Pharmacist Provider Numbers (PPNs) The rationale for government approval

It was very encouraging, at a recent OPA regional meeting I attended, to learn that the Association has established a special committee to explore the issue of direct billing numbers for pharmacists, also referred to as pharmacist provider numbers (PPNs).  Several regional meetings have been held to elicit input from practising pharmacists already.

The committee is chaired by Dean Miller, a seasoned senior executive from the retail pharmacy industry, currently not associated with any chain operation.  This frees Dean from any potential conflict of interest.

I have made my views clear many times that I believe that PPNs are an important pivotal issue.  No single action will accomplish more towards the goal of returning the profession from the vested interests of Big Retail Pharmacy Chain Operations to practising pharmacists.

This issue is less about actual compensation levels, and much more about control and who has it.  PPNs represent an important shift in power dynamics from the pharmacy owner employer (largely non pharmacists) to the practising pharmacy practitioner.

The big hurdle that the committee will face immediately is the fact that governments do not like direct billing numbers, and will consequently reject any attempt to institute such a system for pharmacists.  The government’s experience with the medical profession has not been good: the more billing procedures the higher the submissions and the higher the demands on scarce healthcare dollars.  Governments have been trying hard to get physicians into Family Health Teams (FHTs) and other fixed income arrangements, so why would government now initiate such a system for pharmacists?

This means any argument for PPNs must be framed in such a way that it is in the economic interest and wellbeing of the public, and of government to institute PPNs, and that failure to do so perpetuates a system which reinforces waste and a further potential political embarrassment to government.  About 80 Million dollars has been spent by the Ontario Ministry of Health on MedsChecks alone since inception with no way of measuring what value has resulted, i.e. what is the return on investment (ROI)?  Recently the government launched an official task force headed by distinguished healthcare academics to determine what this ROI might be.

I would not want to predict prematurely any conclusions that this task force might produce, but my guess is that the ROI may turn out to be less than desirable.  In fact, and in advance of these yet to be determined conclusions, the government will soon be initiating much tighter controls and protocols for MedsChecks.  The government has already predicted the conclusions and is acting in anticipation of the results.  One wonders whether this has anything to do with the fact that this is an election year in Ontario.

The reality is that not that long ago a pharmacist and a pharmacy were largely analogous.  Payments to pharmacies were payments to pharmacists.  Today, although independent pharmacies still represent about half the total number of actual pharmacies, 85% of pharmacists are employees of non pharmacist controlled pharmacies i.e. big chain/box stores/grocery store operations.  And 85% of prescription volume flows through such operations…a percentage greatly outweighing the actual number of pharmacy locations.

When payments are made for billable services like MedsChecks, pharmacy opinions, smoking cessation etc, the cash flows to these corporations as pure revenue with zero additional costs. Of course pharmacy corporations love these revenues, and the more the better.  Hence we witness today the scourge of quotas for billable services, performance metrics, forced flu shots…all of which represent great opportunities to create more revenues for the corporate pharmacy owners.  As well, increased store traffic creates the opportunity to sell more inventory, most of which is not health related, and often is actually harmful to health (high margin snack food, frozen pizzas, candy etc)  What an irony.  Health services are used as a draw to sell stuff which is harmful to health.

Witness the financial results of the large retail pharmacy corporations which are public; profits have not gone down in spite of Drug Reform and the loss of several hundred million dollars of generic drug rebates.

Governments must be made to see that the present system which financially compensates one entity (a commercial interest) for the professional/clinical services directly provided by another entity (the pharmacist) encourages abuse and poor value for dollars spent.  This system is damaged and it will get worse. It hurts the profession of pharmacy significantly, but more so from the government’s perspective, it results in a waste of taxpayers’ dollars…not a great story at any time, but least of all in an election year.  There is some evidence that the press is on to this story already.

As more and more of pharmacists’ compensation is determined by the provision of professional services, it becomes even more illogical to flow compensation to an entity whose business is the sale of goods.  Pharmacists remain the only professionals that have no means of being paid for their value and are forced to become employees of retailers in order to make a living.

Perhaps PPNs are not the answer.  Perhaps there is another way not yet thought of, but relegating pharmacists to the equivalency of store clerks governed and driven by retail systems enforced by non pharmacist mangers/district managers, is leading to disastrous results.

If pharmacists are not in total control of the delivery of their professional services, pharmacy ceases to be a profession and any services they provide are not worth the dollars spent on them; consequently governments are largely wasting their money.

This is why a change in compensation systems for pharmacists is so vitally necessary; it’s in the government’s and the public’s significant interest as well as pharmacists’.

