Who does the OPA really represent? billbrownblog.com January 24/2019

I recently watched the YouTube video which the OPA published entitled The Voice of Pharmacy.  Here is the link: https://youtu.be/IFd47I5udgA

It is over an hour long so you do have to invest some time.  Let me say at the outset that this piece is not meant to be a criticism of the video or the OPA.  In fact I was impressed with the sincerity and candor that was displayed by the three presenters, always in a frank and unscripted manner.  The video did reinforce a clear conclusion to me though.

For those who may be interested, here is a brief summary of the contents of the video from my perspective.  I believe the video clarifies who the OPA advocates for, though I am not sure if this was the intent of the video.

The video title is The Voice of Pharmacy, which surfaces the first question.  What is meant by ‘pharmacy’?

The presenters emphasize that the OPA represents the interests of both large corporations (non-pharmacist owned), and independent pharmacist owners. In fact the last several chairmen have all been independent owners from Small Town Canada.

The important Owners’ Council is made up of 24 members, 12 each from ‘corporate pharmacy’ & independent owners.  The emphasis is on representing the “pharmacy system” while it was not made totally clear what ‘system’ actually means.

There is also a clear message that the advocacy effort is with government and pretty well always involves economic issues that affect pharmacy owners.

Although the Owners” Council is self-sustaining, efforts to set up a Pharmacists’ Council made up of staff pharmacists have not been successful.  There was little uptake, and the whole effort is in hiatus at present.  Problem is that these unrepresented retail pharmacist employees apparently have little flexibility to attend meetings.  These individuals represent 80% of the 16 to 17 thousand licensed pharmacists in Ontario today.  It may also be that employers (BPR) are not that nuts about facilitating employee pharmacists attending meetings about issues like compensation & working conditions.

The OPA positions itself as representing the interests of owners, pharmacists, technicians and students.  Multiple approaches and diversity are what this is described as.

Not their fault, but the OPA admits it really has no negotiating power or authority to deal with government, or anyone else for that matter.  The government is just being nice in meeting with the OPA; it does not have to, and when it does, all discussion are covered by a non-disclosure agreement (NDA).  So no one really know what goes on behind the scene.

The video reveals that in original discussions with the government about the flu shot, the government initially wanted to reimburse zero for administering the flu shot.  The government’s argument being that the pharmacy would more than make up for any costs through increased store traffic and thereby sell more frozen pizzas, Cold-Fx, fat flushes, cough syrups, lamb chops, barbequed chickens etc.  The OPA prides itself in finally negotiating a begrudging $7.50 fee…it could have been zero.  Fact is, most pharmacists hate giving the flu shot (a technical act), but pharmacy owners, especially Big Pharmacy Retail (BPR) love them for the very reason government stated…increased store traffic, marginal no cost revenues & quotas to ensure targets are met.  Flu shots may be a small win for pharmacy owners, but the bane of employee pharmacists.  When government thinks of pharmacy it sees Big Pharmacy Retail, not individual healthcare professionals.

Then this zinger.  Apparently the two key initiatives which bind all pharmacy stakeholders together are: Preferred Provider Networks and Cannabis distribution from which pharmacists are presently excluded. What?

Some might have thought that compensation down 40-50%, ever increasing quotas, abysmal working conditions, 12 hour shifts, no breaks, random terminations/job security, no tech support, little or no respect from the employer, might have made the list of issues on the minds of at least some pharmacists today.  Nope.  None of these make the list of issues of concern to the OPA today.  The word ‘quotas’ never came up once in the over one hour video.

And therein lies the problem.  The OPA is a voluntary organization which depends on member fees for survival and credibility, but membership is probably less than 50%.  In an effort to represent the “Pharmacy System”, whatever this term means, the OPA fails to address the everyday issues which affect 80% of potential members.  In fact, these everyday issues are largely the result of the loss of control of the profession to non-pharmacist owned mega corporations…who sit on the very Owners Council in order to ensure their corporate interests are protected.

Really, one has to feel sorry for the OPA; it simply cannot win this game, and it’s not for lack of trying or hard work.  These are good people; they are just misguided.  Why not simply rename itself the Ontario Pharmacy Owners Association, charge $5,000 a year membership fees and then get on with it.

How can the OPA ever hope to garner the support of everyday working community pharmacists who suffer the consequences of issues and policies of other members (BPR) of the very same organization?

The lamb and the lion cannot sleep together

 

A PHARMACIST’S CONUNDRUM in 2019 JANUARY 1ST, 2019

It often seems that as the elephant in the room gets larger and larger, the tendency to look away, and to pretend that the elephant does not exist increases in direct proportion.  The dominant control of the profession of pharmacy by Big Pharmacy Retail (BPR), and the concurrent failure by the regulatory bodies to apply any influence to stem this control, and to put it back into the hands of individual pharmacist practitioners, is such a case in point.

Regulatory bodies like the Ontario College of Pharmacists (OCP) continue to justify their inaction by stating that it is their sole mandate to protect the interest of the public.  “Business models are not within the mandate of the OCP”, the OCP states.   Accepted.  But when the means to deliver standards of practice are not in place, then such models become condition critical and must draw the attention of the regulatory bodies, including the OCP.

Witness that within the next few months, it has been recently announced by OCP, that an initiative will be launched in collaboration with Health Quality Ontario to release a set of system-focused indicators for community pharmacy in Ontario.  An OCP spokesman recently indicated that this initiative is about improving patient and health system outcomes and establishing a way for everyone to measure the impact of pharmacy care in the community and to continually improve.  Who could argue with this one?  What a great initiative and dead on the mandate of the OCP…to protect the public’s interest.

