"For the love of pharmacy!" I shouted (I say shouted, because it was all caps, so it qualifies, in Internet-speak). "Please answer and share!" Soon after, thousands of you clicked the link and gave your feedback on whether or not the profession of pharmacy needs a new representative body to advocate for both our needs as professionals and for the needs of our patients.
Close to the same time, Tom Menighan, CEO of APhA, published a letter to all the pharmacists impacted by the Walmart layoffs, and the firestorm that erupted would answer the question of why this survey was ever needed. Don't we already have too many organizations? Aren't we already splintered enough? Isn't APhA there to advocate for the WHOLE profession? Much of the public feedback to the letter espoused the view that its contents were the equivalent of tossing "thoughts and prayers" to the actively dying and grieving, and did no more than pour salt in the wounds of our profession and fan the flames of dissent among practicing pharmacists who have felt abandoned by the organization for decades.
The letter was shared around to several communities, and eventually found its way to Reddit - specifically to r/pharmacy. There it received much of the same derision seen on the APhA website and on other social media pharmacy hubs.
When, what to our wondering eyes should appear, but... u/bradtice?
In that thread there arose such a clatter,
We all sprang to our screens to see what was the matter.
The matter was the President of APhA, arrived to defend the organization dear to his heart, even going so far as to post his personal contact information online for all to see. It was no Christmas morning for him though, unless you could count scathing and sarcastic comments and even insults as gifts. The theme stuck around for awhile, with every r/pharmacy thread about working conditions and related issues eventually resulting in someone tagging u/bradtice to complain. A few users stood up for him and commended him on having the courage to face the masses and on initiating the kind of engagement that it will take to actually mend the rifts in our profession, but the greatest turning point for Dr. Tice came when a bigger "villain" appeared.
An excerpt of an email was shared which allegedly indicated that another leader within APhA sought to shut down such conversations with the raging masses on social media. Dr. Tice was soon appreciated much more for his willingness to engage and face head on the difficult discussions this profession needs to move forward, and even to save ourselves from irrelevance in the eyes of many.
I reached out to Dr. Tice in the midst of these occurrences and asked if he would be willing to further engage with myself and my site members by answering some questions and attempting to frame some bridges back up in the smoldering ruins of what once connected the world of community pharmacists with APhA. I told him I could ensure that our dialogue would be civil and constructive, but that I would not shy away from asking the hard questions that we as community pharmacists have for APhA and addressing the resentment that many of us feel towards their perceived inaction.
Here is the beginning of our interaction (split into several installments due to length - this section will address introducing Dr. Tice and his background and then segue into pharmacy working conditions):
PA:
Dr. Tice, how did you get involved in APhA? What led to you taking on the role of president?
BT: I got involved in APhA as a student pharmacist, attending my first APhA Annual Meeting in 1992. I have attended every APhA Annual Meeting except one since then. I was a student chapter president and national Member-at-Large on the APhA-ASP Executive Committee. I have continued my involvement ever since and have also been a member of several state and other national associations along the way. I have found value through meeting other pharmacists, collaborating, making friends, and seeing and working towards advances in the profession. In fact, it was through APhA that I met my pharmacist wife, Angela. I have grown through the APhA Academy of Pharmacy Practice and Management (APhA-APPM) and served an important role in the development of policy impacting the profession and Association, serving as Speaker of the APhA House of Delegates and Trustee-at-Large. I decided to run for president to continue to help advance the profession and help pharmacists take advantage of new opportunities within the evolving health care system.
I see our role and responsibility as pharmacists as being caretakers of the profession and working with patients of optimize their medication use. I also have a vested interest in the success of the profession as my daughter is entering her first year of pharmacy school.
If I may, I’d like to share that my colleague-elected volunteer leaders and association staff are all equally motivated to elevate the pharmacy profession for the benefit of our patients and ourselves. APhA is blessed with thousands of volunteers and many who are willing to serve in elected leadership roles. I was fortunate to be elected and I have great respect for all who are willing to participate in the election process.
