PHYSICIANS & PHARMACISTS…PROFESSIONAL EQUALS?

We often hear about the need for more professional collaboration between pharmacists and physicians.   How realistic is this really, when pharmacists often position their raison d’etre as to be second guessing a physician’s direction?   What does it mean to be a “medication expert” and to have the duty of determining if a particular medication is “therapeutically appropriate” when pharmacists most often have no medical data on the patient?   How many physicians welcome pharmacists performing this self-created second guessing role?

All this may be standard procedure in a hospital setting, where pharmacy as a profession not only still exists, it’s thriving.  Too bad all those PharmDs that Academia is churning out can’t get jobs in hospitals and really put to work that 6 years of education, instead of getting stuck in a 10’ by 20’ cubicle in a food/drug combo bagging pizzas and toilet paper, or surfing the internet for something to do.

How does society value a particular profession, and what is society prepared to pay for a service given?  How does society perceive the value of a given function?

Let’s have a brief look at current negotiations which are about to begin between the Ontario Medical Association (OMA) and the Ontario government to hammer out an agreement…the biggest labour contract in North America.

Physicians have seen their fees cut by 7 % during the time they have been without a contract.  The docs want all this money back.  Millions & millions & millions.

Ontario docs bill on average $375,000 annually before overheads.  That’s an average, which needs to take into account part time docs, and female docs who insist on restricted hours, which means many docs are billing well over half a million a year to the Ontario government.

The docs want a 4.26% fee increase effective back to April 1, 2017.  Back pay.  In addition to this, the docs are looking for annual increases which amount to a further 15% increase by 2021, three years from now.  Docs work hard and it takes a lot of time and money to get a medical degree, so why not?  The docs want no cap on the physician services budget.  Limitless physician services is what physicians want, and they believe their value is there. Great if they can get it.

Of course the docs want to preserve the present fee for service system…the more services they perform, the more money they make, even though it is commonly known that this is a highly inefficient costly system which emphasizes the provision of more services while less effort is given to the prevention side.  No money in it.

The government is offering 3% over four years and no back pay.  It also wants to cut back money to those docs billing over one and two million dollars.  Yes…that’s 2 million in billings for just one doc.  Well let’s see how all this is going to pan out.  My hunch is that the docs won’t get all they want, but they will make good headway in recovering their position.

The reasons for this are simple.  Docs have a strong bargaining position, and though they do not always agree that their own association, the  OMA, does the best job possible in getting them the best deal, docs know the government will eventually cave in because the public will not tolerate any interruption in physician services.   The docs’ hands are firmly grasped on the handle of the vice.

Compare this to pharmacists for a moment.  Not that long ago, a pharmacist in a community setting in Ontario was “valued” at about $60.00 per hour in the Greater Toronto Area (GTA)…about $120,000 per annum  Today that number is maybe $38.00 representing a decrease of at least 35% over the past 5 years.  Coincidentally, the business of pharmacy has been hit at least three times from different angles.

Big Pharmacy Retail (BPR) can absorb these hits (though not happily) by selling more stuff, any stuff, and cutting costs (especially pharmacist compensation) to make up for the losses.  So pharmacists, who are essentially unprotected/unrepresented retail employees, just get nailed.  Hence the 35% decrease.  This compensation decrease is not government mandated, it’s commercially driven and to be expected in a highly competitive retail environment.  One wonders if the government even knows (or cares) about the financial impact its policies have had on individual pharmacist practitioners.  When government thinks of pharmacy, it thinks Costco, Walmart, Loblaw, Shoppers Drug Mart, Pharma Plus, Sobeys, and Metro etc.   Big Business, not pharmacy practitioners.   Which advocacy group zeros in exclusively on the financial plight of individual pharmacist practitioners?  It doesn’t exist.

Back to our physician colleagues, the ones taking home a minimum of a quarter million a year after expenses (and often much more).  How do we square pharmacists as professional equals to physicians when docs are valued at a multiple of 6 or 7 times over pharmacists?  This is a tough one.

Whenever pharmacists are portrayed on television in one of the many investigative journalism exposes lately (usually about abuse of the system by pharmacy) the camera zooms in on the little blue tray and the pharmacist is seen counting pills.  Well what’s that worth? … a machine can do that easily.

During the recent devastating Fifth Estate piece about Costco and kickbacks (sorry, rebates) not a single pharmacist was interviewed.  Plenty of great shots of the Ottawa professor who described the whole pharmacy landscape as corrupt and the Ontario College of Pharmacists (OCP) as weak & ineffective.   The OCP building was seen in the background as the CBC journalist and whistleblower hacked pharmacy to bits on the sidewalk; no one came out of the OCP building to defend or represent pharmacists.

The real hero of the CBC piece was a physician at St Michael’s Hospital in Toronto, who through personal efforts managed somehow to get medication to 400 patients who had no coverage.  Get the Super Hero analogy with pharmacy described as the dark side?

