Future in Motion - Neighbourhood Pharmacy Association of Canada
Transcription
Future in Motion - Neighbourhood Pharmacy Association of Canada
2011 report Future in Motion Community pharmacy building an expanded role in healthcare delivery CONTENTS 4 Cover Story While the road ahead is long, community pharmacy has made considerable strides toward fully utilizing the skills of pharmacists 13 New Partnerships A commitment to collaboration has come to guide some negotiations between government and pharmacy. Here’s a closer look at British Columbia Visit www.cacds.com for information on the Canadian Association of Chain Drug Stores: • How to become a member • The position of CACDS on important issues • Upcoming events • Latest products and services 18 Provincial Snapshot An at-a-glance summary of government-funded pharmacy services 21 The CACDS 2011 Report was published in October 2011 by Drugstore Canada, a Rogers Healthcare Group publication. Drugstore Canada, ISSN 1199-2131, established 2008, is published 10 times a year, by Rogers Publishing Limited (www.rogerspublishing.ca) a division of Rogers Media, Inc, One Mount Pleasant Road, Toronto, Ontario M4Y 2Y5. Tel: 416-764-2000, Fax 416-764-3931. Montreal Office: 1200 avenue McGill College, Bureau 800, Montreal, Quebec, H3B 4G7. Telephone: (514) 845-5141. Contents copyright © 2011 by Rogers Publishing Limited; may not be reprinted without permission. Rogers Publishing does not assume liability for content. Our environmental policy is available at: rogerspublishing.ca/environment. President, Rogers Publishing Limited Kenneth Whyte Vice-President, Rogers Publishing Limited Patrick Renard Executive Publisher, Healthcare Group Janet Smith Publisher Jackie Quemby Managing Editor Karen Welds Writers Sonya Felix, Karen Welds Art Director Lima Kim Production Manager Ajay Masih Cover Art: Adriana3d (istockphoto) Technology Tools Introducing MirixaPro CanadaTM, a web-based clinical-decision support tool for pharmacy services. Plus: an update on the Electronic Health Record 25 Time for Change An expert in behavioural change maps out the steps for successful change management 26 Moving Forward Pharmacy associations, regulators, faculties and head offices are mobilizing their resources to support an evolving profession 30 Q&A with the Chair CACDS Chair Sandra Aylward reflects on how pharmacists and their associations are critical agents for change 2011 CACDS REPORT 3 In Higher Gear Expanded scopes of practice and new public funding lay down the mechanics for better patient care; now it’s up to community pharmacy to set the wheels in motion by Karen Welds 4 CACDS REPORT 2011 www.cacds.com V irtually every provincial government in Canada now pays pharmacies for at least one service outside of dispensing. Depending on the province, pharmacy is being reimbursed for injections, medication reviews, prescription adaptations or pharmaceutical opinions. And more funded services are on the way, including programs for smoking cessation in more provinces, the assessment of minor ailments and support for chronic disease management. Just five short years ago, this type of government funding seemed a distant dream. And while the road ahead is still long, the destination—a healthcare system that fully utilizes pharmacists’ skills and training as drug therapy experts—is finally in sight. “It’s a recognition by health policy makers that they’ve had a woefully underutilized resource in pharmacists at the community level,” says Nadine Saby, President and CEO of the Canadian Association of Chain Drug Stores (CACDS). “We need to build on the foundation that’s been laid, with private as well as public payers, by embracing these programs and demonstrating the value of pharmacists’ services.” The journey began almost a decade ago, when the provinces’ health ministers set down the far-reaching objectives of the 2003 First Ministers’ Accord on Health Care Renewal. The demands of an aging population, the growing incidence of chronic disease, spiraling costs and provider shortages had led to a crossroads in the delivery of healthcare. Since then, the road to renewal has produced new technologies, expanded scopes of practice, new classes of regulated health professionals and funding reforms (for a summary of expanded scopes of practice and funding for professional services, see page 18; for an update on the electronic health record, see page 23). “What’s most important is access,” says Michael Nashat, CACDS Board Member and Vice-President, Pharmacy, Prince Theodore Group. “The current system had positioned the doctor as the main solution, but there are not enough doctors, aging patients have greater needs and medications have become more complicated. Pharmacists and other providers simply needed to have expanded scope.” “The healthcare system requires pharmacy to evolve,” agrees Steve Wilton, Vice-President, Pharmacy Affairs, at CACDS. “It is contingent on pharmacy owners and pharmacists to take advantage of the government-funded programs. It won’t be easy because there are unresolved issues, but you can’t be fearful about moving into an area where you might not have all the answers. Sometimes you can’t have all the answers. We have to take action and course-correct as we move forward.” CACDS, the Canadian Pharmacists Association (CPhA) and provincial pharmacy associations are offering tools and training to help pharmacists through the transition, as are regulatory www.cacds.com bodies and faculties of education (for more on change management, see pages 25 and 26). At the same time, it’s imperative that pharmacists guide patients toward a better understanding of how their changing role can directly improve health. “Pharmacists are always at the top of the list for trusted professionals, but we need to educate the public on exactly what pharmacists can do and are doing for them,” says Rita Winn, CACDS Board Member and General Manager and COO, Lovell Drugs Limited. “Pharmacists can no longer afford to be the most trusted professionals. We need to be recognized as the most valued front line healthcare professionals,” states Peter Zawadzki, Board Member of CPhA, member of the CACDS Policy Development Committee, and Professional Affairs Executive, Pharmasave Drugs (National) Ltd. “Pharmacists need to overcome what I refer to as ‘humble pharmacists syndrome’. Value starts with letting patients know Pharmacists can no longer afford to be the most trusted professionals; we need to be recognized as the most valued front line healthcare professionals exactly what you do, each and every time. Pharmacists research and resolve serious drug-related issues every day, but don’t often tell their patients what they’ve done. On the other hand, doctors and nurses consistently communicate the impact of their services to their patients and in the media. The more direct we are about the value we provide, the more patients and payers will recognize the value we bring to the healthcare system.” Canadian Pharmacy Services Framework An important road map for pharmacists, associations and governments alike is the Canadian Pharmacy Services Framework. Drafted in 2010 by practicing pharmacists and representatives for CACDS and CPhA, the Framework was created to support increased availability of pharmacy services. It promotes common terms and definitions of services across jurisdictions, describes labour requirements, work flows and estimated time needed to deliver the services, and helps to facilitate funding models for them. 2011 CACDS REPORT 5 A boost for the profession New Brunswick pharmacy finds ready market for vaccinations The Framework has already proven valuable during negotiations in B.C., Saskatchewan and Nova Scotia in the establishment of new defined pharmacy services and their funding. The Framework can be accessed on the CACDS website (www.cacds.com). “The Framework delivers standard definitions and terminology that pharmacy can use as the basis to promote expanded pharmacist services and to educate policy makers and payers about them,” says Zawadzki. “Our challenge in pharmacy is to keep unified. Sticking to a consistent message will allow pharmacists to be recognized and appropriately rewarded for the valuable services we provide.” The Framework is also “important for education and training because it enables economies of scale and efficiencies,” says Stacy Johnson, a member of the committee that drafted the document and Director of Pharmacy Professional Services, Canada Safeway. Provinces can share training and orientation tools, with minor adjustments to reflect the specifics of provincial legislation. “The Framework needs to be at the heart of standard operating procedures for all pharmacies,” summarizes Winn. “It will enable all levels of