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’.

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