Personalized Medicine and The Pharmacist

Pharmacists have no place in a dispensary. Period.

History of the Profession:

In the past, pharmacists were masters of their domain, they would prepare compounds from scratch, double check their own work, and frequently owned their own businesses.  Like many other industries however, in recent decades the profession has changed.  As new diseases are discovered,  old diseases are better understood, the number of drugs available to treat these have steadily increased.  With this increased understanding, and increased availability of drugs, the number of individuals with regular or recurring prescription drugs has drastically increased.  This has demanded increases in efficiency and scale of dispensaries in communities.  This is not uncommon, the streamlining of professions like pharmacy is akin to the implementation of machines in factories to increase productivity.  It only stands to reason then, that as the sheer volume of prescriptions that are written increases, the community pharmacy industry will find ways to improve efficiencies.

What Pharmacists do (Currently):

As it currently stands, community pharmacists have 3 main roles in pharmacy. The first is assessing the appropriateness of therapy for an individual, this cognitive work is unique to our profession, and because of our specialization in training, we are, bar none, the most proficient profession at doing this. Secondly, is counselling the patient on the medication, this is also a unique skill that only pharmacists can perform, as we receive more training and education on doing this than any other profession. Thirdly, is we physically check prescriptions, ensuring that from point of entry, to point of sale, the drug that was prescribed is in the correct bottle, and goes to the correct patient.  This portion of our job can be done by anyone who can read a doctor’s writing, and who has enough visual acuity to compare tablets in a stock bottle to those in the dispensed bottle.  Pharmacists are no better trained to do this than any technician.  Depending on the pharmacy, the third role of pharmacists can easily take up the majority of the pharmacists time, with the time dedicated to assessing therapy and counselling being severely limited.  Consider the following: the vast majority of community pharmacies are owned by large corporations, with the minority being privately owned stores.  The current business model for community pharmacies is based on the volume of prescriptions dispensed, and not the quality of care.  Additionally, most of these large companies are publicly traded companies, which forces huge emphasis on them to cut costs and maximize profits wherever possible.

The problem:

Community pharmacy in general is trending towards a business model wherein they can accomplish selling the most number of prescriptions, at the least cost to themselves.  As I already stated, the third role of the pharmacist (technical role) occupies the majority of the pharmacists time in most community pharmacies; and this role is easily replaceable.  What we have already begun to see is the training of technicians who will perform the coveted task of “final check” on prescriptions.  Simply put, this job is to ensure that correct product is in the correct bottle for the correct patient.  Herein lays the problem.  Large corporations have the right idea.  There is no reason that pharmacists should be performing this role; we are no more proficient checking prescriptions than a technician, and yet we hold monopoly on it, and expect 2x-5x the salary for it.  Who can blame these large companies for lobbying to have this power relinquished by pharmacists? From a business standpoint, they can eliminate more than 50% of the pharmacist’s workload in the community pharmacy, by replacing them by equally capable, and much cheaper, technicians.

The flaw of current practice model:

So what does this mean for pharmacists?  It means that the fundamental model of community practice is going to change.  The problem is that pharmacists exist in a bizarre loophole of how they are financially renumerated.  The vast majority of pharmacists in community are in one of two situations. They either work for a pharmacy (private or corporate) or own their own pharmacy.  Either situation is faced with the same dilemma.  On one hand, the pharmacy in which a pharmacist may work is reimbursed by the volume of prescriptions sold, which are paid for by the government via pharmacare.  On the other hand, the pharmacists themselves are paid salary by the pharmacy they work for.  Therefore, for pharmacists to protest against the implementation of registered technicians, they are going against their employers best interests.

What this results in is two bodies lobbying the college of pharmacists for conflicting changes to the territory of physically checking prescriptions.  The pharmacists want to protect their monopoly in this area, and the companies who own the pharmacies want to employ skilled technicians to do it for cheaper. The result is a profession which is at war with itself.  When pharmacists are involved in selling prescriptions, they are inescapably stuck in a tug-of-war between good business vs good healthcare.

What is the solution?

Get pharmacists out of the dispensary.

As I already stated, the majority of the pharmacists work currently is performing the “final check” on prescriptions.  Pharmacist should not be doing this for 3 main reasons:

1) Technicians can do the exact same job for cheaper (like it or not).