pharmacy to be clear and consistent, to prove our value to government and private payers.” Medication management Several provincial governments have latched on to medication reviews as a logical entry into paid pharmacist services. The governments of Nova Scotia, Ontario, Saskatchewan and B.C. currently fund medication review programs, and New Brunswick is analysing the results of a pilot project (see details on all provinces on page 18). “Governments realize that appropriate use of medication is a smart investment,” says Paul Foley, Director Private Health, Shoppers Drug Mart. “It has the potential to save the system significant money while improving outcomes—plus it’s a bit of a reinvestment back into pharmacy after significant funding reforms.” “Medication management is gaining momentum because we’re finding that patients aren’t managing their disease,” says Nashat of Prince Theodore Group. “Pharmacists have a role to play: they can ensure patient management, using clinical guidewww.cacds.com When New Brunswick pharmacists gained authority to administer injections in late 2008, Sharalyn Rigby, a pharmacist at Lawtons Pharmacy in Saint John, N.B., jumped at the opportunity. She completed the required training and is now one of two staff pharmacists at the store who regularly gives injections, most frequently for travel vaccines. “It’s a popular option for people who can’t get to their doctor,” she says, “and Sharalyn Rigby we are reimbursed $20 to administer the vaccine.” Although pharmacists can’t prescribe vaccines, Rigby does make recommendations about the types of injections travellers will need, depending on their destination. She also personally calls patients to remind them to come in for booster shots. “That’s particularly important for Twinrix because the third booster must be given six months after the first,” she says. “People often forget but if they don’t get the last booster, then the next time they travel they have to start over again.” Currently, Rigby uses the store office to administer injections and conduct medication reviews, but in November the store is relocating to a site with a dedicated counselling room. “It’s really exciting to have an expanding scope of practice that not only helps patients but is professionally rewarding for pharmacists, too,” Rigby says. “It gives us the opportunity to get out of the dispensary and to really get to know our patients.” lines. Ten years ago, guidelines were not nearly as advanced or comprehensive.” Sitting down with patients to focus their attention on their health in this way “initiates that first discussion that there is more to managing medications than just getting prescriptions filled. Government is starting to understand the scope of what’s possible,” adds Sandra Aylward, Chair of CACDS and Vice-President, Professional and Regulatory Affairs, Lawtons Drugs and Sobeys Pharmacy Group. Similar programs south of the border demonstrate an impressive return on investment. For example, North Carolina hired selected community pharmacists on contract and trained them to conduct ChecKmeds reviews with seniors enrolled in Medicare. The fee schedule includes follow-ups with physicians. After its first year in 2008, pharmacists had educated 15,000 seniors and savings were estimated at $10 million—or a return of roughly $14 for every dollar invested. 2011 CACDS REPORT 7 MedsCheck in Ontario Ontario’s MedsCheck is the most established medication review program in Canada, launched in April 2007. While the government has not released estimated savings, it has signalled its support of the program by expanding it in September 2010 to include specific services for diabetes education, home visits and long-term care residents. In September 2011, the government announced that MedsCheck programs for complex regimens, medication reconciliation, chronic disease management and home diagnostic training are under development. “The Ontario government supports the role of the pharmacist as part of an integrated team that provides an enhanced level of care to their patients,” says Diane McArthur, Assistant Deputy Minister and Executive Officer of Ontario Public Drug Programs. “The government’s MedsCheck program, now in its fifth year, continues to see an increase in the number of Ontarians receiving the medication review service. We are looking for opportunities to expand this service and continuing to increase the value of the MedsCheck program.” For their part, pharmacists and pharmacy head offices in Ontario are adjusting professional and business practices to take advantage of these funded services. The Ministry of Health and Long-Term Care reports paying pharmacies for 50,660 standard MedsCheck reviews and Follow-Ups in June 2011, compared to 36,239 in January, as well as almost 35,758 reviews at home, for diabetes or long-term care, up from 22,537 in January. community pharmacist. As ministries of health change the fee structure to support clinical interventions by pharmacists, the timing is perfect.” With that in mind, CPSI and ISMP have struck collaborative relationships with CACDS, CPhA and the Canadian Society of Hospital Pharmacists as part of a concerted effort to put paid medication reconciliation services on the agenda. Indeed, public funding has already begun: Saskatchewan began paying community pharmacists $25 for medication reconciliation services in May, and Ontario has indicated it will fund medication reconciliation services, possibly under its existing Making the time for medication reviews and other expanded services won’t be easy; pharmacists need to find a way to be very efficient at everything they have to do MedsCheck program. “Reconciliation should be bundled in with medication reviews, they operate on the same principle. There are obvious and immediate safety and utilization benefits,” says Sandra Aylward of Lawton’s. Medication reconciliation Change management Community pharmacists also have an integral role to play in medication reconciliation, an area gaining momentum with hospitals, regional health authorities and public payers. In Canada, studies show that 40 to 50 per cent of patients experience unintentional medication discrepancies or potential errors upon admission to hospitals, and 40 per cent experience discrepancies at discharge. Early this year the Canadian Patient Safety Institute (CPSI), in partnership with the Institute for Safe Medication Practices Canada (ISMP Canada) and Canada Health Infoway, hosted the first summit to strategize on the implementation of MedRec, a system-wide, national medication reconciliation initiative. “Canada is a leader in medication reconciliation,” says Marg Colquhoun, Project Leader at ISMP Canada. “We have tools and resources for acute, long-term and home-care institutions, and now we have a tremendous opportunity to bring in the Making the time for medication reviews and other expanded services is not easy. “You need to find a way to be very efficient at everything you have to do,” notes Winn of Lovell Drugs, which recently hired a pharmacist to specialize in providing at-home MedsCheck reviews. You also have to be realistic. “Change management is a huge process,” says Winn. “I use the analogy of getting fit: you are gung ho at the start, then you drop off. Then you pick it up again, manage for a bit longer, then drop off again. It takes time for something like this to become sustainable.” Financial sustainability is another matter. “It’s a catch 22—in order for government programs to become financially viable you need to do a certain volume, but you’re losing money to get there,” says Winn. “This is compounded by fact that we have to use it or lose it.” “Current funding for professional services may not be enough, but it’s definitely a start,” says Foley. Resource management is www.cacds.com 2011 CACDS REPORT 9 Filling the gaps This Toronto pharmacy draws upon available resources to meet patients’ needs key. “When you build in the cost of labour to deliver these services, the use of technology and regulated technicians becomes very important.” Whether you work in an independent pharmacy or a large head office, the most successful innovators in professional services will also be smart business people—or they’ll hire the business expertise they’ll need. Quantifying a new value As the revenue model for retail pharmacy expands beyond the delivery of product to the provision of service, the door opens to quantify a new value for the profession based on outcomes and savings to the healthcare system. Unfortunately, the mechanisms to do so are not yet in place. “The government is tracking pharmacists’ services, but not measuring their outcomes,” says Foley. “Many pharmacies and chains have taken it upon themselves to measure outcomes in