In this second installment of Dr. Tice's responses, you will find: oversaturation, regulatory capture, PBM/DIR abuse, and questions about the practices of pharmacy schools.
PA:
Secondly, it's not too hard to connect these working conditions to over saturation of the job market for pharmacists. Many pharmacists feel that APhA should have been doing more to control the number of pharmacists entering the job market. What can you tell us about this issue?
BT: One could argue that decreased staffing resources (pharmacist and tech hours) is more a function of plummeting reimbursement than an oversupply of pharmacists. However, we do not mean to diminish the concern we hear about too many schools or too many pharmacists. In addition to the growth in number of schools, we’ve also seen expanded enrollment in legacy schools. And importantly, we’ve seen a generation of more seasoned pharmacists delay retirement longer than in the past.
As one of its three founding organizations, APhA works closely with ACPE and the other founders AACP and NABP. Not a month passes without interaction. ACPE’s board representatives meet with the APhA board at least annually, usually in January. This “supply” issue has been discussed over several years. ACPE is simply not in position to limit the number of schools—it would be deemed an uncompetitive trade practice—as long as those schools meet appropriate accreditation standards.
ACPE is the national organization recognized by the U.S. Department of Education and is governed by the Council for Higher Education Accreditation, which sets standards on how ACPE must function. Lucinda Maine, executive director of AACP, published an excellent summary of the situation in the American Journal of Pharmaceutical Education (https://www.ajpe.org/doi/full/10.5688/ajpe7593). As she wrote, it is a complicated market-based situation with multiple factors (including those noted above) contributing to the current situation. The market is already starting to adjust; there are fewer applicants and schools are reducing class sizes. More pharmacists are retiring. And the growth in numbers of new schools has slowed.
At the same time, we must create more opportunities for pharmacists and we must secure payment for clinical services, thus paving the way for new roles. For example, there is currently a significant shortage of primary care physicians and a need for improvement in how medications are used. Interprofessional practice is today, not the future. For several years now, pharmacists have trained alongside nurses and physicians in team-based care. This is the model this generation of health care professionals expects for their future.
Regardless of the “platform” (community pharmacy, long-term care, health system, specialty, and others) pharmacists will increasingly play essential roles on health care teams.
There is no stronger team in health care than a team that includes a pharmacist, working with physicians and others, diagnosing and treating medical conditions. The evidence is growing! There have been many articles and keynote speeches at meetings lauding this. For example, Aaron Carroll, a physician at Johns Hopkins, published an op-ed in the New York Times in January, called The Unsung Role of the Pharmacist. He also spoke at the Pharmacy Quality Alliance annual meeting in May. He said, “The evidence is there, people just need to utilize it.” The Harvard Business Review published an article in their January-February issue called How Pharmacists Can Ensure Patients Take Their Medicines. At the AACP annual meeting in July, two physicians (Andrew Morris-Singer, MD, and Kari Mader, MD) also spoke of how they will never practice without a pharmacist again. We are also seeing much greater understanding of pharmacists’ value in Congress. Most recently, the National Academy of Medicine’s (NAM) Clinician Well-being Action Collaborative released a case study that showed the benefit of a pharmacist on the team. APhA is a Network Organization member in NAM’s Action Collaborative. You can read a short summary of the study at https://nam.edu/clinicianwellbeing/case-study/virginia-mason-kirkland-medical-center/.
The increased public attention is the result of a lot of hard work and investment of time and money across the profession, especially the fly-ins and congressional visits with APhA, NCPA, NACDS, and others, and the combined effort on provider status.
PA:
Many of my followers are pharmacists and technicians who work for chain pharmacies, but some are still in the independent world or work for smaller chains that are disproportionately affected by the travesty that is DIR fee abuse, unfair reimbursement practices, borderline illegal (or at the very least unethical) steering of patients, and numerous other anticompetitive abuses committed by PBMs and/or their affiliated pharmacies. These practices lead to job loss, pharmacy closures, the formation of "pharmacy deserts", and still more leverage on the part of the chains to treat their employees as badly as they want. What input do you have here?
BT: APhA’s House of Delegates passed the following policy in 2018: APhA opposes retroactive direct and indirect remuneration (DIR) fees and supports initiatives to prohibit such fees on pharmacies. So you might say, “What good is a policy statement?” First, having the statement on the books is a reference point for future policy. APhA references its House of Delegates policy when it gets a request on an issue. This happens almost daily. Also, after policy is passed at the Annual Meeting in March of each year, the APhA staff and board determine what action needs to be taken to address each policy issue. This occurs following the Annual Meeting and is finalized at the June Board of Trustees meeting each year.