In direct contrast to this highly worthy initiative are the hard facts of life.   The vast majority of pharmacists (80% or more) remain unrepresented retail employees of non-pharmacist owned mega corporations, whose single purpose is selling as much merchandise as possible in an ever increasingly competitive environment, now under fierce attack by internet shopping.  It’s total war for the consumer’s dollar.   We know the players, and we know their strategies.  One player alone, Weston Group, through its control of Loblaw and Shoppers Drug Mart must have close to 50% of the retail pharmacy market.  Chairman Galen Weston Jr. is the most important pharmacy leader in Canada today and he may not even know it.  Has anyone at OCP even met him?   Has anyone told him about the new quality assurance initiative?   Has anyone been to a Costco pharmacy lately with customers lined up at the counter 20 people deep waiting to benefit from a $3.89 dispensing fee?

In such a fierce retail environment, driving revenues and controlling costs are the two important orders of the day.   How is pharmacy affected by this reality?  Pharmacists are increasingly forced to work alone, without any tech support, meaning more time spent on technical functions like counting pills, wringing up sales, and bagging groceries.  All this, while at the same time performing flu shots on demand,  and meeting increasing quotas for MedsChecks and other assorted billable services which drive those important revenues.

How is it that the OCP can set out to create professional standards for quality pharmacy services and at the same time totally ignore the hard reality that most pharmacists working in BPR environments are considered (like all the other retail employees) a means of production?  This means driving costs of production as low as possible, while driving top line dollar revenue production as high as possible.  This quest is at the heart of retailing and it never stops.  Sales per square foot is a key retail measurement tool and it has no upper limit.

This is the conundrum, but what brings it to tragic proportions is the failure by regulatory bodies like the OCP to address what is an impossible situation.   This is not just about professional satisfaction, it is about human health.  Pharmacists are actually becoming sick both physically and mentally.  How can pharmacists deliver quality professional services like “therapeutic appropriateness” when they are checking 200 Rxs an hour with no help?

It is well within the regulatory bodies’ purview to set standards like the number of prescription an hour which a given pharmacist can safely fill and still meet minimum professional standards; they just don’t want to tackle BPR.

So much effort has been put forth to create the professional title of ‘Pharmacy Technician’.  What a tragic joke, as these people cannot find work, or when they do, they are not financially rewarded for their status but still must now pay OCP increasing annual dues.

The talk has started that the self-regulation of professions like pharmacy and medicine should go under review.  Some may look in horror at the prospect of government oversight of pharmacy, but one must wonder if it could get any worse than the present untenable situation.

 

PHARMACY, TRUCKING & the OCP

Although not so obvious at the outset, there are a lot of similarities between the trucking industry and pharmacy.  The trucking industry (or the transportation industry) is all about moving stuff from one place to another, and big players in this industry focus on tonnage and distance; they mostly worry about their trucks.

The more trucks the better and keeping these big machines in top notch shape is paramount; regular servicing is the standard.

When it comes to the drivers’ concerns, the same level of care and investment falls far short.  Long shifts and great distances are standard fare for drivers, who are notoriously out of shape due to lack of exercise, fatigue and consumption of junk food.

Is this beginning to make some sense when comparison is made to pharmacy & pharmacists?  Replace pharmacy for truck and pharmacist for driver.

It was not that long ago that pharmacy regulatory bodies were obsessed with details about the actual ‘pharmacy’.  The number of square feet of counter space, beakers, scales, square footage etc. were critical issues.  These aspects have seen less emphasis lately as the notion of the pharmacist as a knowledge worker is promoted, and compounding becomes a specialty activity restricted to a small minority of pharmacies.   But still, regulatory bodies like the Ontario College of Pharmacists (OCP) see fit to charge pharmacy owners annual pharmacy accreditation fees in excess of $1,000 per year.

What are these fees for?  Maybe just a convenient revenue generator?  And still this is not enough.  This year the OCP has dictated that annual member fees will be going up 20% over the next couple of years in order to finance the increasing number of complaints and disciplinary issues the OCP has to deal with.  What a sad comment on the profession of pharmacy.  What has caused this degradation in the moral fabric of the profession, and this spiked increase in assorted misdemeanors involving (ever more frequently) members of OCP council and its very leadership?

This website has been inundated over the years, but much more so lately, with lamentations from pharmacists mostly working for Big Pharmacy Retail (BPR) re compensation decreases as much as 40% from five years ago ($32/hr is fairly common in Toronto today) and abysmal working conditions.  In the name of saving labour costs, it is common to witness pharmacists working alone (no technicians or assistants), trying to serve a dozen patients at a time, perform flu injections, and bag groceries all at the same time.  No bathroom breaks, no meal breaks.  And for this you need a PharmD?

To add insult to injury, while under these terrible conditions, retail pharmacists will now be subject to measurements for productivity and proficiency by both the insurance sector (who is looking to save money for their clients/employers), their direct employers (like SDM), and by the OCP whose stated sole interest is the safety and health of the public.

Back to the trucking analogy.  How can the regulatory system be so concerned about ‘pharmacies’, which are 90% owned by non-pharmacists, and be totally  unconcerned about the health and well being of pharmacists who have to deliver the goods?

When confronted with this issue, the OCP is resolute that its responsibility is solely the welfare of the public, and that business models and the inherent structures of such models are not its concern or responsibility.  In fact, new incoming council members are specifically directed that their personal opinions are not relevant when it comes to fulfilling the mandate of the College, and strict adherence to the edicts as set out in the college’s policies is to be the guiding principle at all times.  Just read & follow the rule book, innovation is neither requested nor welcomed.  In British Columbia the voting turnout for the last council election was something like 8%.  Wonder what the percentage was in Ontario.

The problem here is the narrow interpretation of what is in the public’s interest.  If the health & well being of the pharmacist fulfilling the professional act is of no importance, then how can the pharmacist be judged on his/her professional competency?  How can we have road safety if we have great trucks being driven by overtired amphetamine stoked drivers?