some way, but we need government to do it also.” Until that happens, the priorities of CACDS and provincial pharmacy associations are to meet with governments to determine which pharmacy services promise the best value to payers and patients “in terms of quality, access, safety and cost-effectiveness. These are the filters we use to address return on investment,” says Aylward of Lawton’s and Sobeys Pharmacy, who was a member of the team that met with the Nova Scotia government over nine months in 2010 and 2011 to identify such services and how they should be reimbursed. “It was a very thorough, very good process,” says Aylward, “and the real benefit of it was the mandate was approved by the minister, and the resulting report was a joint one. We’ve laid the foundation of an ongoing partnership by meeting their policy objectives. Now we’ll build on that by measuring outcomes.” To help in delivering that measurement, CACDS has obtained exclusive Canadian rights to MirixaProTM, a web-based clinical-decision support platform that can report aggregate patient outcomes (for details, see page 21). Once that platform has been adapted to the Canadian market, it will be available to all pharmacies with a pricing structure based on a cost-recovery business model. When you arrive to open your pharmacy and find patients already waiting for a monthly diabetes screening clinic, it’s a humbling experience, says Akil Dhirani, pharmacist/owner of Village Square Guardian Pharmacy in Toronto, Ontario. “It shows how much need there is for such services and the important role community pharmacies can play in healthcare.” When Dhirani switched from hospital to community pharmacy a few years ago, he decided to focus on diabetes Akil Dhirani as a niche that would make use of his experience with clinical services and interprofessional collaboration. He works closely with doctors from the neighbouring health clinic and brings a nurse in to the pharmacy once a month to screen patients for blood sugar, cholesterol, blood pressure and general well-being. “It’s easy to combine this screening with a MedsCheck medication review,” he says, adding that he’s able to provide MedsChecks on a daily basis as patients request them. “The new payment for MedsCheck for Diabetes is welcome funding support when I sit down with patients.” As a member of Drug Trading, he has access to an annual fund to conduct clinics that are free to patients as well as relationships with suppliers who contribute educational material in various languages. He also manages his labour costs by hiring pharmacy interns from the University of Toronto’s program for international pharmacy graduates. “There is so much we can do to take a load off of physicians that would be good for taxpayers and patients,” he says. “I’m looking forward to taking on more.” “It is going to take time for the critical mass to emerge for these government-funded services,” says Saby of CACDS. “Fortunately, enablers such as MirixaPro CanadaTM and other technologies, practice legislation and technician regulation are falling into place. It is essential to maintain our course by embracing these enablers, doing the research and the training, transitioning our business model, and pursuing innovation. The evolution of pharmacy has begun.”■ Find the answer at www.mirixacanada.com Charting a course, together Leaders in government and pharmacy are lauding British Columbia’s Pharmacy Services Agreement as a big step in the right direction. Here’s how they did it. by Karen Welds W hen representatives for the British Columbia Pharmacy Association (BCPhA) and the British Columbia Ministry of Health sat down to negotiate in the fall of 2008, they agreed that much more than the dispensing fee had to be put on the table. They released an interim agreement in December to meet contractual obligations, and then, joined by the Canadian Association of Drug Stores (CACDS), they set upon the larger task of crafting what would become the Pharmacy Services Agreement (PSA). Announced in July 2010, the PSA maps out a three-year path to establish new funding for pharmacists’ services, while also meeting government’s mandate to control drug plan spending (for details, see page 18). It is the first agreement of its kind in Canada—and hopefully not the last. Bob Nakagawa, Assistant Deputy Minister of Pharmaceutical www.cacds.com Services at the Ministry of Health, describes the PSA as “a partnership. It has set the stage for a good, ongoing relationship between pharmacy and government.” Participants in the negotiation process outlined the following 10 key elements that laid the foundation for that partnership. 1. Build trust “Trust is absolutely the critical element,” says Marnie Mitchell, CEO of the BCPhA. “The question then is, how do you develop trust? Pharmacy has to be the initiator; we have to demonstrate that we are going to be a good partner.” In B.C., this began well away from the negotiating table, when BCPhA agreed to help distribute a consumer health guide in 2004. The government saw the value not only of using pharmacies as a distribution network, but also of enabling interaction between 2011 CACDS REPORT 13 consumers and pharmacists. “It was a good start, and both sides still reference it during discussions,” says Mitchell. “The goal is to help government achieve what they need and to realize a value for pharmacists and patients as well. When it comes down to the tough talks, you are on a much better footing.” “There can be many different ways to partner—all governments have the desire for that,” agrees Darcy Stann, Board Member of CACDS and Director of Regulatory Affairs, Canada Safeway. “It’s through such partnerships that you meet and develop relationships with the people who will eventually be on the other side of the table. The problem in the past and in other provinces is there were no personal relationships with that level of trust.” “Relationships aren’t built overnight, and they’re not built when you’re in conflict. You need to build the foundational pieces,” says Bob Nakagawa of the Ministry of Health, who has come to know Stann, Mitchell and other pharmacy leaders over the years. “There was a lot of credibility, trust and integrity at the negotiating table.” 2. Keep confidentiality Members of the negotiating committee—two government representatives, Mitchell, three BCPhA Board Members and three CACDS Board Members—maintained confidentiality until an agreement was reached. “That really opened up the dialogue and gave everyone a much more comfortable position,” says John Tse, one of the BCPhA Board Members and Vice-President of Pharmacy, London Drugs. Over the course of approximately 18 months, the committee gave general updates to the rest of the CACDS and BCPhA Boards, but no details. No information was passed on to association members, although regular communication did occur. The ability to maintain confidentiality without alienating those you represent is also a matter of trust. “Provincial pharmacy associations may need to work on that within their own internal cultures,” suggests Mitchell. “The Board has to trust the committee, and the membership needs to trust its association.” 3. Set terms of reference Before talks began, Mitchell developed a document that clearly stated “both parties’ positions and what can and cannot be discussed,” says Tse. “In the past, we would have loose terms of reference but nothing this specific.” “It established clarity from the outset so there would be no uncertainties or misinterpretations,” says Mitchell. Terms of reference also help establish consensus for pharmacy. “Before you initiate discussions with government, everyone has to be clear on what will be talked about and what won’t be talked about,” says Mark Dickson, one of the three CACDS representatives and National Director, Pharmacy, for Pharmasave Drugs. “It is also important to be upfront with government and detail what you are not going to talk about and why, to prevent misunderstanding.” www.cacds.com What is the significance of the Pharmacy Services Agreement? “For pharmacy in B.C. this is ground-breaking. We’ve never had such a comprehensive agreement, including money carved out to enable the community pharmacist to practice to a fuller scope. Government recognizes the value of the knowledge of the pharmacist.” Bob Nakagawa, Assistant Deputy Minister of Pharmaceutical Services, British Columbia Ministry of Health “The length of agreement gives pharmacy a defined period of time to transition to a new business model. We should congratulate government for making the statement that pharmacy needs to transition to a new business model and for putting out the funds to make that possible.” Darcy Stann, Board Member, Canadian Association of Chain