The limited-dispensing community pharmacy would unleash the pharmacist's true potential.
For their entire history, community pharmacies have been solely retail establishments, and pharmacists have been paid for providing a product. During many periods in pharmacy's history, pharmacies have relied on, and made more money for, selling over-the-counter products or even items completely unrelated to health and wellness.
At no point in pharmacy's history, however, have community pharmacies been able to make a substantial portion of their income for providing services rather than goods. It's time for that to change.
As has been pointed out by countless others, pharmacists for too long have provided their training and education for free, in the form of OTC recommendations, drug interaction screening, and recommendations to providers and patients. Pharmacists have also worked hard to help patients with financial resources so they can receive their prescribed medicine, only to receive no compensation for doing so.
We do all these things because the patient needs us, but the model is financially unsustainable and broken. So we are stuck trying to do all these things while also dispensing medicine to pay the bills. It's no wonder burnout is so high and pharmacists are leaving the profession in droves.
To bring dignity back to the profession, to reduce healthcare costs, to improve patient care and the public's health, to allow pharmacists to feel rewarded professionally, personally, and financially and to feel proud of their profession, we need a new model.
Here, I'd like propose a model that can do all this. I'll call it the Limited-Dispensing Community Pharmacy.
What would a limited-dispensing community pharmacy look like?
In this new model, a pharmacy would be established as a clinic, rather than as a store. Patients would walk in to see a receptionist who could schedule them for an appointment or take walk-ins, depending on the clinic. A waiting room in the front gives patients a place to sit until their appointment time. Busy clinics might be staffed by a medical assistant and/or pharmacy technician to assist with medication histories and preparing the patient for the office visit.
Basically, it would look like a doctor's office or an urgent care center. Except it would be staffed by one or more pharmacists.
What services would a limited-dispensing community pharmacy provide?
Everything pharmacists are already doing under a community pharmacy permit, plus more. The big difference, though, is that by being freed from the burden of dispensing pharmacists can provide these services in a much higher volume than is currently possible. The higher volume can have a bigger impact on patient care and also make it financially viable for pharmacists to focus on patient care activities.
To be clear, some of these pharmacies might still provide a very limited amount of dispensing, but that would be tied to the service provided, like with vaccines or smoking cessation. Some pharmacy clinics might have a limited amount of over-the-counter medicines or other health-related products tied directly to the services they provide.
In other words, the product would be secondary to the cognitive service, not the other way around.
The services provided could depend on the pharmacist's focus, but here are some ideas to get started (I hope the pharmacists reading this will come up with many more):
Pharmacogenomics (which will hopefully just become standard of care one day, but for now it's worth mentioning as a distinct service)
Vaccine recommendations and administration
Smoking cessation counseling and product dispensing
Point of care testing, including flu and COVID testing as well as screening for diabetes, hyperlipidemia, and hypertension
Birth control screening and dispensing
Population health management services for health systems, hospitals, and insurance companies
Long-term care pharmacy consulting and chart reviews
Medication access assistance, like help with patient assistance applications or manufacturer copay cards
Aren't pharmacies already doing this?
Yes and no. I understand that many pharmacies have this kind of model, like the often-cited independent Moose Pharmacy in North Carolina.
However, the problem is that in all of these cases the billing and permitting is tied to dispensing. They operate under a community pharmacy permit, and if they stopped dispensing medicine they would no longer be allowed to provide any other pharmacy-related services.
Why should my ability to provide MTM or administer a rapid test for COVID be tied to me dispensing lisinopril? They're completely unrelated.
Perhaps the biggest problem with having services tied to dispensing is the barrier to entry. If I wanted to start an independent pharmacy today, but focus on cognitive services, I would still need to budget for a starting inventory of at least $50,000-$75,000 in drugs, plus the staff to dispense them. Most established pharmacies have inventories higher than that, and busy pharmacies can carry $200,000 or more in inventory at any given time.
Again, let me pose the question: why should a pharmacist have to carry over $200,000 in drugs to be allowed to provide MTM?
How can we create this?
Boards of Pharmacy will need to create this new type of permit, which they can do. While it is ultimately each individual Board's decision, NABP could bring them together to help make this a reality.
There are a few reasons we need a new permit, rather than just allowing a pharmacist to work as a freelancer or independent practitioner working out of a rented space (or their home):
The current billing system for many of these services requires a facility NPI, which is a major reason why pharmacists are forced to dispense medicine while trying to do all this.
As previously mentioned, these pharmacies will still need a limited amount of prescription medications and need a permit to order them. They might need vaccines, testing kits, and some prescription medicines (like for smoking cessation or travel medicine).
While no one enjoys pharmacy inspections, the Board of Pharmacy plays a crucial role in patient safety. Having a permit would allow proper oversight, including inspection of facilities, by the Board of Pharmacy.
Liability would obviously change as well, and having a new permit would allow insurance companies to create a new category of liability insurance specific to this kind of practice.
The entire point of legislation is to protect and promote the public's health. When legislation is designed so that it prevents pharmacists from helping patients unless the pharmacist can cough up enough money to start a dispensing pharmacy, then legislation is getting in the way and needs to change.
In fact, the way legislation is currently designed, which restricts pharmacists from expanding into patient care roles, is harming the public's health. Patients are not able to receive nearly as much preventive care from pharmacists as they could, and everyday are suffering from adverse outcomes due to that.
They suffer the consequences of smoking, they suffer adverse outcomes from medication regimens that our country's brilliant pharmacy minds could have prevented, they suffer from chronic diseases we could have screened for, and they suffer from being unable to access medicines because of a system we could have helped them navigate. The healthcare system pays much more for these poor outcomes than they would have paid pharmacists to prevent them.
Let's not allow that to continue. The pharmacy and regulatory communities need to come together to relieve pharmacists of the burden of dispensing, and the limited-dispensing community pharmacy is one way of doing so.