Such factors as the number of prescriptions filled per hour, level of technician support, flu shot injections, and the capability to perform so called therapeutic appropriateness, must all be of concern to the OCP if it is truly concerned about the public’s interest.

To state sole interest in the public, while having no interest in the pharmacist’s capability to do the work, makes no sense, and reflects an institution which is locked in its past.

It is really time to reconsider the efficacy of self-regulation in both pharmacy and medicine; it’s just not working.

 

 

 

 

Pharmacists on track to be tracked October 29, 2018 billbrownblog.com

Just when you thought the pharmacy world couldn’t get any wackier, bingo, it does.  This week the Canadian Healthcare Network ran the following headline:

“Shoppers Drug Mart (SDM) To Begin Tracking Pharmacy Performance”.

First of all it should be noted that this really is LOBLAW not “Shoppers Drug Mart”.  SDM has really become just a brand, a very powerful brand albeit, but it is LOBLAW, the owner of SDM, that controls and manages SDM.

Second, it is likely ‘pharmacists’ that they want to track not ‘pharmacies’.  Same old challenge separating a ‘pharmacist’ from a ‘pharmacy’.  We know what a pharmacist is, and a pharmacy is just a space (a retail store) with lots of stuff (most of it not health related) on shelves.  Pharmacies in Canada are overwhelmingly owned and controlled by non-pharmacists; in this case Loblaw Companies Limited which is a subsidiary of George Weston Limited, Executive Chairman & CEO, Galen Weston Jr., the most important and powerful pharmacy leader in Canada today.

How the heck do you track a pharmacy?  It is individual pharmacists that LOBLAW wants to track.  To separate the wheat from the chafe, and to set standards which become minimum requirements for continued employment.

As an aside, LOBLAW has 135,000 employees, the vast majority of which are represented by the United Food and Commercial Workers union.  I wonder what would happen if LOBLAW attempted to track performance measurements on even one of these 135,000?

So a more accurate headline might have read: ‘Loblaw To Begin Tracking Pharmacists’ Performance’

A great deal of negative reaction from pharmacists flooded this news, but one particular comment really captured the tragic comedy that the pharmacy profession has become, as the once proud profession has become totally controlled by non-pharmacist corporations, collectively referred to as Big Pharmacy Retail (BPR).

The comment, with minor editing:

“I was left alone on a Saturday night with no assistant from 5 PM onward. I was bombarded with blister pack change requests, drop in requests for the flu shot, phones ringing off the hook, and customer inquiries. At one point I had 7 people waiting at the pick-up counter and 3 people in line at the drop off with 2 phone lines ringing. I wonder what kind of rating I would have had from that night alone. No breaks, no help, no raise in 5 years. It’s a sad state for the retail pharmacist, and then SDM pulls this stunt with a service survey?”

Does anyone believe that this is the exception?  As retail margins and market share continue to come under fierce competitive pressures, and from frontal assaults by online shopping, the pressure to maintain profitability becomes intolerable. Hence, the pursuit to produce more revenues with less cost of production becomes the core driving force.  Those ‘district managers’ (aka the swat teams of the retail offensive) run on high adrenaline 24 hours a day

The immediate question surely must be, what exactly does LOBLAW want to track?  In the case of the example of the pharmacist quoted above, how much more productivity could be squeezed out of this one individual?  If it is quality of patient care that is being measured, how is this squared by the need to cut labour costs through cutting hours and not replacing personnel who quit?

While such efforts to track and measure pharmacists by LOBLAW (and Green Shield) become the new reality for working pharmacists, the Ontario College of Pharmacists (OCP) is also working on an initiative to establish quality indicators for pharmacy care.

http://www.ocpinfo.com/library/other/download/quality-roundtable-synopsis.pdf

Will these OCP inspired measurements or indicators conflict with the ones that LOBLAW demands?  How do the values and obligations of a healthcare profession dovetail with the imperatives of a massive retail conglomerate like Weston/LOBLAW?

In the interest of the mental health of pharmacists (in Ontario anyways), would it be reasonable to ask the Ontario Pharmacists Association (OPA), who allegedly represent the interests of 10,000 members, to lead an initiative with the objective of creating a forum to bring together LOBLAW and the OCP to create a common set of measurements and indicators of success?   Please excuse my sarcasm.

Let’s keep this simple.  A ‘pharmacy’ does not legally exist unless there is a licensed registered graduate pharmacist on the premises, no matter whether it is an 800 square foot pharmacy, or a 200,000 square foot super mega drug food combo.  BPR believes it owns thousands of pharmacies, but really these are all just real estate/buildings which cannot even open their doors without a pharmacist present in the building.  Pharmacists remain the means of production.

Here is a suggested response to this initiative to track individual pharmacists’ performance based on arbitrary measurements, which make no sense in face of the already brutal working conditions most retail employee pharmacists working for BPR endure every day.

Ignore the whole thing.  Pull Martin Luther King Jr…peaceful protest.  The issue is one of control.  Control of the profession is long gone, (just don’t tell the OCP) but control of you as a person must remain with you.  Just do your job according to the obligations you undertook when you became a pharmacist to ensure maximum patient care.  Focus on your professional duties.  In the end they can’t fire everybody.

 

Cannabis, Cannabis, Cannabis: enough already. October 15, 2018

 

This stuff has been around for 5000 years at least.  It’s called grass, or weed, or pot, or hash or dope for a reason; it makes people dopey.  Some people like feeling dopey and that’s OK as long as they don’t harm anyone but themselves.  The latest move to decriminalize cannabis is an overdue idea as it is widely used for so called ‘recreational’ reasons.  To some people, feeling stoned or dopey is their form of recreation.  Apparently as many as 4 million Canadians use pot regularly, in spite of its illegal status.