Drug Stores “The provincial government and pharmacy are prepared to commit ourselves to doing things together on an ongoing basis. Government is bound to it.” Marnie Mitchell, CEO, British Columbia Pharmacy Association (BCPhA) “The PSA expands our position on the healthcare team in the eyes of patients, government and other providers. It not only recognizes pharmacists, it pays them for their services.” John Tse, Board Member, BCPhA 4. Pick the right people CACDS joined the discussions at the government’s request. “CACDS brought a lot of value to the process: the breadth of their representation of retail pharmacies, their experience from discussions with other provinces, and an understanding of the impact or implications of things being proposed,” says Mitchell. “You’re going to see more national players at provincial tables, since what happens in one province influences what happens in others,” adds Stann. Also important, of course, are the individuals themselves. “When you have people at the table who are open-minded and upfront, you’ve got a formula for success,” says Nakagawa. As well, “people in government look to hear from people who are clearly committed to their profession yet also understand the economic realities. Pharmacy associations should identify these pharmacists and use them as part of negotiations and to build long-term relationships.” 5. Remember the common ground “The need to achieve common understanding was bigger than expected,” notes Dickson. “We have to be able to translate our 2011 CACDS REPORT 15 What can individual pharmacists do to support positive government relations? “Connect at the local level with your member of provincial parliament or legislative assembly. Try to understand their perspective and look for ways to connect. If you can bring a positive result, they’re more likely to return the gesture.” Marnie Mitchell, CEO, British Columbia Pharmacy Association (BCPhA) “If it’s your party, work on your local representative’s campaign. It helps you learn the political process, and it establishes a relationship.” Darcy Stann, Board Member, Canadian Association of Chain Drug Stores (CACDS) “The most important thing pharmacists can do is be a professional and provide consistently good service to each and every patient. Every politician is also a consumer—I’ve been at the table where discussions are influenced based on whether the payer has had a good or bad experience with a pharmacist.” Mark Dickson, Past Chair, CACDS For tools that help pharmacists advocate for their profession, go to www.pharmacyworx.com objectives into the bigger picture for government. The place to go for that is to translate everything to the patient’s perspective. That’s our common ground.” For example, don’t argue about why something is important for pharmacists, but “explain why it’s important for patients and how pharmacists can help achieve that,” says Dickson. 6. Share information Information and analysis were key drivers of discussion. “We needed a lot of information from B.C.’s PharmaNet database,” says Tse. “In the past they shared the data but it was much more aggregate. This time we were able to slice it in different ways.” To that end, CACDS also brought forward proprietary data on the costs of professional services in order to enable economic modeling. “Good analytics have historically been a failing on our side,” says Dickson. “As much as we are passionate about patient care, we need to be equally informative about the financial impact of proposed actions.” 7. Compromise “The reality is that the agreement is not a financially beneficial deal for pharmacy—we are taking a profitability hit. The important part is that the time frames for adjustment are reasonable and we have had input into how funding is reinvested to support new professional services,” says Dickson. In other words, it’s a process of give and take. ”You really have to understand the other party’s challenges and www.cacds.com perspectives and listen to find the middle ground,” says Tse. “And no matter what they say or do, never walk away. You can take a breather, but don’t cut off talks or make threats. The momentum must come from the desire to find a solution for both sides—the alternative is that government will force change upon you.” “Always recognize that government is trying to do what’s good for the public,” adds Nakagawa. “For example, the whole generic drug-pricing situation was untenable and had to be addressed.” 8. Communicate with members CACDS and BCPhA regularly communicated with pharmacists during negotiations, even though they had to maintain confidentiality. “Silence starts to get interpreted,” says Mitchell. “If information isn’t fed regularly, something will be created or invented. Therefore we kept putting out messages, even if it was a bit of a broken record.” The associations also promoted communications by asking members for feedback on related issues. “Input from members is critical,” stresses Mitchell. Communication to different contacts in government is also important, in the event they need to respond to rumours brought forward by media, pharmacists or consumers. Once the agreement was made, BCPhA, CACDS and government issued joint statements to pharmacists and the media, and participated in a series of town hall meetings that were also available as webcasts. While they expected negative feedback from B.C. pharmacists due to the complexity and scope of the agreement, people “were by and large quite pleased,” reports Mitchell. She suspects this was partly due to members’ anxiety over events in Ontario, where generic pricing had been slashed and professional allowances eliminated; however, she also credits the joint communication efforts and the agreement itself, which clearly recognizes—and compensates—the value of pharmacists’ services. 9. Make the commitment The committee met face-to-face about once every six weeks from January 2009 to June 2010, weathering the competing demands of a provincial election and the 2010 Winter Olympics. Those who represented BCPhA and CACDS appreciated the full support of their employers. “This was my top priority, ahead of my job,” says Tse, adding that “our role was to negotiate what was good for community pharmacy, not specific chains.” 10. Look forward When asked about obstacles to avoid, several emphasized the need to leave the past behind. “You must avoid bringing up ancient history. It detracts from the realm of what is possible,” says Dickson. “It was what it was—now we have to move forward,” agrees Nakagawa. As well, pharmacists need to keep their eyes on the bigger prize. “We can’t get lost in the details, which can be hard for pharmacists since we tend to be detail-oriented,” says Dickson. “Instead, focus on the ‘big blocks’ at the negotiation table, then leave it to the subcommittees or working groups to work out the details. You are there to build the foundation.” ■ 2011 CACDS REPORT 17 The future is now From coast to coast, provincial governments are implementing, and reimbursing, pharmacist services that directly contribute to more accessible primary care Provincial summary of government-funded professional services* Province Status Fee Nova Scotia Advanced Medication Reviews Basic Medication Reviews Injections or immunizations Prescription adaptations Prescription renewals for continuity of care Therapeutic substitutions Emergency prescribing Minor ailments Lab tests Implemented Implemented Implemented Implemented Implemented Implemented Pending Pending Pending $150.00 $52.50 $10.73 $14.00 $10.73 $26.25 Pending Pending Pending New Brunswick Immunizations Emergency prescribing Injection of medication via intramuscular, subcutaneous, intradermal or IV Implemented Implemented Implemented $12.00 $9.40 $9.40 Newfoundland & Labrador Refusals to fill Emergency prescribing Implemented Implemented $7.15 $7.15 Prince Edward Island Prescription renewals for continuity of care Implemented $8.20 Quebec Pharmaceutical Opinions Prescription renewals (packaged) Prescription renewals (not packaged) Emergency prescribing Refusals to fill Implemented Implemented Implemented Implemented Implemented $18.65 $16.56 $25.20 $16.99 $8.44 MedsCheck MedsCheck Follow-Ups MedsCheck for Diabetes MedsCheck for Diabetes Follow-Up MedsCheck for Long-Term Care Implemented Implemented Implemented Implemented Implemented MedsCheck at Home MedsCheck at Home Follow-Up Pharmaceutical Opinion Prescription adaptations Refusals to fill Pharmacy Smoking Cessation Program Implemented Implemented Implemented Pending Implemented Implemented $60.00 $25.00 $75.00 $25.00 $90.00 (annual) and $50.00 (quarterly) $150.00 $ 0.00 $15.00 Pending $15.00 $40 for first consult; $15/primary follow-up (3/year); $10/secondary follow-up (4/year) Pending