April 2015, Vol 3, No 4 - Inside Pharmacy

In a recent interview with Inside Patient Care: Pharmacy & Clinics, Michael Feehan, PhD, Visiting Professor, and Mark A. Munger, PharmD, FCCP, Professor, Department of Pharmacotherapy, College of Pharmacy, University of Utah, discussed the increasing focus on providing primary healthcare services in retail pharmacies, and how this evolution can be informed by novel, large-scale research, with consumers, pharmacists, and reimbursement decision makers.

What is the premise of your research?

Mark A. Munger [MM]: Our research effort, the Optimal Pharmacy Services Research Program, is a collaboration with myself and Dr Feehan, a former clinical psychologist, public health researcher, and global marketing science consultant in the pharmaceutical industry. I am a pharmacist, clinical researcher, and educator in the University of Utah’s PharmD program.

During the past couple of years, we have conducted surveys on major trends potentially impacting the pharmacy profession, including documenting the significant occupational stress experienced by many community pharmacists—particularly those with PharmD degrees1—and the growing trend for physicians to bypass pharmacies to a large degree and directly dispense medications, which is something that holds appeal for some members of the community.2

Our previous research highlighted challenges in the workflow of community pharmacists who often express a desire to provide more direct patient care, but who are challenged by time-crunch imperatives. These include filling prescriptions and more administrative matters such as patients’ insurance. This research is not static; it has occurred against a backdrop of significant change in the breadth of services offered in retail pharmacies, and as pharmacists increasingly acknowledge the profound role they can play in improving the public’s health by essentially becoming healthcare delivery companies.

In these times of budgetary constraint for research at the federal level, we were very fortunate to receive a significant grant from the philanthropic Skaggs Foundation for Research, and Skaggs Institute for Research to conduct a research program this year that has the potential to inform decision-making by both retail pharmacies and healthcare systems as they develop new healthcare service offerings. We will build a model that will hold the greatest appeal for consumers, with services that pharmacists will be willing to provide, and reimbursement decision makers will be likely to reimburse. By designing services that meet the needs of all 3 constituencies, these services could have the greatest frequency of use by consumers, the likelihood to improve their health outcomes, and the likelihood to improve the occupational satisfaction of pharmacists.

How are pharmacies transforming to become healthcare delivery companies?

Michael Feehan [MF]: When disruptive change occurs in any industry, it is often driven by commercial interests: when a company identifies a potential, new product service offering that can differentiate its brand from competitors in the minds of consumers; provide a “first-mover” advantage; and generate increased revenue.

In traditional healthcare delivery models, decisions about what services to offer, by whom to whom, and under what conditions can very often be driven by the provider clinicians’ and organizations’ perceptions of what consumers need, what services they are willing to provide, and by those involved in reimbursement for services as to what they may cover. We are seeing new initiatives in delivery models in the retail setting appearing at an increasing pace.

For example, Walmart opened health clinics in some of its stores where employees can receive basic acute care and wellness checks for a nominal sum. As an employer of approximately 1.3 million Americans, the financial benefits to the company and potential health improvements for its employees could be dramatic. As we have seen recently, CVS Health, formerly known as CVS Caremark, removed all tobacco products from its stores, and is offering walk-in services at their MinuteClinic, which are staffed by nurse practitioners and physician assistants, without appointments.

Industry-driven initiatives like these have the potential to be at odds with the increased societal focus on consumers making better-informed choices about their own healthcare. Whatever people’s perceptions are of the Affordable Care Act, we should acknowledge its core principle, which “puts consumers back in charge of their [healthcare]. Under the law, a new ‘Patient’s Bill of Rights’ gives the American people the stability and flexibility they need to make informed choices about their health,” according to the US Department of Health & Human Services.3

Of course, a choice where the options available to consumers are set by the organizing providers, with minimal consumer input, is no choice at all. Companies, such as Walmart and CVS Health, have undoubtedly conducted proprietary market research to inform their decisions to become healthcare delivery companies. However, as public health researchers, we would like to see some of the decisions about primary care services that could be offered in the retail setting be informed by broader, nonproprietary science—listening directly to the voices of consumers—with a quantifiable understanding of what the worth or value of each service is to those individuals who will be increasingly making their own choices about what health services they want to receive, from whom, and where.

What changes in retail pharmacies and clinics would impact the consumer most?

MM: As we think about the breadth of services that is currently available—or could be available—in retail pharmacies and clinics, we need to tease out a host of factors that could impact consumers’ demands: Where should services be located? When should they be available? Who are the preferred providers or team composition offering those services—nurse practitioners versus pharmacists, for example? Across a continuum of care, what assessment and diagnostic services should be offered? What treatments should be provided? Other questions that arise pertain to counseling and educational services, follow-up and monitoring services, as well as payment methods for these services.

If we can provide the best answers to all those questions, and design services accordingly, we should see strong consumer use of those services, with measurable improvements in health, and reductions in follow-up healthcare costs, including less frequent hospital admissions.

MF: You may recall the episode of The Simpsons where Homer Simpson designed his dream car with multiple features, and only after it was made into a prototype did the manufacturer realize its exorbitant cost: “D’oh!” To design and promote a car, the manufacturer must make trade-offs: Is the incremental cost of adding 6 more cup holders worth it?

