Drugstores poised to become true health-care hubs

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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.

Industry insiders single out the University of Waterloo, which recently opened Canada's first new pharmacy school in two decades, for being on the cutting edge. The country's first co-op pharmacy program is geared toward giving students more practical experience in patient care. Like some other schools, it's preparing them for an expanded role - including the possibility of prescribing some drugs - by teaching patient assessment.

But if pharmacists are willing to change their role, it doesn't necessarily follow that their employers will be as eager. The current system is working pretty well for the large chains that increasingly control the market; as the government is fond of pointing out, the number of pharmacies has gone up even during tough economic times. Unless pharmacies are convinced that every dollar of savings will be spent paying for new services - which probably won't be the case - they'll be highly resistant to changing the status quo.

The pharmacies' case will be that losing money from the rebates will drive them out of business, leaving some communities without access to medications. The government seems prepared to fight back with a divide-and-conquer strategy. Sources say that, much like Alberta's, it will offer higher dispensing fees for rural and small-town pharmacies. That won't thrill the major drugstore chains, which will suffer at their urban locations, but it will neutralize their best argument.

The government will try to convince the industry that it's in its own interests to adapt, or else somehow strong-arm it into doing so. Otherwise, Ontario pharmacies will remain hooked on a system that's only driving up costs.

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BEHIND THE SCENES

• Public plans in the big provinces - Ontario, Quebec and British Columbia - buy generic drugs for about 50 per cent of the brand price. Alberta now pays the lowest, at about 45 per cent. Ontario hopes to go even lower than that. (The percentage is higher in some smaller provinces.) Generic costs in Canada are higher than in other countries, including the United States, because of rebates paid by manufacturers to pharmacies in return for stocking their products. The competition is not to sell medications at the lowest possible price, but to offer pharmacies the biggest rebate, thus raising the price to consumers. Between 40 per cent and 60 per cent of the total amount paid by consumers goes toward those rebates.
• Public drug plans account for 48 per cent of prescription expenditures in Canada. The rest is spent by private plans and cash-paying customers.
• In Ontario, private plans and cash-paying customers now pay much higher prices than the public plans, because the rebates on their purchases are unregulated. Unregulated rebates are often as high as 80 per cent of the drug's price. Quebec is the only province to regulate both public and private rebates, capping both at 20 per cent.
• Canada has 8,214 licensed community pharmacies (ones not located in hospitals).
• Canada has 31,284 licensed pharmacists, and 22,000 of them work in community pharmacies. About 80 per cent of that 22,000 work in chain drug stores, which fill about 80 per cent of prescriptions.
• The Shoppers Drug Mart quarterly report for the 40 weeks ending Oct. 4, 2009, shows that prescription drug sales accounted for 49 per cent of revenues, while the rest of sales ("front store") accounted for 51 per cent.
• Generic drugs are used to fill 52 per cent of prescriptions - a number that may rise in the coming years, as several major drugs (including Lipitor, the anti-cholesterol drug) come off patent.
• Ontario has 2.88 pharmacies for every 10,000 people, compared to 1.46 for every 10,000 in the U.S.
• British Columbia and Quebec have largely taken the lead on changing the role of pharmacists, with Alberta and Ontario catching up. Among the ways they are doing so:
• Non-dispensing fees: Pharmacists are paid for refusing to fill prescriptions that they believe are not in the patient's interest.
• Robo-pharmacists: Provinces are beginning to place "remote dispensing machines" in far-flung communities, allowing pharmacists to approve prescriptions without actually being there.
• Prescribing: Provinces are clearing the way for pharmacists to prescribe drugs to treat minor ailments, and to adjust doctors' prescriptions where they feel it is appropriate.
• Counselling: Pharmacists are increasingly being encouraged to advise customers on how to take their medications properly, and to provide guidance on conditions such as high blood pressure.