Pending Pending Pending Ontario Name or description of service MedsCheck Complex Assessment Medication Reconciliation Chronic Disease Management Home Diagnostic Training 18 CACDS REPORT 2011 Pending Pending Pending Pending www.cacds.com Provincial summary of government-funded professional services* Province Manitoba Name or description of service Status Fee Expanded scope of practice legislation pending passage of regulations Pending Pending Implemented Implemented Implemented Implemented Implemented Implemented Implemented Implemented Implemented Medication Assessments Emergency contraception prescribing (with training) Emergency continuation of existing prescription Non-emergency continuation of existing prescription Refusals to fill Prescription renewals or refills Adjustment of dosage form Medication reconciliation Smoking cessation Minor ailments Advanced prescribing services Pending Pending $60.00 2 x dispensing fee $10.00 $6.00 Dispensing fee plus 50% $6.00 $6.00 $25.00 $2.00/minute up to $300.00 per patient per year Pending Pending Alberta Injections or immunizations Emergency prescribing Prescription adaptations Lab tests Advanced prescribing services Implemented Implemented Implemented Implemented Implemented $10.93 Pending Pending Pending Pending British Columbia Prescription adaptations Therapeutic substitutions Refusals to fill Injections or immunizations Medication Reviews – Standard Medication Reviews – Pharmacist Consultation Medication Review follow-ups Prescription renewals for continuity of care, chronic disease Implemented Implemented Implemented Implemented Implemented Implemented Implemented Implemented $10.00 $17.20 2 x dispensing fee $10.00 $60.00 $70.00 $15.00 $10.00 Saskatchewan * Note this chart is current as of October 12, 2011. www.cacds.com 2011 CACDS REPORT 19 Technology solution Introducing MirixaPro CanadaTM, the webbased platform to help patient-focused expanded services become a reality in pharmacies across Canada by Karen Welds P harmacists in Canada will soon be able to tap into an exciting new online tool for the delivery of a wide range of patient services, such as medication reviews and immunizations. MirixaProTM, embraced by pharmacists in the U.S. and Australia, is coming to Canada under an exclusive licensing agreement with the Canadian Association of Chain Drug Stores (CACDS). “This is the tool we’ve been waiting for,” says Darcy Stann, CACDS Board Member and Director of Regulatory Affairs, Canada Safeway. “We have a tremendous opportunity to move towards expanded services, and www.cacds.com this is a tool to help achieve that,” agrees Bobbi Reinholdt, also a CACDS Board Member and Senior Vice-President, Pharmacy, Loblaw Companies Ltd. CACDS has entered into an exclusive agreement with the Mirixa Corporation, the creator of MirixaProTM, to adapt and distribute the web-based platform (see “MirixaPro CanadaTM quick facts”). The association’s objective: 100% availability to all community pharmacies across Canada. “We know that technology is a key enabler for expanded services. Based on our research, MirixaProTM is the right technology,” says Nadine Saby, President and CEO of CACDS. “There’s nothing like this in 2011 CACDS REPORT 21 MirixaPro Canada™ quick facts Canada right now. Other systems contain certain aspects, but there’s nothing with the full scope of MirixaPro CanadaTM.” Distribution will be based on a costrecovery model, which “mitigates financial risk for the buyer and removes control from a for-profit third party,” says Justin Bates, Director, e-Health, at CACDS. “It’s a standardized, clinical-decision support tool that enables effective patient care across all provinces.” CACDS is also working with vendors to develop the integration piece that will seamlessly connect MirixaPro CanadaTM with existing “fill and bill” dispensary sys- Hooked on technology Just seven years ago, Nirvishi Jawaheer didn’t even know how to open an email. But today, the pharmacist and owner of a Jean Coutu franchise in Montreal, Quebec, has become a technology whiz who uses an iPad to look up information and make notes when counselling patients. “My iPad and iPhone are both loaded with knowledge-based software, which has 16 different programs for everything from pregnancy to medication interactions,” she says. “Having the information at my fingertips saves me a lot of time and is really helpful, especially when I visit patients in their homes.” Jawaheer is eagerly awaiting the implementation of MirixaPro CanadaTM, a webbased clinical decision support platform that the Canadian Association of Chain Drug Stores is customizing for Canadian pharmacies (see main article). “We fill a large volume of prescriptions every day and MirixaPro CanadaTM will make it easier for us to educate patients and document their progress,” she explains. “I love having Nirvishi Jawaheer access to the latest technology and can’t wait to use it in my practice. These programs help us to take charge of our patients’ needs and to follow professional guidelines for documentation.” 22 CACDS REPORT 2011 tems. “The interface is vital, and will save pharmacists tremendous time and effort,” says Anthony Silva, Director, Technology Initiatives at CACDS. “The standard interface also means that when pharmacists move from one job to another, which they do a lot, they don’t have to worry about learning a new system—and management doesn’t have to worry about the high cost of technology training,” adds Stann. MirixaPro CanadaTM will also reflect the objectives of the Canadian Pharmacy Services Framework, which provides consistent definitions of services and an understanding of the work flows involved to ensure consistency and reliability (for more on the framework, see page 5). It will also initially contain modules for expanded services for which payment already exists in some provinces, such as medication reviews, prescription adaptations and immunizations. More will be added over time. “The more we have a single system, the more that system can be enhanced over time to give pharmacy what it needs, which is operational efficiency, professional support and a business model built on professional services,” says Stann. CACDS’s endorsement of MirixaPro CanadaTM will also send the message that “you don’t need a different tool in every chain in every province,” says Reinholdt. “Professional services need to be consistent across all formats, and we need to leverage those areas where there is a shared need, where differentiation doesn’t matter. MirixaPro CanadaTM is a solution for the profession.” Last but not least, the non-competitive platform gives the profession access to aggregate data that can be used to both measure health outcomes and demonstrate the value of pharmacists’ services to public and private payers. “Epidemiologists and other researchers can use the findings. The real winners are the rest of the healthcare system,” says Stann. “This is not just technology for the sake of technology—it has a purpose,” says Reinholdt. “We will collect the data and go back to the provinces to show the return on investment for our services.”■ • The National Community Pharmacists Association, which represents more than 39,000 chain and independent pharmacies in the U.S., established Mirixa Corporation in 2006. • In 2009, the Pharmacy Guild of Australia, representing 5,000 community pharmacies, became the first national pharmacy association to purchase an exclusive licence to adapt and distribute MirixaPro™ to its marketplace. • The Canadian Association of Chain Drug Stores (CACDS) will become the second national pharmacy association to adapt MirixaPro™, under an exclusive agreement. • CACDS will pilot the Canadian version of the system in the first half of 2012 . • MirixaPro Canada™ will initially include modules that support expanded services for which payment already exists in some provinces, such as medication reviews. • MirixaPro Canada™ will reflect the definitions and work-flow analyses contained in the Canadian Pharmacy Services Framework (CPSF), a Blueprint for Pharmacy implementation plan component led by CACDS, with the support of Canadian Pharmacists Association and numerous other pharmacy stakeholders. • At the pharmacy level, MirixaPro Canada™ core functionalities include: - Evidence-based counselling and adherence support in accordance with available clinical guidelines, including recommendations for lifestyle modifications, self care and preventative care; - Standardized documentation processes for interventions, development of care plans and follow-up; - Standardized documentation for expanded services, such as medication reviews - Documentation and communication tools to collaborate with physicians and other providers; and - Development of a