2) Being responsible for the “final check” ties pharmacists inexorably to the current business model which requires high volume of prescription sales. This generates the conflict of interest between pharmacists and the employers.

3) This is not what they are trained for, and is an inefficient use of pharmacists as a resource.  In current practice the two roles we are actually trained for: Therapy assessment and Counselling, are SECONDARY to checking prescriptions.  Pharmacists are the experts at counselling, and therapy assessment, NOT physically checking prescriptions.  Perhaps more importantly however, is the fact that because of current business models, these important skills  of pharmacists are woefully underutilized.  Were pharmacists able to provide adequate therapy assessment and counselling to every patient, the adherence to medications, quality of life, and savings to healthcare system would be extraordinary.

How do we accomplish this?

It is a simple as passing legislation which mandates that “before any prescription can be filled, it must be signed by both a physician (prescriber) AND pharmacist (assessed proper therapy)”.  One such model of this would place the pharmacist in the medical clinic, right across the hall from the physician.  For instance:  A patient comes in, sees the physician, gets diagnosed with a strep throat, the doctor writes a prescription for antibiotics, and the patient leaves, walks across the hall to the pharmacist. The pharmacists takes the prescription, assesses the appropriateness of it, evaluates the patients other medications, and then counsels the patient on the antibiotics right then and there.  After counselling, the pharmacist signs off on the prescription, which the patient can take to any dispensary, and have filled. At this point the prescription has been assessed for appropriateness and the patient has been counselled.  The patient goes to a pharmacy, and the technicians which work there count the correct number of tablets from the correct bottle, perform a final check, and dispense it to the correct patient.

With this model, pharmacists are now able to perform the job they are trained to do, and because they are situated in the same geographic location as the prescribing physician, they are much more apt to communicate as a team, resulting in better healthcare.

There are many different possible models of payment for pharmacists with this model.

• The first options is that pharmacists could have a billing account like physicians do, and be renumerated different amounts depending on task which they performed.  Assessing new therapy can be billed at X, whereas doing an entire medication review could be billed at Y… etc..
• Alternatively, the pharmacist could be paid a salary, much like nurses and other staff in a medical clinic are.  For instance, the physician has a billing number which he bills for all patients that he sees.  Out of the money he is renumerated, he pays the wages of any associated staff at the clinic.  Pharmacists could be paid in the same manner that nurses at the clinic would be; hourly or monthly etc.  This may require adjustments to the amounts that physicians can bill for, but these are small details in the grand scheme of things.

The net result is that the government will be paying pharmacist’s wages instead of community pharmacies.  This removes any conflict of interest between pharmacists providing thorough care to patients, and the rush to sell as many prescriptions as possible.
How would we finance this?

Easy. 

Change the dispensing fee on prescriptions from $10 per prescription, to $1.  Dispensaries are no longer providing the cognitive services that used to be fulfilled by pharmacists, so this professional fee no longer applies.  This makes dispensaries much more like any business which sells goods, where the profit is due to mark-up on the drug costs.

This means that all the money that the government would have paid for dispensing fees, is now available to fund pharmacists.  The same amount of money that the government had set aside for cognitive service before will now be available to pay pharmacists! The only difference is that now, without the burden of the technical work they previously were buried under…. pharmacists will be able to provide much more time, and much better care to each and every patient.

A functional model of practice for pharmacists:

What would happen:

1. Pharmacists move out of dispensaries.
2. Legislation passed requiring prescriptions to be signed off by both a Physician and Pharmacist before getting filled at a dispensary.
3. Pharmacies (dispensaries) no longer need pharmacists, and only employ technicians.
4. The professional fee on each dispensed prescription is drastically reduced, and the money is reallocated to paying pharmacists directly (in their medical clinic setting).

Who this is good for:

1. The patient.  Pharmacists will have SUBSTANTIALLY more time to counsel patients, develop a therapeutic relationship, and assess their current therapy completely, on a much more regular basis. Results in better medication adherence, decreased risk of complications from diseases, and improved quality of life.
2. The taxpayers/government.  The amount of money available to pay pharmacists after cutting the amount of professional fee currently reimbursed will pay for pharmacists salaries, so the net cost is the same.  In addition, by providing much better care, the pharmacists will be able to reduce the number of hospital admissions every year, and prevent many medication related complications with any patient’s health, resulting in substantial savings.
3. The community pharmacies.  These businesses will no longer have to employ pharmacists.  They can save substantial amounts of money by employing completely capable technicians to do the entire technical role of dispensing a prescription.  Whether or not these savings are balanced with the loss of revenue due to not receiving dispensing fees however, remains to be seen.