If we ask consumers what they want from, any health-related services, without some form of trade-off, they will tell you it has to be efficacious, safe, and as cheap as possible. They will also tell you what they want based on their attitudes and beliefs and, in some cases, may tell you what they think you want to hear. These issues also apply to pharmacists when we ask them what services they would want, or are willing, to provide. In research interviews, healthcare providers can be prone to social desirability—giving the ostensibly “right” answer—when responding to questions about their professional lives. For example, they may say, “I would certainly want to provide care on weekends to patients who need it,” but in practice, not want to work extended hours, or if they did, find it stressful and have it impact their job satisfaction.

MM: In our research, we get around Homer’s car design issue by not directly asking people what they want, but rather by getting them to make trade-off decisions when choosing healthcare services.

We will survey approximately 10,000 consumers and 300 pharmacists across the country, along with a sizable group of reimbursement decision makers, and pre­sent experimental scenarios where people choose their preferred pharmacy or clinic, and make a trade-off decision. Consumers will be shown a series of scenarios describing 2 pharmacies, and be asked which they would prefer to use. Pharmacists will be asked which of these 2 settings they would prefer to work in. Reimbursement decision makers will be asked to indicate which setting would be more likely to have its services reimbursed.

Behind the scenes, these scenarios will consist of a host of service attributes that are systematically varied.

We will then model the drivers of the choices people make, and illustrate how much each is worth to the consumer and pharmacist. For example, hypothetically we could find that “consumers may strongly desire the ability to receive examinations after hours for minor injuries, and don’t have any preference whether this should be provided by a physician’s assistant, a nurse practitioner, or a qualified pharmacist.”

Although we obviously have some hypotheses that consumers will value certain services—as evidenced by the public’s use of the Walmart and CVS Health consumer-health programs—it will be exciting to see what this large group of nationally representative consumers actually value and will use.

MF: Importantly, our large sample will allow us to explore variations of what the optimal service packages might be in African American or Hispanic populations, or how services might differ for pharmacies and clinics serving urban populations versus rural communities.

How do you think the model for retail pharmacies and clinics will evolve in the next 5 to 10 years?

MM: This is an exciting time to explore changes in healthcare delivery models, especially with increased consumer choice, easily accessible Internet-based information to inform those choices, and retail pharmacies and clinics redefining themselves as healthcare providers.

We see our research contributing to the discussion about what may be considered optimal service options. Hopefully, this may get us a little ahead of the curve of what is unquestionably a groundswell of support for bringing primary healthcare closer to the locations where people engage in common activities that support their health and the health of those they care for.

Consider the following case of an elderly woman with limited mobility who waits 3 weeks for an appointment to see her physician. She asks her daughter to take time off from work to drive her there, and gets a hard copy of a prescription that she has to physically take to a pharmacy. She has to wait for her pharmacist to fill said prescription—a pharmacist who has no time to speak with her about the medication she is picking up, since the pharmacist hasn’t even had time to take a break during the day.1 She realizes the medication has to be taken with food only after the fact, and then has to be taken to the local market to purchase her groceries. If we were designing a healthcare model, would we really design a system like the one described in this case? Probably not.

MF: There is an inherent logic in an alternate model, where the same woman, as she purchases her groceries for the week at her local market, can see a nurse practitioner for a walk-in examination, get a diagnosis of her condition, and have a prescription filled then and there. In this scenario, the pharmacist in the care team has his or her workflow organized so that he or she is free to explain the medication comprehensively and to give advice ensuring adherence for refills, which the pharmacy can then monitor as the woman returns to that location each week for her basic needs.

However, any organizational change can meet resistance because practitioners can be wedded to their belief systems that have been reinforced by their professional training and occupational practice and experiences. To facilitate change, it is very helpful to have data that are incontrovertible. If we can demonstrate that certain service designs hold greater utility for consumers, that healthcare providers such as pharmacists are willing to provide them, and that they are sustainable through likely reimbursement, then there is little risk in making systemic change.

It is our hope that the research we are conducting will stimulate evidence-based pilot interventions to be implemented across a range of pharmacy and clinic settings in partnership with local healthcare systems, and that they be thoroughly evaluated to see what gains in public health can be made.

Do you have any concluding remarks?

MF: We can learn a lot from movies. In Field of Dreams, Burt Lancaster’s character, Dr Archibald “Moonlight” Graham, said, “We just don’t recognize life’s most significant moments while they’re happening. Back then I thought, ‘Well, there’ll be other days.’ I didn’t realize that that was the only day.”

A transformation in the “retailization” of healthcare is a significant moment that is already happening. By conducting strong research we hope to be able to proactively shape that transformation, because 5 to 10 years from now it will have occurred, and there may not “be other days” on which to design these services optimally to maximize their utility and better improve people’s lives.




References

  1. Munger MA, Gordon E, Hartman J, et al. Community pharmacists’ occupational satisfaction and stress: a profession in jeopardy? J Am Pharm Assoc. 2013;53:282-296.
  2. Munger MA, Ruble JH, Nelson SD, et al. National evaluation of prescriber drug dispensing. Pharmacotherapy. 2014;34:1012-1021.
  3. US Department of Health & Human Services. About the law. www.hhs.gov/healthcare/rights/. Updated November 14, 2014. Accessed April 17, 2015.
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Last modified: May 15, 2015
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