Canadian database of pharmacy services. www.cacds.com Electronic health record: one province at a time Ten years have passed since Canada’s provincial health ministers established Canada Health Infoway to support the development of a network of electronic health record (EHR) systems, compatible from coast to coast. Since then, the federal government has committed more than $2 billion in funding, roughly matched by the provinces and territories, towards an estimated total cost of $10 billion. Once fully implemented, the EHR is expected to generate significant savings annually due to anticipated reduced healthcare costs (including fewer adverse drug events) and improved efficiencies. Infoway’s 2010 Annual Report states that, as of March 2010, EHR systems were available to 22% of the Canadian population through authorized physicians. It forecasted an availability level of 46% by the end of the year, falling just short of its target of 50%. It is targeting 100% availability by the end of 2016 (assuming continued funding). Six core elements comprise the EHR: a client (i.e., patient) registry; a provider (i.e., physician) registry; a drug information system (DIS, which captures all medications dispensed at all locations); diagnostic imaging; laboratory test results; and hospital clinical reports or immunization records. For the DIS, Infoway estimates that 43% of all information for dispensed medications is now captured and stored electronically, and 33% of retail pharmacies have access to a DIS. These results vary significantly by province, however; in B.C. and P.E.I., for example, 100% of pharmacies have access to a DIS. Here’s a province-by-province snapshot: Quebec The development of a regional DIS that is fully Infoway-compliant is well underway, although the timing for implementation is to be determined. Nova Scotia The province is close to completing its planning process, with implementation anticipated in 2013 and 2014. New Brunswick The prov- British Columbia B.C.’s PharmaNet system was Canada’s first integrated DIS, implemented years before the creation of Canada Health Infoway. As a result, work is ongoing to make it compatible with Infoway standards. The province is also focused on electronic prescribing, which is expected to become available in 2012. www.cacds.com ince’s DIS is being built to meet Infoway standards, with expected implementation in 2012. Alberta Work is well underway to upgrade the province’s existing Pharmaceutical Information Network to meet Infoway’s DIS standards, and pharmacies should start coming online by the end of 2011. Manitoba Work to upgrade the province’s Drug Programs Information Network to become an integrated DIS is at the early stages, as the province focuses more of its efforts on other components of the EHR. Saskatchewan The province’s Phar- Ontario Canada’s largest province maceutical Information Program is approaching compliance with Infoway standards, with rollout to pharmacies expected by the end of 2011 or early in 2012. is still at the planning stage and expects to have a DIS, complete with e-prescribing, in 2014 or 2015. Newfoundland The province is piloting its DIS with a limited number of pharmacies; full implementation is scheduled to occur through 2012. Prince Edward Island P.E.I. was the first province in Canada to develop a DIS based on Infoway standards, implemented in September 2008. 2011 CACDS REPORT 23 Building blocks for change Behavioural change consultant Peter Sheahan explains how successful change management is powered by the people by Karen Welds C hange management is a dedicated field of study for psychologists and engineers alike, and research repeatedly shows that its absence is the leading cause of failure for major initiatives. In fact, a growing awareness of the implications of change management has resulted in a whole new business sector—that of companies helping other companies implement change. But what, exactly, is change management? In very simple terms, it is managing the “people side” of change. Peter Sheahan, an internationally renowned behavioural change consultant and founder of ChangeLabs, spoke at the annual conference of the Canadian Association of Chain Drug Stores in June. Here’s a synopsis of his thought-provoking presentation. Identity-based decision-making Successful change management focuses on the individual, not the change. Whether it’s a New Year’s resolution to get fit or legislation that expands pharmacists’ scope of practice, it all begins with the personal decision to change. Decision-making, in turn, is most powerful when it “taps into what someone aspires to be,” says Sheahan. “If you were to distill everything down to one concept, the one thing that drives human behaviour is the gap between who Peter Sheahan we are and who we want to be. We call it identity-based decision-making, and it’s the most underutilized change-management tool.” All too often, daily pressures or uncontrollable events get in the way of identity-based decision-making. The brain rationalizes this by diminishing or even dismissing the aspiration. Yet aspiration never fully disappears, and the most successful companies are those that communicate a clear aspiration to employees. One step at a time Once the aspiration is in place, employers “need to scale back and get very, very specific,” says Sheahan. “In pursuit of this, we will do this.” It could be a particular service offering or a new technology— do one thing, and do it right. Staff feedback is essential throughout. “You need to connect closely with your stores and employees, making frequent visits to determine their reality. Incorrect www.cacds.com assumptions kill the change process,” emphasizes Sheahan. Bring in the incentives Traditionally, companies begin with incentives to motivate the individual to change. While incentives can play a role, they need to be “part of a deeper, more important journey” that’s driven by identity-based decision-making. “Incentives are anchored in rationality, and people are not always rational when it comes to major change. First, you need to engage their emotions,” says Sheahan. When using incentives, “always leverage the positive, even when issues related to the change are on the down side,” he adds. As well, offer an incentive for no more than six weeks at a time— after that, it becomes a “given” in the minds of employees. Rally the mentors In any given group of 100 people, about half are neutral or undecided about change, about 20% say they’re not interested and perhaps five per cent are “dead set against it,” says Sheahan. That leaves about 20% who are interested, and five per cent who have already embraced the change. Among those who are already active and most interested, employers can recruit and support mentors to serve as practical guides for the remainder of the “interested” group, suggests Sheahan. “Once they’re fully engaged, use more of these ‘catalysts’ to convert the neutral group.” As for the 25% who are not interested? If dismissal is not an option, you’ll need to put them in positions where they contribute to the company’s requirements, without interfering with the change process. “Otherwise, they are destructive,” states Sheahan. Expand your partnerships As part of his closing comments, Sheahan urged retailers, manufacturers and distributors in the room to consider new ways to partner. For example, manufacturers and retailers can enter into revenue-sharing arrangements for higher-margin, higher-risk inventory. “It is time to collapse the barriers in the supply chain,” says Sheahan. “You are all at the same table now, and you can’t navigate through this type of change alone.”