In summary:

As a pharmacy student, I am in an impossible situation.  I am less than halfway through training for a profession which is in very dire straights.  If it doesn’t extricate itself from its current entanglement with business, it will die.  This will be a huge loss to the healthcare system, patients, and the pharmacists.  Currently, many practicing pharmacists are either too complacent, or too busy trying to stay afloat with the onslaught of prescription volume they see at work, to address this overarching problem.  As a student, I hardly have the time to think of solutions for our profession’s problem.  However, the frightening reality is; that unless we make these changes, and soon, the profession might very well go down a path from which there is no return.

Jordan S, Pavan M, Erik M, Jonathan C, Justin T, Jieun K,  Maggie C

Personalized medicine is a type of medical model that utilizes an individuals genetic information to either predict disease susceptibility and/or optimize drug therapy. This process involves patients undergoing genetic sequencing and analysis. Analysis would compare the patients genetic code to known indicators of disease, by pin pointing specific genes that cause disease, or recognizing a series of multiple gene interactions to determine the prognosis. Information from the statistical data would indicate predisposition to certain diseases. Personalized medicine has the potential to completely change how several health care professionals approach diagnostics and treatment.Traditionally people are treated in a reactive manner (signs and symptoms lead them to seek medical care), but by having an understanding of which disease states one is predisposed to, proactive health measures can be undertaken. Patients are more likely be receptive to preventative measures after receiving  genetic diagnosis, knowing that they have the ability to increase their chances of a positive outcome vs. a potential of life long drug therapy or debilitation. Furthermore, personalized medicine has to ability to decrease the emotion burden that comes with a diagnosis that a patient has limited or no control over. It is important to consider patient compliance with taking an initiative and getting their genome sequenced. Misconceptions about confidentiality and discrimination would have to be addressed, and a cost consideration and potential for subsidization.  Patient compliance is a concern because patients may have mixed feelings about knowing their prognosis, especially for unpreventable diseases that appear later in life. The opportunity of targeted drug therapy is a further benefit of personalized medicine, as adverse drug reactions and toxicity would be preventable. Gene-centered research could also contribute to speed up the development of new therapeutic agents, this would be particularly useful in diseases such as cancer, or diabetes  in which the patients own cells could be used and modified to become reactivated or targeted towards fighting disease.

Since current health care is a collaborative effort, there is a definite role for a pharmacist in personalized medicine. Physicians can alter their focus to preventing disease, and pharmacists can work towards decreasing adverse drug reactions and making drug therapy more patient specific. The unique and specialized knowledge of drug therapy that a pharmacist has leaves pharmacists in the perfect position to implement personalized medicine into their practice. In an ideal situation, pharmacists would have access to a patients genetic information in the pharmacy so they could refer to it when checking the safety and efficacy of a new medication. However, it is unlikely that such widespread application of this technology will be available any time soon. In the more foreseeable future, we imagine pharmacists implementing personalized medicine in a hospital environment. Pharmacists would be trained to interpret genetic data and they could then apply their knowledge of a drugs pharmacokinetic properties to determine the ideal drug or ideal dose of a drug for a specific patient. We can see this being an efficient process, especially if the pharmacist and physician can work collaboratively in the initial prescribing of medication. This would reduce the amount of trial and error prescribing, and reduce the number of serious adverse drug reactions that are seen in certain populations. As one of the most accessible health care professionals that interact with a large number of patients a day, pharmacists are in a perfect position to promote personalized medicine to the public. They have the ability to educate patients and encourage them to support the idea of genetic testing to improve patient health outcomes.

Alesha Cvenkel, Shaylee Peterson, Charissa So, Emily Wharton, Sharon Liang, Kenji Nakajima and Kenji Kashiwagi

     To the general public, pharmacy practice may seem to centre primarily on dispensing medications with minimal patient interaction; a profession that hides behind the little white counter more than arms reach away – impersonal. However this is grossly untrue, reflecting only a small portion of the pharmacists’ role.