Docs are always portrayed as kindly counselors with a stethoscope wrapped around their neck patiently listening to their patients with only the patient’s welfare in mind.  That, or they are doing brain surgery.

It begs the question.  Why spend 6 years earning a pharmacy degree to earn one seventh of what a GP earns after spending years of study at an equal level of academic challenge?  Why, when the value is clearly not recognized?

And how do our various pharmacy associations respond to this terrible image problem?  The latest is the suggestion that Pharmacist Awareness Month (PAM) be changed to Pharmacy Awareness Month to “recognize the whole pharmacy team”.  Is this an effort to be inclusive and politically correct?  Dilute the pharmacist?  Is this a move in the right direction for an already besieged ‘profession’?

There’s a whole lot of difference between the OMA and the OPA, and it goes a lot much further than a change in the middle letter from an ‘M’ to a ‘P’.  The image of pharmacy today cannot get much lower, hence its value continues to go down with it.

Pharmacists deserve a great deal more from their leadership whether academic, association, or regulatory.

 

A CLEAR SIGNAL March 2, 2018

Last week, the Chief Executive Officer (CEO) of Loblaw Cos Ltd. (Loblaw/Shoppers Drug Mart, Zehrs, Super Store, Fortinos, No Frills, etc.) while addressing financial analysts, made the following statement:

“We face exceptional external headwinds in 2018 ranging from higher minimum wages in some provinces, to the effects of generic drug reforms.”

The Chief Financial Officer (CFO) later went on to state that … “to put the $250 M generic drug pinch into perspective, it compares with $70 M to $80 M in annual drug reform costs over the past three years”.

He also stated that higher minimum wages will cost Loblaw $190 M this year alone.

These statements from the CEO and CFO resemble the sound of those big bells ringing through the village foreboding something really important is about to happen

These are big numbers.  Half a billion dollars to the bottom line in this year alone.

The problem for CEOs is that their job is not to make excuses; it’s to find solutions.  Shareholders are not going to respond with…’well that’s OK, nothing we can do about it.  We’ll just take the hit.’  Shareholders will vote with their feet and take their money elsewhere if these funds are not recovered and recovered fast.

A rough estimate of the market share of Big Pharmacy Retail (BPR), which Loblaw companies have in Canada today, might be close to 40%, give or take.  My best guess.

This makes the CEO of Loblaw Cos. one of the most important pharmacy leaders in Canada today, and he probably doesn’t even know he is.  He needs to recover half a billion dollars, which was yanked out of under his feet by government, through two possible ways.  He must increase top line revenues in any way he can, which means selling more stuff, any stuff.  Secondly he must cut costs.

And all this before we calculate in Jeff Bezos and Amazon, who is out to eat the grocery and drug industries’ lunch.

Automation comes to mind.  Look for even more self-serve checkouts.  More ScriptPro Robotic Prescription Dispensing or other types of human replacement technologies.  More central filling stations.  In other words, more ways of taking relatively high priced human resources out of the equation.

In many ways, BPR and governments share a common perspective.  When they look at ‘drug costs’, in other words what insiders describe as AAC (actual acquisition cost…meaning the real cost of the drug to pharmacy), plus a mark-up (a retail concept), plus the dispensing fee (meaning counting the pills on the little blue tray and putting the pills in the little vials, from their perspective)…when both BPR and governments add up these three components, they see one thing: drug costs.

There is a very important, not so subtle message here.  The pharmacist bit is considered a cost, not a service.  Pharmacist compensation is totally integrated into the cost of drugs.  As drug costs go down (which is good for the public) so does pharmacist compensation, and this process is just beginning.  National Pharmacare is coming up with the objective of universal coverage (a most worthy goal) and more so, lowering the cost of drugs.

When pharmacists have to create a ’Pharmacist Awareness Month’ (a whole month?), …when pharmacists have to constantly preach out how they are ‘medication experts’ and ‘therapeutic appropriateness experts’ …and how they are the ‘most trusted’ practitioners in the healthcare system, …and still the value of a pharmacist is relegated to a cost component within drug costs, we know there’s a problem.

But the problem is eventually manageable for BPR and for governments.  These corporations (Amazon, Loblaw, Walmart, Costco, Sobeys etc.) are massive, with hundreds of thousands of employees and experts who will find ways to survive and thrive in a viciously competitive environment.   Pharmacy remains an opportunity for growth and profit for BPR, and a big opportunity area for massive cost savings for governments at all levels.

The problem, with an uncertain outcome, is for the profession of pharmacy which continues to flounder, and to attempt to create a value proposition outside the cost of drugs.

Some things for sure:  flu shots, and meds reviews, and counselling with constantly reduced technical help, while professional fee discounting, are not going to cut it.  Yet this is where all the effort by associations and other bureaucrats appears to be concentrated.  Increased ‘scope of practice’?

Once again, what is academia’s role in informing pharmacy students of the future which lays before them?