In this fifth and final installment of Dr. Tice's responses, you will find: discussion of compensation for services, corporate abuse of scope of practice, polling and scientific studies on the state of the profession.
On to the questions from another powerful voice out there in the world of pharmacy social media, The Cynical Pharmacist, who has been advocating for changes to the profession for years. I asked them to contribute a few questions, and they really wanted to get some input on the finer points of "Provider Status". Let's go!
1) Once pharmacists finally achieve Provider Status, what are you doing to ensure we are paid as healthcare professionals?
BT: We have definitely learned lessons on that throughout my career, the first one going back to just before I entered the profession with the passage of OBRA ‘90. The lesson there was that the profession got the requirement for “patient counseling” passed but then did not follow up to see that pharmacists were paid for it. With MTM we got the legislation passed and got compensation established, but it has still not materialized fully how we would have liked.
With provider status, payment will not happen overnight. There are a lot of lessons being learned in those states where provider status has been passed. APhA established Pharmacy Profiles to create a mechanism for pharmacists to document their authenticated credentials. This does not require extra training or residencies, but rather provides a mechanism for payers to know the pharmacist they are paying has a valid, active license and is in good standing. Should there be payer requirements must be met in order to be reimbursed as a provider, we’ve now got authenticated documentation for pharmacists that should accelerate the approval process.
a. In states that use Protocol Doctors for immunizations, pharmacies pay those prescribers. As we would be able to write our own prescriptions, are you working to ensure we will receive the compensation that went to these providers since we will now be writing those prescriptions?
BT: APhA’s focus is getting pharmacists recognized and compensated for the provision of quality patient care services. The assessment, ordering, administering, and documentation of immunizations are part of the immunization standards and pharmacists should be compensated, like any other provider, for providing those services. When pharmacists are able to authorize these types of services on their own, oversight such as this would likely not be necessary.
b. I have had an NPI for nearly 15 years, since I first trained as an APhA immunizer, yet I have never been able to use it to bill for services rendered. Along with writing prescriptions for immunizations, will I be able to bill for other “professional services” I provide?
-Administration fees of vaccines ($20.00 per shot) are paid to the employer and not to the immunizing pharmacist. How will you ensure we recover that since we are the ones actually providing the shot?
-MTMs are required by many employers. The consulting fee is again paid to the employer and not to the professional providing these services. How will you ensure that changes in our favor?
-Some chains mandate offsite flu clinics but do not reimburse the pharmacist for either her time or the administration fees for shots. How are you going to make sure we are treated and paid as professionals in these situations?
BT: APhA has developed and provided programs and resources to help pharmacists participate in various practice models and has worked with the AMA, CMS, and other entities to establish or identify codes or processes (e.g., incident-to billing) pharmacists could use to bill for their services. Individually, and collectively, APhA advocates for the adoption and utilization of these processes by payers. Who the payment goes to, just as in medicine and other health professions, is a discussion among individual practitioners and their employers. We have provided practice approaches in APhA’s publications that individuals can use as they navigate potential opportunities and our Special Interest Groups (SIGs) provide an opportunity for networking with individuals attempting to do similar things.
2) How will you ensure that the retail pharmacies do not take our new provider status and use it to enforce another metric for us to meet? Immunizations were originally provided as a service and now they are a metric. How will you ensure that pharmacists are not required to write “X” number of prescriptions per day? That would be akin to having prescribers do the same.
BT: Metrics are not uncommon across health care and the use of metrics seems to be the direction the health care system is going as we move to value-based payment models. Pharmacist peers working in community chain and independent practice discussed this at the Enhancing the Well-being and Resilience of the Pharmacist Workforce National Consensus Conference. They agreed that all businesses are going to use some sort of metric or measure to track their business performance. The concern is, “Are the metrics appropriate, reasonable, and transparent?” Consensus recommendations related to metrics include:
- Employers should promote professional autonomy, seek pharmacy team input, and encourage open communication to effectively establish and meet patient care and business objectives (e.g., quotas/metrics/goals) and achieve shared success.
- Professional associations and schools and colleges of pharmacy should conduct research to establish national standards related to pharmacy metrics that promote patient safety and pharmacist well-being.
This is also where I believe it is important to get more pharmacists in corporate management positions so that there are better considerations for patient care implications when these metrics are put in place.
3) When was the last time you actually polled the entire profession and not just your paid members? I believe there is a disconnect between your organization and the pharmacy world you purport to represent. For as long as I have run my blog, I have found the pulse of the profession to be in a completely different body than the one you seem to be taking.
- When will we see studies about the risks of overworking pharmacists? How will you remedy these risks?
- When will we see studies about the risks of understaffing pharmacies? How and when will you remedy this?
- When will we see states remove chain pharmacy representatives from their Boards of Pharmacy? (They do not represent our interests or the citizens of their states.)
- When will we see studies about distractions in the pharmacy?
- When will we see a fight to close the pharmacy off from the public (due not only to risk of robberies, but to constant patient and customer interruptions)? Can you imagine a doctor’s office with an open-concept floor plan and people walking in on a visit to ask “where is the bathroom”?