While anecdote is not evidence, there are some documented experiences of patients using so called ‘medical cannabis’, especially in treating chronic pain, nausea during cancer treatment, and some forms of epilepsy gaining some benefit, largely from the cannabinoid component in weed.  This is a teeny fraction of cannabis users (about 120,000) and for them the term medical marijuana may not be an oxymoron.

For everyone else, the term medical marijuana is an inside joke.  It is ‘medical’ if the person says it is, kind of like ‘medical bourbon’.  It’s all in the eyes of the beholder.  The CMA remains doubtful about the usefulness and/or efficacy of medical cannabis.  Only 10% of physicians will even touch the stuff.  So why does pharmacy keep talking about it?  The main reason is as always money, big money.

In reality, what most ‘users’ are after is the THC; the “good stuff” that makes you stoned.  The use/harm of cannabis is probably no worse or no better than the use of alcohol, another toxin widely used by people for ‘recreational purposes’.  Way too much money, police resources, courts and prisons and way too many ruined lives have been wasted since the prohibition of cannabis in the 1930s.  Criminalizing cannabis for political and misinformed reasons, has been one of the largest examples of wasted taxpayers’ money in history.

Cannabis legalization is coming to Canada on Oct. 17, finally legalizing the stuff.    Plenty of enterprises across the country, from growers to retailers to the tech and tourism sectors, to stock brokers and of course drug stores are all chomping at the bit to reap a windfall from legal marijuana. But there remain difficult questions about cannabis use in the workplace, in homes, & while driving or operating dangerous machinery.  How many lives may be lost on the roads before someone realizes that maybe this whole thing was rushed for political reasons?  It’s fine if people like being stoned while listening to Pink Floyd in their own home or at a party.  It’s another thing if a stoned truck driver hauling 100 tons of steel plows into a stream of stopped vehicles on a highway because of his reduced reaction time.

Globe & Mail October 15, 2018                                                                                              Cannabis makes it harder to identify and react to driving distractions that can result in crashes, a clinical trial at McGill University found. About 80 per cent of the participants, aged 18 to 24, also reported feeling less safe to drive after using the drug, including five hours later.

One thing for sure, lots of people are going to make many tens of millions of dollars on cannabis.  The stock market thrives on hype like this.  It reminds one of the heady days of high tech.  As always, the usual suckers are going to get burned badly.

So what is Pharmacy’s official position on cannabis?  To say it is total confusion would be an understatement.  Note that at this point in time, pharmacies are not even part of the distribution channel for either ‘medical marijuana’ or the recreational stuff.  Pharmacies are presently not in the loop.

But as pharmacy struggles to find a place in this Wild West cannabis landscape, it is torn between its professional obligations , and the dominating reality that pharmacy is largely now controlled by corporate interests (BPR) in search of profits from the sale of any products, even the many useless or even harmful products found in many drug stores today.

To illustrate this embarrassment to pharmacy, this week an email was sent out by the OPA (Ontario Pharmacists Association) re a deputation made on October 11th before the Standing Committee on Social Policy at Queens Park.  The delegation consisted of the Chief Pharmacy Officer and the Vice Chair of the OPA.  In this document the OPA clearly states that the 10,000 pharmacist members represented by OPA OPPOSE the sale of recreational cannabis products in pharmacies.  The deputation largely advocates that pharmacists be allowed to dispense medical marijuana; the document also alleges that cannabis is just another drug that pharmacists can and should be available to consult on.

OPA deputation October 11, 2018                                                                                                   “In the absence of an amendment we would ask the Ontario government to seek formal approval of the Federal government for provincial authority to task pharmacists with the dispensing of medicinal cannabis pursuant to a medical order

At the same time, we want to make it absolutely clear that the members of the OPA   DO NOT want to distribute recreational cannabis”

Of course everyone knows that this is NOT where the real money is.

In contrast to this position, the NPAC (Neighbourhood Pharmacy Association of Canada (hitherto known as the Canadian Association of Chain Drug Stores) made a submission recently to the government of British Columbia (as well as to other provincial governments) re cannabis regulation.  In this document, argument is presented that pharmacists should be part of the distribution channel for medical marijuana for the same reasons as the OPA submission did.  The big difference in this NPAC document is that the NPAC clearly states that its members (Big Pharmacy Retail/BPR and all the assorted pharmacy brands/banners) DO want to sell recreational marijuana, and a spurious argument is outlined to support the position that pharmacists know how to handle tricky goods.  So does the LCBO.

Recent submission by NPAC to BC government                                                                         “Our members strongly believe that the Access to Cannabis for Medical Purposes Regulations should be amended so that pharmacists can be authorized to distribute and dispense medical cannabis.  Pharmacies play a significant role in managing the distribution of controlled products and they would be committed to work with all levels of government to ensure that recreational cannabis products are also sold legally in pharmacies”

And of course everyone knows that this IS where the real money is.

The large majority of the 10,000 pharmacist members of the OPA work for NPAC companies.  What is their individual position?  Who really represents them?  What about individual choice?  Do pharmacists support their provincial advocacy body’s position or their NPAC employer?  Some may not want to get involved with cannabis at all?  Will they be granted this choice by their NPAC backed employers?

Recognizing this contradiction, does anyone know what most pharmacists really think about being involved in the sale of cannabis products?  The non-pharmacist pharmacy owners (BPR) know what they want; they see a great opportunity to create traffic and boost profits at the retail level and there is no way BPR wants to be left behind.

Additionally, what is the position of the Pharmacy Regulatory Bodies?  The OCP (Ontario College of Pharmacists) has declared its position.  As part of its ‘Opioid Strategy’, it will now require all Ontario pharmacists to complete formal cannabis education as a condition for licensure by the year 2020.  Why isn’t there compulsory education for other drugs?  What makes cannabis so special?  Is this just more politics and an attempt at appearing proactive?   Isn’t this a case of overreaching of authority?  Would this OCP licensing requirement withstand a legal challenge?