APhA and many others at the state and national levels in pharmacy practice and business are working to put a stop to these fees. We’re also opposing similar fees under different names. This is a huge battle. We need everyone involved. Thanks to our advocacy and that of our colleague organizations, we’ve gotten the attention of the U.S. Senate. If you have not spoken to your legislators or patients or contributed financially to help address this, now is the time. We need a revolution of pharmacist grassroots efforts. Unless we can reverse the downward spiral of reimbursement to pharmacies, employers will continue to feel pressured to cut staff to keep doors open.
Pharmacists need to understand the power they have and act on it. Pharmacists in practice see legislators’ constituents every day and multiple times a year. If you use your voice and those of your patients, we can make an impact. Simply tell legislators that you are watching how they vote and you are sharing with their constituents that the reason drug prices are high and wait times at the pharmacy are long is because people in the middle (i.e., PBMs and manufacturers) are taking upwards of 30–40% of the fees they are paying while the actual providers of care are getting paid less and less.
PA:
Another common complaint I hear from pharmacists is that of the concept of "regulatory capture"...the idea that appropriate regulation is not being achieved in the world of pharmacy due to the occupation of state boards of pharmacy by chain pharmacy executives who use their positions of authority to prevent any actions detrimental to their companies from moving forward and actively resist measures that would protect consumers from corporate greed. What solutions would APhA offer to such a deep-rooted problem?
BT: It would help to have specific examples here. I know that perception exists, but I think we need to quantify it better to truly understand it. It is fair to point out that many members of state pharmacy boards are chain executives. However, at the consensus conference this summer this was specifically discussed and the pharmacist from a chain pharmacy’s leadership with state board experience adamantly stated that he believes he gets no special favors. The cynics might say, “Of course he would say that.” This is where the one-on-one conversations are key. If you are one of those people, consider attending meetings and having real conversations with real people. Or even consider sending a letter to the board and if you feel you need to do so anonymously, do so.
State boards of pharmacy exist to protect the public, and they take that role seriously. Most state board meetings are public and open. There’s no reason any pharmacist wishing to know more couldn’t just attend a few meetings to see for him/herself.
I have provided my e-mail and if anyone wants to e-mail me directly, even anonymously, I would be glad to look into it and see if it is an issue we need to address. I would also say if you think it is an issue, bring it up with the state board, or your state legislators who ultimately oversee the functioning of regulatory boards in your state.
PA:
As you've said before, the ACPE, not APhA, controls the accreditation of new and existing schools of pharmacy. However, many pharmacists have expressed deep concern over the quality and rigor of the education level of many newly graduated pharmacists. They are rightfully concerned not only for oversaturation of the profession, but also for the potential impact on patient safety and the public perception of our profession if these new practitioners do not live up to the high standards of competence set by pharmacists of past generations, when pharmacy school was exceedingly competitive and rigorous course of study. What input do you have on this issue?
BT: As I mentioned earlier, APhA is one of three founding organizations of ACPE, and our appointees represent the perspective of practitioners. Each ACPE board member has a responsibility to ACPE—not to the organization appointing them—and is expected to guide ACPE in accordance with the U.S. Department of Education and other accreditation oversight entities.
I encourage practitioners who are concerned with the quality and preparation of graduates to communicate those concerns to ACPE. I can tell you APhA’s board raises concerns we have heard when it meets with ACPE leadership. We have also commented on draft accreditation standards and guidelines to preparing students and practitioners for patient care and practice needs. There is also an ACPE complaint process so individuals can submit concerns regarding an accredited education institution. If you have a concern about an institution and its implementation of the standards, I encourage you to visit www.acpe-accredit.org/complaints.
PA:
An additional concern about many of these schools is that they may be financially abusing students - by admitting students with little chance of success and then charging them outrageous tuition, allowing struggling students to repeat numerous expensive courses, and finally graduating classes of pharmacists with sub-60% pass rates on a minimal competency licensure exam, and leaving said students with insurmountable student debt loads. What is APhA's position on this? And while we are at it, could you also tell us why APhA lobbied AGAINST pay increases and overtime protections for pharmacy residents?
BT: APhA submitted comments to the U.S. Department of Labor in 2016. While indicating our support for modernizing compensation and benefit levels, we expressed concern regarding the impact and implementation timeframe of the rule on residency programs. We called for equity with physician residents in the way pharmacy residents are viewed, including funding from CMS. Without additional funding, increasing costs to the programs could jeopardize current and future residency programs. APhA did not lobby against pay increases and overtime protections but highlighted the need for equity with other residency programs and funding for residency programs to protect against reductions in residency positions.
Interview continues in:
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."
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.