the services of a pharmacist, according to the health system.

A group of small practices that are relatively close to each other might share a pharmacist who rotates through the different offices, for example. More distant locations might do better with video and data links to a central pharmacist.

Either way, pharmacists are part of the care team and their salaries are covered by the practice. Regardless of the specific arrangement, the goal is the same-to incorporate pharmacists into team-based patient care.

Allegheny’s decision to put pharmacists on patient care teams can be traced back 30 years, to when inpatient physicians began working with clinical pharmacists. Then, Michael Korczynski, PharmD, BCAP, came on board as manager for Clinical Services, Pharmacy – Ambulatory Care.

“I had come from Kaiser Permanente and the VA, so I was familiar with an autonomous role for pharmacists,” Korczynski says. “But it was a foreign concept here.”

Even so, in the years before Korczynski started at Allegheny, its physicians and pharmacists had built up a strong relationship working together on the inpatient side, he says. “I started an anticoagulation service and working with a primary care practice. Physicians quickly latched onto the new-to-them services.”

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Changes in physician education also helped foster physician acceptance of pharmacists on care teams, says Kennedy. Most younger physicians train with pharmacists on inpatient care teams. Once they join a practice, they expect the same access to a medication specialist, he says. Practices and health systems that can offer a pharmacist in the office have a hiring advantage as the physician shortage grows.

Putting a pharmacist in the office brings quality and financial advantages, which is critical in value-based reimbursement models, such as Allegheny Health’s ACO.

“Like all things in healthcare, it is about the dollar,” says Paul Lebovitz, MD, vice chair of the Allegheny Health Network Medicine Institute. “The present model, which is physician-centric, is not getting us to that quadruple aim of better outcomes, lower costs, better patient satisfaction, and improving the work life of our healthcare providers. We are moving to a patient-focused model using team-based care. Pharmacists are an important part of the team and the model.”

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Eric Maroyka, PharmD, BCPS, director of the Center on Pharmacy Practice Advancement at ASHP, says placing pharmacists in the primary-care setting ensures care is provided in the most cost-effective location. “We are seeing care moving toward a more preventative model and not just episodic acute care,” he says. “The sickest of the sick will be in hospitals. Anything that can be done on an ambulatory care basis will be done that way and that is where the maximum payment will be.”

A single physician cannot provide the same quality of care as a team that incorporates a pharmacist, says Lebovitz. “I have made a significant impact with patients, but I recognize that there is so much more I could have done with help,” he says. “That’s what this transformation of care is all about.” Patients have better outcomes in team models, he says, because there are more eyes on the patient from the entire team.

Pharmacists also can lower costs of administering services, improve physician efficiency, and curb physician burnout, says Lebovitz. Anything pharmacists and other team members can take off the physician’s plate saves money and gives physicians more time to spend with patients.

“It doesn’t take physicians long to recognize that team-based care makes their lives easier,” Lebovitz says. “They realize they are no longer responsible for everything, there are other team members who can and should be doing specialized activities. It allows our physicians to work at the highest level of their training. That makes their life better.”

Helping physicians work at the top of their training also benefits pharmacists. They are information resources, not dispensing resources, Maroyka says. Pharmacists managing patient medications or developing opioid stewardship for the practice are working at the top of their training, which boosts job satisfaction.

Pharmacists working with clinics or practices is new territory for both pharmacists and physicians. Arrangements could be as formal as a full-time medication specialist in the practice or as flexible as a few hours of telephone consultation as needed. Either way, working more closely with clinics and practices begins with physician awareness.

Physician practice and clinic leaders may not know what pharmacists can do for them. For example, they may know that up to half of new scripts for chronic care meds are never filled; they may not know that pharmacists can help patients start to use their meds.

The key is talking with physicians about practice problems, then showing how pharmacists can address them. The whole discussion is about improving outcomes, reducing costs, and boosting satisfaction, Korczynski says.

Pharmacists looking to start these discussions can consult ASHP’s sections for ambulatory care practitioners and pharmacy managers, which can provide hands-on information for pharmacists interested in working with practices.

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Another resource is the American Medical Association’s physician practice improvement strategies: STEPS Forward. For information on how and why to embed pharmacists in practices, 

AIMM, the Alliance for Integrated Medication Management, is another resource. 

, Apexus (the HRSA-designated Prime Vendor for the 340B drug pricing program), and ASHP sponsor the A3 Collaborative. The year-long program helps provider organizations such as Allegheny create value-defined initiatives to build population management strategies by implementing clinical pathways that integrate medical care and comprehensive medication management services.

“Practices are seeing more and more pressure to account for outcomes,” says Todd Sorensen, AIMM executive director. “That changes the whole focus from quantity care to quality care.”

The lack of provider status isn’t keeping pharmacists out of ambulatory care clinics and medical practices. But more pharmacists would be in more practices if they were recognized as providers and could bill directly.

“Not having provider status has an impact at the executive decision-making level on whether or not to hire a pharmacist for the practice,” says Kennedy.

When the pharmacist cannot directly bill for services and generate revenue, the practice must find other ways to support the role. That usually means looking at cost savings, which may not appear until the second or third year. That lag can slow adoption.

“Right now, the system is paying for pharmacists in practices,” says Cuevas. The need to demonstrate a return on the pharmacist investment is slowing pharmacist hiring.

Though Allegheny Health is in the process of adding pharmacists to 250 practices, they currently only have them in a handful of clinics, Cuevas says. “The pharmacist is not able to bring in direct revenue, but you can see a decrease in 30-day readmissions, a decrease in morbidity, a decrease in ER admissions because you have a pharmacist doing medication management and reconciliation. It is a matter of recognizing that the costs you are saving are different from direct billing.”

Pharmacy organizations are pushing for provider status at the federal and state levels, but that alone isn’t enough. Legislation must also allow pharmacists to bill at realistic rates.

“There is literature showing that when pharmacists are allowed to bill at higher levels, they can generate revenue to cover their salaries,” says Korczynski. “If the rules say pharmacists are providers, but they can’t bill at higher levels, provider status won’t help.”

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Commercial payers are part of the picture as well. Change is coming, but slowly.

“Direct billing for pharmacy care out of medical practices is still in its earliest stages,” says Keith T. Kanel, MD, MHCM, clinical associate professor of medicine at the University of Pittsburgh School of Medicine. He was principal investigator for the Primary Care Resource Center Project. The CMS Innovation center project put pharmacists in primary care practices in parts of Pennsylvania and West Virginia. The project, which began in 2012, showed a 25% reduction in 30-day hospital readmissions and reduced 90-day costs of care by more than $1,000 per patient.

“Forward thinking commercial plans are beginning to develop ways to pay for an office-based pharmacist,” Kanel says. “That is going to become a game changer when it becomes more common.”

Just as hospital pharmacists have moved out of the basement and into direct patient care, outpatient pharmacists are moving out from behind the counter and into medical practices. Here’s what’s driving the trend and how it could impact you.

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