PHARMACY RELIEF AGENCIES PHARMACY’S SCOURGE

 

The profession of pharmacy faces formidable challenges.  Many of these challenges stem from the loss of control of the profession to vested interests.  These vested interests include Big Retail / grocery /box stores, i.e. merchants whose prime business is selling as much as possible while tightly controlling costs.   As the pharmacy profession moves ever more closely to a clinical services orientation and away from a purveyor of goods, practising community pharmacists and big retail pharmacy will diverge further apart.  It bears repeating that a profession that does not control the professional services that it is highly educated, trained and licensed to perform, ceases to be a profession.  The pharmacy regulatory bodies have the power to intervene but continue to turn a blind eye towards the big players.  The regulatory bodies may soon rue the day, as media and governments challenge their privilege, as well as the lack of exercise of their responsibilities.

As big retail pharmacy imposes more retail systems like quotas for billable services, performance metrics, forced flu shots, etc, enforced by non pharmacist store managers/district managers, the stress on practising pharmacists approaches a crisis.  These are not pharmacy’s best hours.

But, among all the vested interests which live off the pharmacy profession, the race for the bottom of the barrel has without dispute been won by the so called pharmacy relief agencies.  These organizations have capitalized on the surplus of pharmacists, and the desperation of some pharmacists (not exclusively, but primarily new grads and International Graduates) to drive compensation and working conditions to the lowest possible levels.  And just when we thought the bottom had been reached, we discover a new low.  Rates of $28 / hr have now been posted in Toronto.   This rate is lower than some RPTs are earning in hospitals today.   Compensation levels are a measure of the value of a profession; these low rates have done much to denigrate the profession.

These agencies will stop at nothing to promote their narrow business interests.  One agency advertised that it will guarantee that any pharmacist placed through its agency will complete two Medschecks during the assigned shift.  What happens if the criteria for conducting a Medscheck are not met during the shift?  A guarantee being a guarantee it must be assumed steps have been developed by this agency to get around this problem.

Do the math.  An 8 hour shift at $28.00 / hour equals $224, minus a ‘refund’ of $120 for the guaranteed Medschecks, equals $104, or an effective rate of $13 / hr.  This rate remains above the minimum wage in Ontario or this agency would have a legal problem.  How do we assume our position as equals in healthcare provision when pharmacists have been driven to such low values?  This is not pharmacy’s finest hour.

In a current ad for a pharmacy technician by one of these agencies the following headline was displayed: “Wanted, the Wayne Gretzky of Pharmacy Technicians; must be better than the average pharmacist”.  This insult got a few pharmacists’ attention and the OPA was notified.

To its credit, the OPA followed up with this particular agency, which then ignored the Association and persisted with their insulting ad.   In the final analysis, there is nothing anyone can do to stop these agencies from degrading the profession of pharmacy at will.

These relief agencies are parasitic opportunists who care nothing about the pharmacy profession, which they are turning into a commodity; lowest price is their value proposition.   Do they even bother to verify the credentials of the pharmacists they place? Professional qualifications, experience, PharmDs mean nothing to them; pharmacy licenses are all the same, and plugging a shift is their game.

These agencies live off the spread they contract between their client pharmacies, and the actual rate they reimburse the contracted pharmacist.  Once they peg the contracted rate with the pharmacy owner, they hunt for the lowest rate they can find a desperate pharmacist will accept.   This is very similar to the migrant workers and the California grape growers.  We have all seen this movie.

In the final analysis, all pharmacists must  take considerable responsibility for the existence of these relief agencies.  The responsibility is with pharmacists who allow themselves to be degraded in this fashion.  Certainly times are tough, but a little bit of effort and pharmacists could find their own placements and at least earn the agency spread for their own account.  In other words, cut off their inventory.

The second level of responsibility is to pharmacy owners who utilize these agencies.   This very often includes independent pharmacist owners who have lost their ethical responsibility to the profession, and are driven by greed.  Big retail pharmacy does not even give this issue second thought; in fact these agencies are often preferred service providers to these large businesses.  Low cost pharmacists, with no benefits, no statutory obligations which can be turned away at the last minute; what a great deal for these big retail operators.

Here is a great opportunity for the Pharmacy Associations to take over this function.  There will always be a need to provide such services between pharmacies and pharmacists; this can’t be rocket science, and it can represent something concrete associations can do for their members relatively easily.   The sooner the better that a matching service be controlled by pharmacists and their associations.   Let us hope that we can make these agencies part of history soon.  In the meantime, all relief pharmacists should refuse to serve as cheap inventory, and pharmacy owners should avoid utilizing their services.

This call will not likely be heeded by big retail pharmacies, as it does not serve their need for the relentless pursuit to drive down costs, which is what they consider pharmacists’ compensation to be.  But at least independent pharmacy owners, still controlled by pharmacists, should have some moral obligation to put some balance into their business and professional obligations.