In BC only 8% of registered pharmacists voted in recent council elections.  The BC College of Pharmacists is puzzled as to why.  Wonder what the percentage is in Ontario.

All this for a substance which may never actually come under the control of pharmacists, ‘medicinal’ or recreational.  There is a good possibility that pharmacy may be shut out altogether…not even the medical stuff, let alone the recreational stuff.

All this hype acts to give a 5,000 year old herbal substance, known as cannabis a heightened position within society that it simply does not deserve.  In the final analysis cannabis is just dope by another name.  Enjoy it if it’s your thing, but remember it still stinks, turns your hair yellow, probably does nothing for your libido, and makes you slur your words…so please don’t glorify it

Those pharmacists who consider themselves to be ‘conscientious objectors’ when it comes to cannabis in any form, must retain the right to just say no.

 

 

 

 

 

THE PHARMACY PROFESSION & THE EVENT HORIZON September 20, 2018

You know the pharmacy profession’s future is looking somewhat dim when people continue to proselytize that you should look at the cup as half full, or to put on your rose coloured glasses, or to examine your feelings and start thinking positively.  The big put is to “just get involved” in your association, or latest committee, or attend a conference, or seek representation on your regulatory body.  All this to suggest that if you just keep moving, turn on and tune out, it will all go away somehow.

Maybe.  And then maybe not.

The past reactions to a few blogs on the Canadian Healthcare Network (especially the comments from readers both young and old) have been especially angry and despondent re the profession of pharmacy and what it has degraded into.  But this did not just happen recently.  This was a gradual process which started exactly 64 years ago when the 1954 Pharmacy Charter was enacted.

Think of this date 1954 as an ‘Event Horizon”.  An event horizon is that special place in space where objects, as they are sucked towards a black hole, cross a point, and once they cross it can never turn back.

The 1954 Pharmacy Charter recognized the looming danger approaching by the entry of big business interests into pharmacy.   From that date forward all pharmacies were to be owned and/or controlled by pharmacists, and corporations had to have a majority of directors as pharmacists.  Great idea, except for the ‘grandfather clause’ stating that all existing pharmacies (pre-1954) were exempt from this provision, and could be sold to anyone, pharmacist or not.  From this single grandfather clause provision, motivated by the greed of those pharmacists involved and in power at that time, today we are rewarded with Big Pharmacy Retail (BPR) which has taken over the profession.  Even the provincial regulatory bodies quake in their boots in the presence of BPR.

Fortunes were made selling a single pre 1954 existing pharmacy to a grocery chain or big box merchandiser etc.   From that single charter purchase, a non-pharmacist retailer could open hundreds of locations across the country to the point where today BPR controls 85% of pharmacy across the country.  With this kind of clout, BPR can exercise the Golden Rule: ‘He who holds the gold makes the rules’

It was pharmacists who allowed this to happen.  It is pharmacists today, ensconced in the multitude of pharmacy associations national & provincial, regulatory bodies, and academic institutions, which continue to sustain the status quo and to gain succour feeding off the existing system.  Pharmacists did this to themselves and continue to put personal gain above the interests of the profession.  Hence professional fee discounting, fierce retail competition and plummeting compensation.  A race to the bottom, and no end in sight.

What to do?  The event horizon analogy, dictates that there is little one can do except to get sucked into the vortex.

In fact, there is much that can still be done in spite of the consequences of the mistakes that were made in the past.  The first and most important thing is to refuse to accept the status quo.  Radical thinking and disruptive actions are required.

Over and over, ‘pharmacy advocates’ come up with weird ideas and initiatives which deny the reality that the profession of pharmacy is not controlled by individual pharmacists; pharmacy is controlled by BPR.  BPR are not bad guys, they just have a different agenda from pharmacy professionals and the two often have diametrically different mandates.

First thing.  Severely limit the number of graduates coming out of pharmacy schools across Canada.  Some schools should be shuttered.  How much worse must the present pharmacy reality be for recently graduated PharmDs with six years of education, $150,000 in debt which they can never pay off and working in a 10’ by 20’ cubicle in a grocery store?  The professors and deans will squeal like crazy of course.

Second, shut the door tightly to any further foreign trained pharmacists.  Zero.  No more International Pharmacy Graduates get licenses.

These two actions will begin to tilt the supply and demand curve back towards pharmacists and away from BPR as retail employers.  It will take 10 years to have an effect.  BPR won’t like this as it was BPR who encouraged opening the floodgates to international graduates for good reason, to depress wages, and it worked big time.   Tell the IPGs working today in Toronto for $30 an hour with no tech support that immigrating to Canada was a great idea.

Third, encourage all existing pharmacy students to parlay their degrees into new directions, not necessarily retail pharmacy which is a dead end professionally which will destroy their souls within six months of graduation.  Law, business degrees, politics, education, anything but not the black hole vortex of retail pharmacy controlled by non-pharmacists totally consumed with commercial interests.

Fourth, put pressure on the regulatory bodies to tackle the real issues confronting pharmacists today, those which are having a negative effect on the public interest; tackling things like fee discounting, unlawful rebates, performance quotas, dangerous working conditions, etc.  There is much that these regulatory bodies could do if they had the guts to do it.  Requiring mandatory cannabis education to qualify for licensure (while both medical and recreational cannabis may never be sold in a pharmacy) is a good example of wrong-headed focus.

Fifth, inundate the so called pharmacy associations, with letters, phone calls & emails to turn their attention towards the interests of individual pharmacist practitioners, and less to the interests of pharmacy businesses large & small which employ these pharmacists as essentially retail employees.   Are they ‘pharmacist associations’ or are they ‘pharmacy associations’?

