In a big-box world, the role of pharmacists seems increasingly humble. Camped out at the back of chain drugstores, counting out pills and providing occasional advice on which over-the-counter cold medication to take, they often seem more like clerks than health-care professionals.
That's the case in Ontario, at least, which has lagged behind other provinces in allowing pharmacists to make good use of their training.
But now Dalton McGuinty's government is positioned to leap to the front of the pack in transforming the profession.
Not only has it empowered pharmacists to perform certain services traditionally restricted to doctors - such as giving vaccinations and prescribing some medications - but it has the chance to provide a groundbreaking incentive to take on those tasks, turning pharmacies into health-care hubs.
Before Christmas, the Ontario legislature unanimously passed Bill 179, which permits pharmacists (along with nurses and nurse practitioners) to perform services normally limited to doctors - services they have already begun to provide in other provinces, including British Columbia, Quebec, Alberta and New Brunswick.
But Ontario's opportunity goes beyond that. While other provinces have encouraged new services in a piecemeal fashion, the province with the size and buying power to set Canada's pace on pharmaceutical policy could create a new model of funding that significantly changes what it means to be a pharmacist.
The impetus is a brewing battle over costs, with the government trying to shift away from an opaque system in which pharmacies make most of their profits through rebates paid by generic drug manufacturers in return for stocking their products.
In 2006-07, Ontario tried to ban the rebates, which drive up the price of prescriptions. Instead, it settled for rebranding them as "professional allowances," and restricting them to 20 per cent on drugs purchased by the province's public plan. (The rebates had previously been in the neighbourhood of 50 per cent.) But it failed to impose the same restrictions on drugs purchased by private plans and cash-paying customers, so the pharmacies simply demanded bigger rebates on those prescriptions - leaving the stores' profit model more or less intact.
In a new round of negotiations, the Ontario government now seems more determined to do away with the "allowances" altogether. If it succeeds, it will need to provide pharmacies with a new way of making money.
Partly, it will do so by raising dispensing fees. But mostly, it wants to replace the pharmacies' lost income by paying them for new services - creating the first system in the country in which those services are central to pharmacies' business model.
Shifting toward that model could provide the government with some moderate savings, because it would reduce the reliance on doctors to carry out relatively simple tasks. Doctors, unsurprisingly, are highly skeptical of the encroachment onto their turf, as evidenced by a public-relations campaign aimed at emphasizing their unique qualifications to deliver health care.
Both government officials and pharmacists' representatives, though, contend that greater interaction between pharmacists and customers would improve patient outcomes. The challenge for both sides will be to arrive at a funding model in which pharmacists are encouraged to actively take an interest in ensuring prescriptions are being taken properly, rather than just trying to fill them as quickly as possible.
One example - already adopted in Quebec, Saskatchewan and B.C. - is to pay pharmacists not only for filling prescriptions, but also for not filling them in cases where they believe it's unsafe to do so.
The idea is that non-dispensing fees encourage pharmacists to notice problems such as patients taking two medications that shouldn't be mixed, or going through their prescriptions too quickly. They also have a better chance of spotting outright drug abuse, of particular concern in communities under siege by OxyContin.
As promising as all this sounds in theory, overhauling the way a province's pharmacists are paid is a complex process that takes years to get right, and requires goodwill on both sides. And because Ontario's deficit-plagued government is clearly hoping to reduce its overall costs along the way, that goodwill may be lacking.
Pharmacists' Ontario representatives say that members of the profession, especially younger ones, are already trying to engage in more "face-to-face" time with their patients. And they say schools are attempting to turn out graduates prepared to adopt a more active health-care role.