■ 2011 CACDS REPORT 25 Making change happen Associations, regulators, faculties, owners and head offices step up to support pharmacists who are ready to expand their role by Sonya Felix W hile expanding scopes of practice and new funding for pharmacist services are positive developments, the rapid pace of change and a long list of uncertainties can temper the desire to celebrate. Pharmacists and other pharmacy stakeholders need to rework professional and business practices before they can take full advantage of their expanding role in the delivery of primary health care. “The building blocks for the future are being put in place, but there is a lot of work ahead,” says Nadine Saby, President and CEO of Canadian Association of Chain Drug Stores (CACDS). “Change is hard and while it ultimately rests with the individual, support is there from retail head offices and pharmacy associations.” The need to adapt—and adapt quickly—is particularly acute on the business side. The traditional model based solely on the distribution of medication is no longer enough, due to recent government policies that reduce generic drug prices and lower or even eliminate professional allowances. “In the past decade pharmacists haven’t had to push to do well but now there is a real economic necessity to be creative and innovative,” says 26 CACDS REPORT 2011 Zubin Austin, Associate Professor at the Leslie Dan Faculty of Pharmacy, University of Toronto. “I think we’ll be happily surprised at the outcome.” Training tools available Pharmacy faculties, regulatory bodies and professional associations understand that community pharmacists need support as they move into a new role. “We look at enhancements and expansions to scope of practice as tools that will help pharmacists to fulfill their potential in healthcare,” says Ray Joubert, Registrar of the Saskachewan College of Pharmacists. “But the ability to embrace change is all about capacity and we need to make sure that the new demands don’t impose added burdens. As a college we are consulting with members and we’re definitely feeling pressure to help.” Regulatory bodies and pharmacy associations are also rolling out training programs that teach the new skills required under an expanded scope. This past June in Saskatchewan, for example, almost half of the province’s pharmacists trained for the new minor ailments program. In B.C., more than 1,200 pharmacists www.cacds.com have become certified to administer injections since that authority became available in 2009. In Ontario, although legislation is pending for injection administration, the Ontario Pharmacists’ Association has already graduated the first group of pharmacists from its new injections training program. Last year, Dalhousie University in Halifax developed an injections training program for pharmacists in New Brunswick and Nova Scotia. Associations and regulators also recognize the need for less tangible change-management skills. The Canadian Pharmacists Association and the Canadian Society of Hospital Pharmacists already has a waiting list for its new ADAPT program launched in August. The online, interactive, 19-week course helps pharmacists enhance patient care and medication management skills by exploring such topics as evidence-based clinical decision-making, validated documentation practices, collaboration with other providers and the implementation of patient care plans. A new workshop from the B.C. Pharmacy Association addresses ways to incorporate new clinical pharmacy services into existing community practices, while a continuing education course by the College of Pharmacists of B.C. focuses on how to better utilize professional judgement. Such training programs give pharmacists the confidence they need to shift from a role driven by distribution, where patient counselling is tied to prescriptions as they are dispensed, to a role driven by patients’ overall medication and healthcare needs, where pharmacists consult with patients and other providers to make recommendations for drug therapy and self care. Marshall Moleschi, Registrar of the Ontario College of Pharmacy and former Registrar of the College of Pharmacists of British Columbia, recalls that “in B.C. the change started with a small group of pharmacists. Then we saw more people become willing to step up as they gained confidence. It’s much like riding a bike—it takes practice and the more you do it, the more natural it becomes.” For future pharmacists, faculties are adjusting admissions requirements and curricula to better prepare students. “It’s not enough to have the right GPA for admission anymore,” says Austin of the Leslie Dan Faculty of Pharmacy at the University of Toronto. “Now we test for communication skills, conflict management and stress management. We’ve also introduced longer clinical rotations and service learning where students volunteer in healthcare organizations so they can talk to patients and develop better sensitivity to their needs.” Faculties are also developing programs in direct response to new legislated authorities. “We’ve developed an immunization program that’s given through the continuing education department, and now we are determining how best to incorporate prescribing authority,” says Neil MacKinnon, former Professor and Associate Director, Research and Graduate Program, at Dalhousie University’s College of Pharmacy. Aside from the obvious skill sets involved, it’s a “fairly complex process” to ensure students can apply the appropriate decision-making skills to assess patients’ needs and make recommendations. “We don’t want to train pharmacists to be diagnosticians like physicians, but they need to develop confidence to prescribe according to their own scope.” www.cacds.com Techs and technology The regulation of pharmacy technicians is one major initiative considered critical to enable a stronger focus on professional services. All provinces are at various stages of registering licenced pharmacy technicians, with Ontario being the first to do so as of December 2010. British Columbia and Alberta began registering techs this summer. In those three provinces, 45% of pharmacy owners and managers say they plan to actively encourage selected pharmacy assistants to become licenced, according to the Trends & Insights 2011 Survey of Pharmacists. Technology is another vital enabler, on two levels. First, automated dispensing equipment and robotic systems significantly improve efficiencies and free time for patient care; second, specialized software is necessary to support, document and meas- One patient at a time Retail pharmacy partners with health organization to build bridge for patient education As pharmacy manager at a Loblaws supermarket located in an ethnically diverse neighbourhood in Etobicoke, Ontario, Carlos Rubio-Reyes knows the importance of convenience for busy customers. He’s also aware of the importance of early detection of chronic disease. He’s recently been able to combine the two using assessment programs for diabetes and cardiovascular health that are free to patients. The “Get Checked Now” program, created by Loblaw Companies in partnership with the Canadian Diabetes Association (CDA), includes a blood pressure check, an assessment of diabetes risk factors, Carlos Rubio-Reyes an information brochure and a one-on-one consultation with the pharmacist to discuss lifestyle issues. For those who need more information, the pharmacy and CDA also offer diabetes education sessions, which include cooking demonstrations and store tours with a dietitian. As part of Loblaw’s “Healthy Heart Check” program, consumers receive a blood pressure check and cholesterol test followed by a pharmacist consultation. While advertising draws people to the programs, RubioReyes also approaches patients when counseling about prescriptions or over-the-counter medications. “If there is any indication that they are at risk of diabetes or heart disease, I can offer to do a risk assessment on the spot.” It takes additional time to do these consultations, as well as MedsCheck medication reviews, but RubioReyes says technology and other supports from head office help. “It’s great to be able to provide programs that are convenient for patients,” he says. “I am anticipating the next changes in scope of practice that will allow us to offer more services and even better patient care.” 2011 CACDS REPORT 27 ure clinical decisions and health outcomes. CACDS recently signed an exclusive licensing agreement to bring MirixaProTM to Canada, a web-based platform for clinical decision support and documentation that will be customized for the Canadian market (for details, see page 21). A new business model While an expanded scope opens up major opportunities, the loss of dispensary income poses major challenges. Particularly hard hit is Ontario, where the government’s ban on professional allowances is taking a big chunk out of operating budgets. Pharmacies in other provinces with slashed generic prices are also feeling the pinch. The result is a Catch-22 scenario, where stores try to cut costs by reducing staff and store hours, then struggle to find the resources to offer new services. “It’s critical to remain profitable through the transition,” says David Montisano, Vice-President of Total Health, a chain of 37 owner-operated pharmacies in Ontario. “You can’t rely on professional allowances any more so you need to look for other ways to make money by raising the dispensary volume and emphasizing paid services. Although we now have to run a tight ship on human resources and everything else, I’m excited about any opportunity to do more and welcome any changes that will help us be more profitable. But we will need more reimbursement for services to be successful.” No one can expect to replace all the money that’s lost in the short term, says Jeannette Wang, Chief Pharmacy Officer, Remedy’s