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GfK Healthcare | February 2011 | |
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The Role of the Pharmacist/Pharmacy in the Future of Health Care  A critical topic for pharmaceutical marketers and marketing researchers, often receiving far less attention than it should, is the changing role of the pharmacist, and of the pharmacy in which he/she practices, in the delivery of health care in the United States. I recently came upon a reprint of a paper, “THE CRITICAL LINK: Patient-Pharmacist Interaction Is the Pathway to Improved Healthcare in the United States,” by Harold E. Cohen, RPh, editor-in-chief, U.S. Pharmacist. In this paper, Mr. Cohen argues that compliance is a major problem in the U.S. health care system and that the pharmacist is best positioned to improve this situation based on training, availability, patient trust, etc. Needless to say, this brief paper got me thinking about the numerous issues this argument raises, many of which deserve serious consideration and study by those in health care marketing and marketing research. As a key first step in such deliberation, we need to break the argument down into its component parts. First, there is little question that lack of patient compliance is a major problem in the health care delivery system. Orphan script (i.e., prescriptions presented to the pharmacy but never picked up) rates hovering around 30 percent to 50 percent, half of patients spontaneously discontinue their chronic medications because they don’t see the benefit in taking them, although efforts put against solving these problems have historically been feeble at best. I have written and spoken on this topic before, so I will simply note here that there is still much important work for us to do in this area, since patient health, manufacturer profitability and employer lost-work-day costs are all significantly and negatively impacted upon by noncompliance. The next distinction that needs to be made is that between the pharmacy and pharmacist. Again, as I have commented on previously, chain pharmacies are without a doubt significantly increasing their roles in health care delivery. More specifically, in-store clinics are greatly increasing the convenience and lowering the costs of dealing with many day-to-day medical conditions, with no-appointment/drive-in treatment provided by nurse practitioners having significant positive effects here. The “key” role of the pharmacist in generating compliance that Mr. Cohen posits, on the other hand, is more open for debate. Again, there is no disputing the fact that pharmacists are seen by most Americans as being trustworthy professionals who are ready, willing and able to answer questions about drugs, both Rx and OTC, when asked. But, it must be kept in mind, this function is so positively perceived because it is provided only when patients request it, i.e., “pulling” the information, in cyber speak. Pharmacists’ efforts to “push” information, on the other hand, are typically limited to the insertion of computer-generated information sheets into the prescription bag. I have never had a pharmacist come down from the filling area to the counter to spontaneously offer information and/or to encourage compliance. (The fact that several of my chronic medications are now handled through mail service pharmacies, recommended by my health insurer because of their greater convenience and lower costs, further reduces the possibility of such interactions.) Even in high volume pharmacies, where by definition most patients receive their medications, pharmacists have strict productivity metrics applied to their prescription filling speed, making it unlikely that they will pro-actively step to the counter for an extended conversation. Sadly, talking to pharmacists reveals that the likelihood of such professional activity is even further reduced by the reliance for profitability, in most pharmacies, on the patient wandering around the store’s front end, buying chocolates, greeting cards, etc., while prescriptions are being filled. Whether pharmacists in independent and chain settings could be integrated cost-effectively into solving the compliance problem is open for debate and study. Although Mr. Cohen cites “The Asheville Project” as a clear demonstration that such outcomes are possible, it needs to be noted that diabetics and other chronic patients managed in this project were first exposed to “intensive education” at a medical education center and then “teamed” with a local pharmacist for follow-up. Though a significant improvement in compliance resulted from these interventions, it is impossible to tease out the role each of these individual steps played in leading to this positive outcome. Moreover, it may not be desirable to try to tease out the impact of each individual element, but rather rely on a multifactorial approach to compliance that Mr. Cohen refers to as Medication Therapy Management. That having been said, a meta-analysis of many of the projects that I have conducted, and those conducted by others that I have reviewed, indicate that it is probably folly to try to identify any health care professional as being the critical link to patient compliance. Physicians, we have repeatedly found, report that they have not been trained in patient compliance enhancement, that they don’t have the freedom to spend intensive amounts of time on efforts aimed in this direction and that, most tellingly, they don’t believe they can make a difference anyway. Patient compliance/non-compliance, they believe, is more related to patient personality than to anything that the practitioner can do, thus providing doctors with a convenient, though frustrating, escape from responsibility in this area. Projects which have investigated nurses, pharmacists and other providers as having the potential to be the critical link in patient compliance have also found many practical reasons that one cannot rely on any specific profession to serve this function, unilaterally and without systematic support. Rather, Mr. Cohen’s paper reminds us that noncompliance is still a major problem in U.S. health care which, despite the intent and focus of the article, can only be solved through the careful coordination of professionals and supportive materials to accomplish the well-named, and up to this point much-ignored, end point of Medication Therapy Management. Such a system, our research has found, needs to be initiated less with education and more with motivation so that patients understand the value proposition of taking their medication. Put another way, a patient knowing “what is in it for me” if I take my antihypertensive medication is far more important than understanding the intricacies of the mechanisms of hypertension in terms of driving compliance. Once the patient gets it in terms of the value proposition of taking the medication, a system of obstacle removal then needs to be established that can help patients remain on the medication. Hot lines/websites for discussing side effects; reminders to take the medication and obtain refills; mail service pharmacies that deliver 90 days worth of medication to the patient’s door; and, where necessary, financial support, are all components of such a systematic approach. I’ve said it before and Mr. Cohen’s paper makes me say it again. Noncompliance is one of the most crucial problems standing in the way of making U.S. health care more effective and more efficient, and we all will be well-served by a collaborative effort to design the best possible system, likely variable by patient ailment and demographic and psychological segment, that is most likely to reduce its impact.  Richard B. Vanderveer, Ph.D. Strategic Advisor, GfK Healthcare   |