     Whilst some aspects of the traditional roles of pharmacists are being transposed to licensed pharmacy technicians, pharmacists are now able to focus more on patient drug counseling and medication management.

     Pharmacists are in a unique position precariously situated between public duty and private enterprise. In evaluating the fundamental components of the pharmacy profession… Pharmacist compensation is a major weakness; an inconsistent component of our public healthcare model. Unlike physicians who are paid per patient visit, pharmacists are currently paid per prescription. This means that pharmacists are not appropriately compensated for time, knowledge and expertise spent on quality patient counseling on prescription, over-the-counter medications, health products and related concerns).

     Pharmacists are the gatekeepers to accessing medicines, the connection between various health professionals (include doctors, all prescribers) whereby issues surrounding proper medication use, safety and effectiveness are addressed. As drug specialists, pharmacists are unique in managing patient health alongside fellow healthcare professionals. Patients are encouraged to take an active role in their health management and pharmacists are in a key position to aid this dynamic relationship.

     As an easily accessible information source, pharmacists are often torn between providing quality patient care and compensation reflective of pharmacy practice.

     As the population ages, demands on pharmaceutical services will increase inevitably.  Without reflective pharmacist compensation, the current pharmacy business model will not be able to sustain quality patient care to the masses.

Written by Eileen Song, Margaret Chan
Group 9

The question for topic one was “What do you think personalized medicine is? Do you think pharmacists should be doing personalized medicine?”

Personalized medicine means to me, in a broad sense, that patients receive optimal medication therapy based on their own personal situations. So this is a move away from “trial and error medicine” with first, second etc line therapies that get adjusted and changed based on a patient’s bad experiences (side effects, lack of compliance, whatever the issue may be) or lack of drug effect. Use of personalized medicine looks at a patient as a whole, incorporating a patient’s previous medications, current medications, other disease states, and finally their genetic profile into the decision making on what the best, safest and most effective drug therapy is for the individual.

Optimally, in a perfect world, I absolutely think pharmacists should be doing personalized medicine. We are the “drug experts”, and should thus be using current and previous knowledge and skills to the best of our abilities to make interdisciplinary decisions WITH the patient on the best therapy to fit them. However, with the status quo in pharmacy, personalized medicine is a difficult entity to get the ball rolling on. To start with, there are a lot of unknowns surrounding genetics still. The sequencing of the human genome was only done recently, and although there has been promise in certain drugs and their dosing, such as codeine, warfarin and anti-cancer drugs, there might still be more to learn about these genetic polymorphisms and their consequences. Secondly, your average pharmacist does not have extensive knowledge of genetics. Although there is a course on pharmacogenomics here at UBC, there is bound to be additional information needed for pharmacists to assist in making the optimal choices for patient care, and pharmacists who graduated pre-human genome sequences likely did not get exposure to this kind of education. At the current moment, I don’t know of any additional training available for pharmacists to, for example, do a residency or clinical rotation in pharmacogenomic research. And finally, pharmacists are in a difficult situation with respect to pay scale and business models. At the current moment, most pharmacists (at least those outside of the hospital setting, as they are paid by government funds) are paid a salary by private sector corporations which own the pharmacies. These corporations are, as any other business, looking to make money. Money in a pharmacy comes from scripts filled, dispensing fees, and kickbacks from pharmaceutical (generic drug) companies. Without adequate financial support for expansion into additional fields such as pharmacogenomics, it will be difficult to get the ball rolling on this one as nobody wants to work for free and corporations, unless they see the value of this kind of service, are unlikely to pay the extra wages for specialized pharmacists if they are not bringing in money for the services. In a hospital setting, I think this kind of personalized medicine service has more promise. Warfarin therapy, in the small sliver of practice I have seen, is very labour intensive with frequent lab tests, frequent changes in dose, and can be dangerous to the patient resulting in ineffective therapy or dangerous bleeding consequences. If something such as this was introduced prior to a patient beginning warfarin therapy, I wonder if it would save on pharmacist and physician time and take some of the “guesswork” out of warfarin dosing.

Well that’s my thoughts on personalized medicine…anyone else want to weigh in?

Melissa Twaites

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