Rx. “But paid services can replace some of it and demand for these services is only going to rise. Pharmacy owners who are ahead of the curve have already accepted the reality and put into place what they need to do to survive and prosper. Now we need to help others along the continuum to make sure the positive mentality spreads.” Russell Cohen, Executive Vice-President of Industry and Government Affairs at Katz Group Canada, agrees. “We need to accept the evolving healthcare landscape and realize that we’re heading towards crisis mode across the country and that government budgets are stretched. Pharmacy can be either part of the problem or part of the solution and we see ourselves as part of a solution. We’ve been talking about a greater role in healthcare for years and now we’re there! It is time for pharmacists to decide how to respond. Yes, start-up costs to implement pharmacy services can be high, but I believe that expanded scope and patientfocussed services will eventually be profitable in the future.” Retail pharmacy head offices are pursuing a range of supports and resources to help pharmacy staff. The hiring of regulated pharmacy technicians and greater use of robotics and automated dispensing equipment will boost efficiencies in the dispensary and improve work flow; store designs and renovations, including private counselling rooms, are putting more emphasis on health care; and new or upgraded software will simplify documentation and the development of patient care plans. Changing mindset among private payers While provincial governments are clearly starting to recognize the value of pharmacy services, private payers are remaining relatively quiet so far. “It’s still a chicken and egg scenario,” says Cohen. “There is a role for the private sector to pay for pharmacy services but there is definitely a gap between the way public and private payers see it.” Marilee Mark, Vice-President of Marketing, Group Benefits at Manulife Financial, agrees that pharmacy’s expanded scope of practice can be viewed as an opportunity for private payers— with certain considerations. “The biggest challenge for payers is added fees,” she explains. “Anything billed as an enhanced service needs to be separated from regular dispensing fees so it is clear where the value is. Unless they can see return on investment, many employers aren’t willing to pay more.” Private payers can see the potential for pharmacists to support chronic disease management and provide one-on-one health coaching, “but to manage quality this type of service needs to be done through a PPN [preferred provider network] or through a separate specific agreement that lays out more detail. We aren’t seeing this yet,” adds Mark. Pharmacy needs to do a better job explaining what they can offer, says Francois Joseph Poirier, Partner at Mercer Human Resource Consulting. “As payers become more educated on what pharmacists can provide, then perhaps there will be more interest. But the nature of Canada’s health and drug system is that plan sponsors don’t want more of the healthcare costs transferred to them.” Still, he notes that some pharmacy services such as on-site dispensing of drugs and preventative care clinics could be immediately useful for employers. “The price tag on some new drugs runs to five or six digits and it could be useful to have a pharmacist help sponsors better manage those costs. But that’s not likely to happen under the current pharmacy model unless pharmacists become very innovative.” It will take some time yet before private payers feel comfortable enough to incorporate pharmacy services into their drug plan management strategies. In the meantime, they’re keeping a close eye on how pharmacy progresses with expanded scopes and the development of new services. “We are absolutely willing to talk to pharmacies as we look for the best opportunities to bring value to our clients,” says Mark. “There is definitely potential there but we need to see more transparency on costing and understanding of needs.” Pharmacy is just beginning its transformation into a new practice and reimbursement model. It will take hard work, commitment, patience, vision and optimism. “We need to be proactive and have a positive perspective as the culture shifts from a product focus to a patient focus,” says Cohen. “At the end of the day, it’s about providing better health care to patients and if we do it right, then our businesses will benefit.”■ Q&A with the Chair The next level CACDS Chair Sandra Aylward reflects on how CACDS and individual pharmacists are rising to the opportunities of a profession in transition You have participated in a number of negotiations between pharmacy and provincial governments. What have you learned so far? We’ve learned the value of not assuming that provincial governments—elected officials or bureaucratic staff—understand all the complexities of our profession and our business. It is worthwhile— critical—to provide a good grounding in both the nature and scope of our pharmacy practice as well as its economic elements before new models can be considered. Similarly, in each province, pharmacy representatives have to quickly get a clear understanding of the government’s priorities and mandate and how they pertain to the negotiation. We also need to understand the nature of the current political environment and its potential for distracting from or, at worst, interfering in the negotiations. It’s surprising how easily a disconnect can occur between pharmacy and government when it comes to the financial assessment of a current situation or a proposed model. Your understanding of “the numbers” depends on the information that you have, its currency, how you define the variables, and the assumptions you make (or don’t make). Both parties need to come to a shared understanding of the baseline—and then resist the urge to take “short cuts.” A careful consideration of all possible variables is key to a successful outcome. This process is detailoriented, and can be difficult for “big-picture” thinkers. It takes time and commitment on both sides. We’ve also learned that what happens in one province influences other provinces. We have to focus on achieving the best possible, sustainable model and migrating each province to its guiding principles, in order to establish a new, viable version of a “normal” operating environment, and get on with the expansion of the services and role that pharmacists offer Canadians. Why is it so important for individual pharmacists to become more involved in the future of their profession? How can they do so? Like many pharmacists (and other Canadians), initially I was not interested in getting involved in “politics.” However, I now realize that 30 CACDS REPORT 2011 politics is, at its heart, citizen engagement. That engagement can vary significantly based on the individual, from being informed about issues generally and voting, to running for office. Tools such as Pharmacyworx (www. Sandra Aylward pharmacyworx.com) help us become engaged, whether before elections or between elections. The fact of the matter is that we each have a role to play—as individuals, as members of the community, and as pharmacists within our communities. Our ideas and opinions can help to shape better government policy, and as professionals we will benefit from taking the small step of introducing ourselves personally to candidates and elected officials and letting them know that we care about health-related issues. It can feel awkward at first—it did for me—but then you realize: “This is how democracy works—this should be part of how pharmacy works.” You’ve just begun a two-year term as Chair of CACDS. What do you look forward to accomplishing during your tenure? In a word: evolution. It’s an exciting time for CACDS. We have over 15 years of experience advocating for our profession and our business. We’ve developed strong relationships across the country with everyone in the pharmacy profession and a reputation as a credible and resolute advocate for community pharmacy in Canada. I’m looking forward to the continued evolution of CACDS. We will become even more inclusive as we represent those who are responsible for the delivery of pharmacy services in communities across this country. We will continue to advance the discussion about how pharmacy can play a new and enhanced role in front line healthcare, by developing support tools, demonstrating the value of pharmacists’ services and bringing a strong, collaborative voice to discussions on pharmacy policy and funding. As the past few years have so clearly demonstrated, pharmacy is experiencing a time of tremendous transition. CACDS is committed to evolve in response in order to continue to fulfill our purpose. ■ www.cacds.com