At the end of the day, all of these people are pharmacists, passionately working to make the profession better. We do not take lightly the frustration pharmacists feel and have expressed to us. Heck, I am frustrated too with what is happening. We are all looking for solutions and working to get them implemented. The cynical comments we hear and read are honest expressions. People’s frustrations are real, passionate, and justified. We encourage your readers to focus their frustration into energy and get engaged with APhA and other professional organizations. They can be much more influential by working collectively.
PA:
Could you give us a bit of background on your career in pharmacy up to this point?
BT: I started my career in chain community practice with Osco Drug. My goal and mission since graduation was highly shaped by doing a summer internship with the COSTEP program (Commissioned Officer Student Training Externship Program) with the U.S. Public Health Service. Because of this, and my training at the University of Kansas, I have always been focused on pharmacists delivering "pharmaceutical care" and getting pharmacists paid for delivering services to improve people's outcomes with medications.
After a few years in chain pharmacy practice I took a position at Drake University in what was called a "shared faculty" position, where 75% of my position was funded by Osco Drug to work with those pharmacies to test and implement clinical services. I was there for 8 years and during that time developed an interest in entrepreneurship. I started my first company, RxInterventions, using Palm Pilots in the early 2000s to document pharmacist services and capture the value of pharmacists' services. I was then recruited to a start-up in Nashville, PharmMD, as medication therapy management (MTM) was getting started in 2006 with Medicare Part D. During that time, I completed an MBA at the Vanderbilt Owen School of Management. I left there in 2012 and was at Humana a brief time before joining Cardinal Health as the product leader for MTM. I was there for 5 years. During that time, the work I did led to their acquisition of OutcomesMTM, and I was also able to work in their technology innovation center called Fuse.
I left there in September 2018 and joined Aspen RxHealth, a new business model where pharmacists can get paid directly for delivering clinical services, similar to Uber. Along the way, going back to my time at Vanderbilt, I also started RxGenomix to develop a business model for pharmacists to advance the benefits of pharmacogenomics in patient care and get paid for consultations using that science. Throughout all my career experiences my focus has been to gain pharmacist recognition and compensation for their patient care service provision.
PA:
Can you clear up any confusion about your role within APhA and your compensation for your duties?
BT: The positions that are held in associations are volunteer, elected, or appointed leadership positions. Expenses associated with attending meetings are generally paid by the association. APhA’s presidential officers (president-elect, president, and immediate past president) each receive a stipend of $10,000 before taxes to help cover additional expenses that are not compensated. My position takes me away from home for about 50 days per year. I would estimate in most weeks of my presidential year I spend 20-60% of my time on APhA matters.
PA:
To cut to the chase, a large number of pharmacists practicing in the community setting have expressed a great deal of derision and resentment towards APhA for its failure to prevent the situation we see today. These complaints are centered around several topics. I'd like to get your input and feedback about each of them and what your view of these issues is from your vantage point as APhA President.
First, let's talk about the number one complaint of most pharmacists I've heard from: working conditions. I've already shared with you several accounts of unfair treatment of pharmacists and technicians upon your request, and I'm sure you're already aware of the typical complaints- exceptionally long hours with no breaks, undue stress due to corporate pressure and metrics, physical injury, illness, and pain from these workplace conditions, continuous interruptions, lack of physical security in the pharmacy etc. How do you see APhA working to change these conditions?
BT: Workplace conditions have been an issue the entire time of my career. The first panel I was on as a student at a national meeting was in 1994 and its focus was on workplace issues. I have witnessed pharmacists voicing opposing thoughts on how to address the issues over the years. I have been involved with many discussions, debates, and APhA House of Delegates policies over the last 25 plus years. There have also been various actions, testimony, and outreach activities conducted by APhA and others using these policies over the years. Improving pharmacist well-being is among APhA’s top goals in its strategic plan. Seeing shifting environments within health care and society, the Association has facilitated programs, information, research, and resources that its members can use to address changing work environments and health system changes. We are seeking the engagement of all pharmacists and receiving input on what a professional association could reasonably do.