Agreed, some of these suggestions may never come to fruition, but at least they speak to developing the right attitude, an attitude of not complacently accepting the status quo and developing a willingness to do anything to avoid the despair and complacency prevalent today.   Take action against the realities facing pharmacy today, and avoid delusional Pollyanna thinking wherever it comes from.

Naval gazing, denial, and especially false rosy outlooks are never going to cut it.

‘PHARMACY’….WHERE’S THE MONEY?

If you asked anyone (in any way connected to pharmacy) about the financial health of pharmacy today, the response would be largely by way of lamentation, & weeping and gnashing of teeth.

Government cut backs, never ending reductions in drug costs, elimination of ‘professional allowances’, depressed wages, unemployment, and it goes on and on.  Not a pretty picture.

But is this an accurate picture really?  Well it all depends on what you define as ‘pharmacy’.

I have written before about the difference between a pharmacy and a pharmacist.  The two are so different with different goals and objectives that they hardly share a common genesis.

A pharmacist is an individual who practices the profession of pharmacy, drawing upon the education he/she received, and in adherence with the regulations as set out by his/her provincial regulatory body.

A pharmacy is a place, a store, a department, a kiosk where stuff is sold.  Some of this stuff is health related and OK, but a lot of this stuff is useless, the opposite of health related, and often even harmful.

Just look at the next grocery store or big box merchandiser you approach.  The name of the store is front and centre: Sobey’s, Metro, No Frills, Food Basics, Super Store, Walmart etc.  Then in large letters, usually to the right side of the front door logo, is just the word ‘PHARMACY”

What does this one word signify to the average consumer?  What is the word intended to inform the shopper as to the type of merchandise which will be found inside the premises?

Apart from the obvious ‘prescriptions’, which are increasingly not the priority of the non-pharmacist owner of the pharmacy, the word is supposed to convey to the shopper that drug store type merchandise (DSTM in industry parlance), & so called Schedule 3 drugs are available for sale.

DSTM can be virtually anything from tooth paste, to hot water bottles, to health & beauty aids, candy, soft drinks etc. etc.  …all stuff which can be sold anywhere, but which usually people go to the ‘drug store’ to purchase.  Here the words ‘drug store’ stands in for ‘pharmacy’.

Then there’s Schedule 3.  This is all the stuff which “although does not need the direct intervention of the pharmacist, must be within a specified distance from the pharmacist, in case the consumer wants to ‘consult’ with the pharmacist.   This includes cough syrups, analgesics, hemorrhoids preparations, vitamins, antihistamines etc. etc.   …so called over the counter drugs or OTC’s.  This stuff can only legally be sold in a ‘pharmacy’.

So now we now understand why all the members of Big Pharmacy Retail (BPR) have inserted a ‘pharmacy’ into every grocery store or big box merchandiser.  It’s an opportunity to create increased store traffic and to boost revenues through increased sales.  This is exactly what BPR is supposed to do…sell as much stuff as possible.  Any stuff.  BPR now controls over 80% of Canadian pharmacy sales.

Interestingly as well, the sales volume of all the other stuff that the grocery store sells, like carrots, meat, beans, bread etc. all goes up by more than 10 % just because the DSTM & Schedule 3 stuff is under the same roof.  Increased store traffic.

The truth is that much of this OTC stuff is ineffective and/or useless.  Most vitamins are way over hyped.  Cough syrups are both useless and can be harmful.  Then there are the ridiculous diet aids, fat flushes and COLD-FX  And a thousand other products which are hyped on television to a gullible audience which will purchase anything it sees on TV…one big waste of money, and which any respectable pharmacist would try to persuade a patient to walk away from.  Such action would of course not be consistent with the non-pharmacist retailer’s objective, which is to sell stuff.  Hence the contradiction between a pharmacist and a pharmacy.

There is big money to be made in selling OTC’s, DSTM, and all Schedule 3 stuff.  Not so much money selling Schedule 2 drugs (a drop in the bucket) nor selling prescriptions which are becoming less & less profitable by the day.

The truth is that most consumers of so called Schedule 3 drugs, just pick up what they want (and have been presold on) from the shelf and leave the store.  No ‘pharmacist intervention’. Maybe 10 % will ask “which is the best cough syrup?” as they look confused at 40 feet of cough syrups with various claims slapped on the labels.  Hard to answer this question and remain honest to the profession which is always to act in the interest of the patient.

Schedule 3 products are dream products for BPR.  These are products have limited distribution channels for reasons mostly dealing with dubious regulatory issues, and are driven by big money advertising, not pharmacist recommendation.

In this story, the pharmacist is a prop. The pharmacist presence allows for the word ‘pharmacy’ to be slapped to the side of the building, and hence allow for the sale of all this high margin restricted distribution stuff.

Also, the designation ‘pharmacy’ conveniently allows the regulatory bodies to collect big bucks annually by way of so called accreditation fees.   Not sure what is being accredited.

So now at least we know what the word ‘pharmacy’ means.  The word ‘pharmacist’ remains a bit of a question however, as the profession attempts to evolve in a fast changing, cost reduction environment which is totally dominated by non-pharmacist pharmacy business owners.

The conclusion to this story is still up in the air, but the plot at present is not looking too good for the profession of pharmacy.  Pharmacy however is looking great.  Making lots of money.

 

HOW MEDICINE EATS PHARMACY’S LUNCH June 20, 2018

The pharmacy profession is faced with many challenges today.  The profession’s financial viability is under siege from many fronts as a result of government pressure to address spiraling healthcare costs, with a particular focus on the cost of drugs.

Pharmacy Business is in less financial trouble, as the retailing and mass merchandising of drug store type merchandise (DSTM) and endless aisles of OTCs, many of which are useless, continues to grow unabated.