- When will we see guaranteed breaks (as in mandatory closing times for the pharmacy) for the entire staff, especially the pharmacists?
- After all of this, when will we see working conditions improve as the chains, and retail in general, are held accountable for their risky behavior?
BT: APhA represents all pharmacists, whether or not they are members, but it requires pharmacists being involved. I specifically reached out into social media to get to the voices we have not been engaging with directly. If a voice needs to be heard louder, that voice needs to engage and make these things happen. We are all pharmacists equally engaged in protecting and advancing the profession. These suggestions for further studies are valid, but at the same time, I do not think most pharmacists would agree with you on all of them. Many pharmacists see value in being accessible to patients and not being closed off like other health care professionals. It certainly comes with its risks, distractions, and pitfalls, but many consider it a strength of the profession as well.
What is preventing you, or anyone in practice, from doing these studies in your work environment now? I would bet that you could easily reach out to someone at a pharmacy school and they would be interested in helping you design a study, even one that could be done anonymously, to quantify these issues and get them published to increase awareness. There is a section within the Academy of Pharmaceutical Science and Research made up of pharmacists and faculty in academia devoted to this type of research. APhA provides a mechanism to connect to these people, have a dialogue, and recommend studies. You could even do the studies together or guide them in the direction of what needs to be studied. In doing a quick search, there are some examples of these types of studies readily available. There have also been chain pharmacies that have incorporated meal breaks, and one national chain is starting to mandate those nationally right now.
As far as when was the last time APhA polled non-members, APhA has done significant outreach to non-members over the last 2 to 4 years to establish the new membership model. APhA has also partnered with the Mayo Clinic and just launched the Well-Being Index for Pharmacists that is available to all pharmacists. The goal of the index is to create a way to monitor pharmacist well-being and communicate it to others. It also provides resources, such as a hotline, for those who are identified as “in need.” The index is also used by physicians and nurses and pharmacists’ results will be compared to other health care professionals.
4) Personally I believe we should employ an Independent Contractor Model. In this scenario we are employed to perform our normal duties by “The Company”. Anything that we wish to do above and beyond these duties will be paid to us using our NPI as an Independent Contractor, (e.g. prescriptions written as a provider, immunizations administered as a provider, MTMs consulted, etc.) This works for pharmacists who wish to do more or, in many cases, less than their colleagues. What are your thoughts on this arrangement and could it work with your support?
BT: A part of what APhA provides to members is access to new business models and opportunities. There are many pharmacists implementing new services—like chronic care management services that are paid for by CMS—and setting up partnerships with physician practices that are similar to independent contractor relationships. APhA provides resources for how to get started providing services and establishing partnerships like these and access to other pharmacist members who are doing this to help break down the barriers.
As an example, as I stated on some of my posts and in my responses to Pharmacist Anonymous, I currently work for Aspen RxHealth. This is an independent contractor model for pharmacists, like Uber for drivers, where pharmacists can get signed up to deliver services and get paid directly. Pharmacists can work as much or as little as they like. This is just launching in Florida. We will be expanding beyond Florida in 2020 and will be expanding the types of services pharmacists can get paid for as well. Another example is RxGenomix, a company I started where we pay pharmacists as independent contractors to perform pharmacist consultations on pharmacogenomics results and enable pharmacists to create business practices for themselves.
I can see these models growing, but at the same time, what will be the unintended consequences? Currently, for example, meal breaks are being mandated by a major chain where the pharmacy will be shut down from 1:00–1:30 pm during the day. Will the pharmacist disengage from work and take the break, or will they use the time to get caught up on prescriptions? Pharmacists have also complained about these breaks because now they must be “at work” an additional 30 minutes, so where an 8-hour shift was something like 8:00 am–4:00 pm, now the shift is 8:00 am–4:30 pm. Some of these issues are employee–employer relationships that are also affected by federal and state labor laws and not in the control of APhA. More specifically to the independent contractor question and example, what are the unintended consequences here? I could see lower starting wages for pharmacists if they are not salaried and a point where pharmacists have to “build their practice” like many other health care professionals. What will be the reaction to that when just after graduation a pharmacist has lower wages and more difficulty paying back student loans while they are “at risk” to earn more based on their productivity? When working as an employee and getting a guaranteed salary and employer-offered health coverage, the pharmacist would be expected to perform the functions of the job for what they agreed to work for.
Do other health care professional employees, like nurses, physician assistants, nurse practitioners, or even physicians get paid more based on what they bill? I would say in some cases yes, and in many, where they receive a flat salary, they do not. I could certainly see incentives and bonuses being built in for performance, but then you have the issue of metrics and people being motivated for the wrong reasons. Regardless, there needs to be an environment conducive to appropriate patient care. We have all heard how physician visit time has been compressed and how they have metrics in place for how many patients they need to see a day. These numbers also seem to be getting more challenging. I think across the board, health care practitioners need to gain back more control of their work environments. This case is made well in the recent book by Ewe Reinhardt called Priced Out.
As a final 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 1: background, introduction, pharmacy working conditions
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, and Dr. Tice's new opportunity, Aspen RxHealth
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 firstname.lastname@example.org or text me at 615-574-9638."