APhA’s direction is guided by policy developed within its House of Delegates, the only democratic body that comprises the entire array of practitioners across the profession to debate and adopt formal positions. Many years ago, APhA and its House recognized the shifts in product reimbursement and the health care system’s increased focus on outcomes. The delegates in the House knew we had to be a part of the profession’s transformation to providing patient care services and that we had to help pharmacists obtain recognition as valued members of the health care team, while still maintaining pharmacists’ oversight of the medication distribution and use system. We have not given up on making this a viable reality, although we recognize progress is painfully slow. We work daily in the federal, state, and private sectors seeking necessary changes. As I and other leaders in the profession have said, we cannot do it alone. We need the support and engagement of ALL pharmacists in this fight. We need your membership, your voice, and your stories!
I am telling the story in my advocacy work about a need to focus on the safety of patients. Patient safety is put at risk when we make decisions motivated solely by payment policies and investor return on the delivery of patient care. I ask that you join me in these efforts. The recent activities by APhA around well-being are meant to shine a light on the problems and facilitate action. Yes, I have heard that these problems have been there for years and nothing has changed. What has changed are the economics and the politics in health care. As a former APhA president was known to say, “Even when it is not about the money, it’s about the money!” We must impress upon policy makers the patient safety impact of their economic policies more than ever before.
APhA is a professional association representing individuals, not a trade organization representing the commercial interests of pharmacy owners. However, we recognize the importance of maintaining open dialogue and collaboration on common interests. And we do express the concerns of our members at all levels. I know we’re heard, but effecting change has been difficult despite our efforts. Our focus has, and will continue to be, on the pharmacist and their value to patient outcomes and safety.
We heard pharmacists’ concerns regarding the need for meal breaks because of patient safety concerns and advocated for its adoption. The recent recommendations from the consensus conference, which included meal breaks, provided additional attention to this issue. We are gaining traction because this is a patient safety concern, and some companies have begun to institute meal breaks. If you haven’t reviewed the recommendations from the national consensus conference focused on the well-being and resilience of the pharmacist workforce, please take a few minutes to review them www.pharmacist.com/wbrecs. APhA will do its part to address as many of them as we can, but no one organization can undertake all of them. It’s going to take all of us.
I believe one of the root causes of the workplace conditions is the erosion of reimbursement on the product. This has been grown much worse very quickly over the last several years because of what has been done with DIR fees. We are attacking PBM clawbacks and other misguided policies because it is not good for our patients, the safe provision of patient care, and the viability of the profession—no matter what practice setting you are in. DIR fees have closed pharmacies and threaten to cause the closure of thousands more. This term “DIR” (see https://www.cms.gov/newsroom/fact-sheets/medicare-part-d-direct-and-indirect-remuneration-dir) is a term actually used in a CMS regulation intended to create transparency and to capture the benefit to patients of rebates paid by pharmaceutical companies to PBMs for driving market share. The term has been hijacked by PBMs largely in the name of quality and imposed on pharmacies. Retroactive or even point-of-sale imposition of these fees often drives reimbursement to pharmacies below their cost. We’ve heard recently that many employee community pharmacists may be unaware of these fees or the impact on profitability and even viability of their employer.
We are all for accountability for quality. But we must only be responsible for quality we can control. Today’s use of data on adherence that compares one pharmacy against another is a statistically invalid use of those data. While we embrace the notion that we should be accountable for quality, we must be given the tools and resources to have an impact on that desired quality metric. So APhA is very focused on eliminating these egregious fees that prevent pharmacists from providing care. In doing so, we collaborate closely with many other pharmacy advocacy organizations. While community pharmacy has taken the greatest hit from these reimbursement policies, there is no area of pharmacy practice that is immune from its impact. It is time for all individuals and organizations within the profession who are concerned about the viability of our profession and the patients we serve to engage, tell the story, and use your influence.