Against this backdrop, the independent pharmacist today who attempts to set up a practice in a medical building together with several doctors and the usual ancillary medical services like radiology, lab, physio, etc. is confronted by yet another challenge.

Medical practitioners directly represent roughly 30% of healthcare costs, but through their ability to generate prescriptions, lab tests, and radiology they control a far larger percentage of healthcare costs (excluding hospital costs).  The problem is that many physicians believe they are entitled to benefit somehow from all these activities which they directly generate.

So today we are increasingly seeing two unfortunate scenarios developing.  These are not new developments, but lately they are becoming more and more the norm, and represent yet another challenge to individual practicing pharmacists attempting to set up their own practices outside of Big Pharmacy Retail (BPR).

Scenario 1 involves the situation where the physician is the developer of the medical building or medical centre.  The physician may build the real estate or may lease it, but in either case he/she is in control of the leasing of the complex.   Through various complicated arm’s length structures, the lease rate for the pharmacy in the building is set at a multiple many times greater than the going rate for the geographical area in which the complex is situated.   Through this disproportionately high rent, pharmacy profits (thin as they may be) transfer from the pharmacist to the physician.   Clearly, both the pharmacist and the physician are complicit in this scheme, and both are willing parties to this arrangement with the obvious conflict of interest implications.  The reason this scenario happens at all is the subtext that the pharmacist owes the physician something beyond rent for the prescriptions generated by the medical complex.

Scenario 2 involves the situation where the pharmacist is the developer of the medical complex, once again as either builder or lease holder.  In this scenario the pharmacist controls the leasing.  So in order to attract physicians as tenants, especially those who write high prescription volumes like pediatricians and general practitioners, the lease rate for medical office space is set at a fraction of the going rate for office space in the geographical area the medical complex is situated in.   Once again this transfers potential pharmacy profits from the pharmacist to the physician through subsidized lease rates.  This again represents a direct conflict of interest.

The two scenarios described are common practices, and every pharmacist knows the rules when it comes to any effort to situate themselves in a potential medical complex.

The College of Physicians & Surgeons of Ontario (CPSO) are well aware of this situation, but choose to turn a blind eye to it as it pursues what it believes to be more important transgressions like sexual abuse or opioid overprescribing.  The overall number of complaints the CPSO receives apparently runs into the thousands per year, most of which are frivolous, but every one of which still requires a file opening & investigation in every case.

The Ontario College of Pharmacists (OCP) is also aware of this situation, but once again turns a blind eye in the face of what it considers  to be more important issues like sexual abuse & fraudulent billing,

This whole situation is most unfortunate because these scenarios represent major obstacles to independent pharmacists working collaboratively with physicians and other healthcare providers in a collaborative setting with the goal of the development of improved patient care, to say nothing of the conflict of interest these scenarios create.

Both physicians & pharmacists need to be held accountable here, as these scenarios only serve to perpetuate the notion that pharmacy serves as a hand maiden to medicine.  Beyond this, this situation is not in the interest of patients or the healthcare system.

In this regard, both the CPSO and the OCP are derelict in their responsibility as regulators of the respective professions of medicine and pharmacy.

Recent CPhA Conference: What I learned. billbrownblog.com June 11, 2018

When I was recently approached by officials from the CPhA to participate in this year’s conference in Fredericton NB, I was frankly surprised; I have often been critical of the CPhA, and I have questioned its relevance in the face of today’s seemingly overwhelming pharmacy challenges.  I have also been generally sceptical of the value of the many endless conferences that pharmacy seems to hold (the Ontario Pharmacists’ Association Conference followed immediately on the heels of this CPhA national conference).  Admittedly, I had not been to a conference in many decades.

Nevertheless, I agreed and I took part in ‘The Great Debate’ re the viability of pharmacist prescribing, or expanded scope of practice (ESP).  My position was to act as ‘antagonist’ meaning I was to be against this initiative to expand pharmacists’ role in the healthcare system.

This premise was difficult to defend, and I indicated at the outset that I was indeed NOT against pharmacist describing or ESP.  As I have indicated in my previous two blogs, I believe ESP is critical and timely in the face of three realities:

  1. Automation which is rapidly overtaking many functions which are data based, repetitive in nature and subject to algorithmic applications
  2. The ‘corporatization’ of pharmacy as a profession by non-pharmacist owned & controlled Big Pharmacy Retail (BPR)
  3. Plunging drug prices, which are inherently good for patients, but bad for pharmacy under present pharmacist compensation structures.

It’s not the rationale, or the justification, or the clear & urgent need that are the problem; it’s whether the pharmacy landscape, as it exists today, is conducive to the professional development of pharmacists’ patient skills.  And I still maintain that the landscape is not fertile for this kind of development; I wish it was.

While the profession of pharmacy is under the control of non-pharmacist retailers, and pharmacists are essentially unrepresented retail employees of BPR, these kinds of initiatives will remain successful largely ‘in vitro’, and will fail the test of time ‘in vivo’.

Of course the young, enthusiastic, passionate delegates at the CPhA conference would have none of this, and more power to them!

I would not have wanted to throw cold water on their vitality or their optimism for the world.  I admire them all greatly, and I truly hope they achieve their life goals and enjoy outstanding successful careers and total professional fulfilment.

And this is the big lesson I learned from the conference.  No matter how dark the present situation may appear, the vitality & passion of youth can overcome many obstacles.  These traits can lead to the achievement of the dreams this new cohort of pharmacists seeks to turn into reality.  I will be first in line to boost them on.

My only parting words of caution and advice are these.  In order for a tree to flourish and grow, it must be planted in fertile ground.  Do not make the mistake of believing you can achieve your goals if you plant yourself in the wrong environment.  I know this will be tough, especially in markets where BPR totally dominates the landscape/marketplace.  Find or create your own environment and then do what you were educated to do, and do it with passion.

Choose the wrong environment, and it will take less than six months before your spirit is broken.  Search out your predecessors and find out how they feel after a year in the BPR trenches.  Don’t rely on my warning alone.

You have so much to offer.  Put it all to good use where it can flourish and make a difference.   This is your obligation and your destiny if you take control of it now.

 

 

EXPANDED SCOPE OF PRACTICE (ESP)? (PART 2) MAY 14/2018.

The reaction to the topic of ESP, by way of comments, appears to have hit a nerve.  Clearly there is a high degree of mixed feelings as to the direction in which ESP is headed. Most comments suggest caution.

Everyone appears to agree that expanding the scope of pharmacy practice is urgent, especially at this historic juncture when automation, decreasing drug costs and corporate (BPR) domination are all approaching the high water mark.  Any divergence of opinion appears to be questioning the particular direction this expansion is taking.

It is a statistical fact that the majority of pharmacists are employed by Big Pharmacy Retail (BPR) as unrepresented retail employees.  U of T pharmacy Professor Austin Zubin refers to this as the “corporatization of pharmacy as a profession” in his seminal paper Barriers to Pharmacy Practice Change. It is also a fact that success in retailing is all about scale.  This means selling as much stuff, any stuff, as possible out of a given foot print of retail space.  Think Costco or Walmart here, masters of this skill.  This is what retailers are hard wired to do, and in a highly competitive market, threatened by internet shopping, only the strong will survive.

So the initial question becomes: how will these pharmacists (the 85% employed by BPR) who are to diagnose & to prescribe for minor ailments, and to perform more time consuming non scalable patient focussed care, square this with their employers’ number one, seemingly contradictory, priority which is to increase productivity at all costs in a razor-thin margin industry?  .

Severe cut backs in pharmacy assistants and technician assistance are the prevailing trend.  Larger quotas to perform even more medication reviews and any existing billable services are the rule.   Pharmacists are now expected to perform as many flu injections as come through the door while still maintaining their responsibilities as dispensers of medications.  As well, any existing monies which are derived from providing any of these professional services goes to the non-pharmacist owner, none goes to the professional who delivers the actual service.

The whole notion of non-scalable professional services is diametrically at odds with large scale retailing.  This becomes even more untenable when so far there is little or no funding for these professional services except when a product is actually sold.  In other words, only when a product is actually sold to the patient directly & money transfers hands.

Even in Alberta (the provincial leader in government recognition of pharmacy professional services) has recently slashed funding by 150 million dollars.  It boils down to one thing.  Government considers these payments as a cost, one to be controlled and minimized.  Government does not consider pharmacy professional services as an investment.  Pharmacy has done a very poor job of establishing a clear value proposition.

In jurisdictions where Med Reviews have enjoyed a significant thrust like in Ontario, evidence has shown little measurable financial benefit over the long run, and initially, at least, a significant degree of abuse and poor quality.  This has not been aided by aggressive quotas to churn out these “revenue generators” by big business imperatives.  It bears repeating that when and if professional services are recognized and funded, the business of pharmacy will predictably institute yet new quotas and treat such services as additional SKUs (stock keeping units).  Five UTI diagnoses per eight hour shift.  Retail business is hard wired to think this way.

Further, the inherent conflict of interest created by both prescribing and fulfilling medication cannot be denied.  This situation is greatly exacerbated when the compensation is all on the fulfillment end, and none is on the front end, which at present is largely free.  This reliance on the actual selling part is almost guaranteed to deliver compromised healthcare and to validate what physicians are already warning, fragmented healthcare.

When it comes to the provision of flu injections, some pharmacists profess it brings them ‘closer to their patients’.  But how far does this thinking go?  Are wound management & direct diabetes care next? As one physician recently wryly wrote in, “will it be “pap smears in aisle four?”.

Many students enter pharmacy because they do not have to physically engage with patients; it is not their inclination.  It is clear that physicians, nurses and pharmacists are quite different from one another in personality and approach.  This has been borne out in many studies.  If pharmacists are going to do physician and nursing type stuff, then the entrance criteria into pharmacy schools will need to take this into account.  Professor’s Austin’s paper clearly sets this out.  But what about the existing cohort of pharmacists who will be around for the next 30 or 40 years who are being pushed in a direction they are not comfortable with and never asked for in the first place?

The reality is that pharmacists are missing the really big opportunity.  Pharmacists have a great deal to offer by way of medication management, therapeutic determination, dosing, monitoring therapy, therapeutic substitution etc.…all of which evolve out of their core skills which are by discipline pharmacological/pharmaceutical.  This happens today in many major hospitals.  This is what pharmacists are educated to do, and any practice expansion should consider this direction, not some whimsical notion of playing doctor or nurse.  As one physician recently aptly put it, “there is a big difference between medicines and medicine”.

To notion of imposing patient focussed, time consuming, professional services into a retail environment owned & controlled by non-pharmacists with little compensation, appears to be a significant leap of faith.  And then to suggest that it is sustainable under the present scenario where any compensation would flow not to the pharmacist, but to the non-pharmacist owner, is even a wilder stretch. Why would pharmacists want to do this?

ESP is timely, but presently it appears to be taking a poorly thought out direction out of a desperate attempt at survival, and is mostly based on the notion of ‘accessibility’.  Certainly pharmacists are very accessible.  In many urban environments there are at least two or three times as many pharmacies as the market actually demands.  If this is the value proposition, it’s an awfully thin one.

This accessibility notion, and the further self-described notion of ‘most trusted healthcare professional’ are very shaky platforms on which to build pharmacy’s future and they will not withstand the test of time.

Pharmacy ‘leaders’ must be compelled to take a second breath before going much further in this present rather ill-fated direction.