We continue to drive for recognition of the value of pharmacists’ services, but unless pharmacies can keep their doors open and stay properly staffed, the provision of needed services will continue to be a challenge. We are fearful of the emergence of health care deserts where no health care is available as pharmacies close. With the vast array of issues impacting our profession and limited human and financial resources, our professional organizations in recent years attempted to better coordinate efforts. To do so, we led efforts to promote pharmacists’ services as a solution, with NCPA and NACDS taking the lead at the national level on product reimbursement issues because they represent the pharmacy business side of practice.
Over the last two congresses, we’ve made provider status our lead issue by leading a coalition of more than 40 aligned organizations, believing we needed to create a different path for the profession’s revenue and patient care model. Clearly, pharmacy associations have been working well together in tandem to address the many issues of the profession. APhA also works closely with NASPA and the state associations across all these issues, recognizing that health care delivery is local and successes at the state level ultimately rise to the federal level.
As I mentioned at the top, APhA has been “on” workplace issues for many years. However, I would say APhA refocused on workplace issues as there were pharmacists literally in tears in the 2018 APhA House of Delegates because of their work conditions. That led to four significant steps most recently: APhA’s statement on well-being and resiliency, released by the Board of Trustees last November. Meetings held one-on-one between APhA CEO Tom Menighan and chain pharmacy business leaders and others seeking to raise awareness, open dialogue, and seek solutions. The partnership with the Well-Being Index, invented by the Mayo Clinic and adapted for pharmacists, that creates a validated instrument and objective measures of pharmacist well-being. Individuals can track their own state and compare it to other health practitioners, and the aggregate results will be communicated to stakeholders and used to demonstrate the state of pharmacist well-being and to tell the profession’s story. Access it at https://www.mywellbeingindex.org/signup using invitation code APhA. You do not need to be a member and it is 100% anonymous. Most recently and significantly, the Consensus Conference on Pharmacist Well-being and Resilience in late July of this year with the initial summary report found at https://www.pharmacist.com/enhancing-well-being-and-resilience-among-pharmacist-workforce-national-consensus-conference. These recommendations have been issued for the entire profession of pharmacy—individuals and organizations—to review, identify, and take steps to address. APhA cannot and should not be expected to do it all, but we are committed to do our part. We should also take note that this is not just a pharmacist or pharmacy problem. It seems we pharmacists are not alone, as every health care practitioner is experiencing similar issues. The National Academy of Medicine has focused its attention on this issue for all health care professionals through its Clinician Well-being Action Collaborative, of which APhA is a member. APhA is the profession’s organization and needs your active engagement and support if it is to effectively be your ally!
As a note from PA to my readers: PLEASE, help with providing constructive feedback and represent our community well. Dr. Tice spent a great deal of time to provide us with these answers to questions I curated from site member feedback. If you take issue with his answers, please say so in a respectfully dissenting manner. Dr. Tice's contact information is listed at the bottom of each installment and he is listening to your feedback. I would love to see the conversation continue in the blog comments below each installment.
Interview continues in:
Part 2: oversaturation, regulatory capture, PBM/DIR abuse, and the practices and number of pharmacy schools, resident pay
Part 3: lack of professional mobility between types of practice, board certification, age discrimination, calling out companies for abusive practices, traditional pharmacists and technicians
Part 4: CEO compensation, provider status, "too little too late", Dr. Tice's blogging and social media involvement, and Dr. Tice's new opportunity, Aspen RxHealth
Part 5: The Cynical Pharmacist came to play! Read about compensation for services, corporate abuse of scope of practice, polling and scientific studies on the state of the profession.
Footnote from Dr. Tice:
"Thank you for the opportunity and taking the time to read the responses. If there is something missing, that you do not like, or even better yet, that you do like and what to get more engaged, please feel free to reach out to me directly at bptice@gmail.com or text me at 615-574-9638."