COVER STORY

THE POWER OF THE PHARMACIST

Pharmacists feel they're gaining authority in some areas and lagging in others

As the role of the pharmacist continues to evolve, R.Ph.s' influence over drug product selection, drug administration, and drug therapy management is also changing. To gain insight into how much professional clout pharmacists possess, and how this may be changing, Drug Topics surveyed pharmacists on where they believe they are gaining authority and where they are falling behind.

In this first of a two-article series, pharmacists rate their own professional influence. The second article, in our May 20 issue, will examine how consumers view the power of the pharmacist.

Our survey covered a range of areas, including the authority to prescribe, the offering of immunization programs, and the practice of generic and therapeutic substitution. Also probed were the R.Ph.'s role in determining drug regimens and R.Ph. influence with doctors, patients, legislators, and insurers. The survey also explored how pharmacist views vary among different practice settings, geographic regions, and job positions and between men and women.

Out of 700 randomly selected R.Ph.s, 30% responded to the three-page questionnaire, including 119 male and 82 female R.Ph.s. Respondents came from every age group and every region of the country. The average number of years in practice is 20, and the average age is 46. What follows are some of the survey findings.

The right to prescribe

Today, more and more states allow pharmacists to prescribe drug therapies under protocol with physicians. Among our sample, only 24% said their state provides them with prescriptive authority. Those in the West (65%) are more likely to have this authority than are their counterparts in the East (16%), South (22%), and Midwest (23%).

However, when it comes to exercising this authority, of those who can prescribe under the law, less than half actually flex this muscle (see Table 1). The No. 1 reason for choosing not to prescribe is lack of adequate training, cited by 32% of those who are allowed to prescribe. One in five respondents said time constraints are a barrier, and 16% cited liability issues for giving them reason to refrain from the practice.

"The doctors aren't ready for this," noted Lori Archibald, a hospital R.Ph. from Hettinger, N.D. "My duties are to check prescriptions for accuracy," said another. Lourdes Cuellar, another hospital R.Ph. from Houston, cited a lack of reimbursement for prescribing as a sticking point.

Many retail pharmacists seem to believe prescribing is for hospital pharmacists, not for them. "I'm in retail," said one. "I don't work in a hospital," noted another. Indeed, hospital pharmacists are much more likely than other pharmacists to exercise their authority to prescribe. Among pharmacists with prescriptive authority, almost seven in 10 hospital R.Ph.s said they have ordered drugs, while only one retail pharmacist has done so. Among all R.Ph.s who do prescribe, the average number of Rxs written is 10 per week. The average time spent with the patients to whom they prescribe is 14 minutes.

The average incentive paid to R.Ph.s who prescribe is $32, although a hospital pharmacist from Colorado said his only incentive to prescribe is "personal growth."

Who is offering incentives to encourage pharmacists to prescribe? Employers led the list, followed by Medicaid and private insurers. When asked about the diseases for which they would most like to prescribe, R.Ph.s cited hypertension (77%), asthma (69%), diabetes (69%), and hyperlipidemia (46%).

M.D.s rely on R.Ph.s' expertise

Along with the right to prescribe, another important measure of the R.Ph.'s power is how often doctors turn to them for drug information. Our respondents said doctors or their offices call them an average of nine times a week for drug information. Hospital pharmacists receive the most queries from physicians—an average of 12 questions a week, versus six for independent, chain, and supermarket/mass-merchandiser pharmacists.

Doctors call mostly for information on drug interactions, followed by drug costs, generic substitution, and side effects, but pharmacists said that physicians seek a wide range of information from them. The information cited included dosage and the best or most appropriate drug for a condition, as well as questions on compounding and drug availability.

Patients often turn to R.Ph.s

Patients are much more likely than doctors to turn to R.Ph.s for drug information. Patients initiate an average of 18 face-to-face consultations a week. And unlike doctors' queries, many of which are directed at hospital pharmacists, most patients' questions are asked of retail R.Ph.s. The average number of consultations for supermarket and mass-merchandiser pharmacists is 23 per week. Both chains and independents report 21 per week, and hospital R.Ph.s said they are sought out by patients about 12 times per week.

Patients also don't hesitate to call their pharmacist with questions. The average number of calls to R.Ph.s is 17 a week. Not surprisingly, patients call retail R.Ph.s with their drug questions more than they do hospital pharmacists; retail pharmacists report 21 calls a week, versus nine a week for hospital R.Ph.s. Pharmacists in the West and Midwest said they get more questions from patients, compared with those in the East and the South. For all respondents, the time spent in consulting averaged four minutes per consultation. Hospital R.Ph.s spend a little longer with each patient, averaging six minutes per consultation, compared with three minutes for retail pharmacists.

Patients most often want to know about side effects, followed by adverse effects, drug interactions, and then drugs costs. Among the other topics cited were insurance coverage and formulary drugs.

When asked whether OBRA (the Omnibus Budget Reconciliation Act) '90—which requires pharmacists to offer counseling—has increased pharmacists' influence over patients, 68% of the respondents said Yes. Apparently, those in the West feel most strongly that OBRA '90 has made a difference; 88% of them agreed that the law has boosted influence, compared with 79% in the Midwest, 63% in the East, and 59% in the South.

Pharmacists often recommend OTCs

Pharmacists were also asked to rate their influence when it comes to over-the-counter medications; that is, how often they recommend OTCs and how often patients heed their advice. Overall, 47% of the respondents said they often recommend OTCs to patients, and more than two-thirds of the time, patients follow their advice. Not surprisingly, this aspect of pharmacy depends largely on practice setting and is most common in supermarkets and mass merchants, followed by chains and independents. Hospital R.Ph.s give far fewer OTC recommendations than do R.Ph.s in retail.

Interestingly, new R.Ph.s tend to give more OTC recommendations than do those who have been in practice longer. Nearly two-thirds (61%) of those in practice for 10 years or less recommend OTCs often, compared with 44% of those practicing between 11 and 20 years, 41% practicing 21 to 30 years, and 44% in practice longer than 30 years.

Male pharmacists are also more likely to give frequent OTC advice (50%) than women (41%). More than half (52%) of rural pharmacists said they recommend OTCs often, compared with 40% of urban R.Ph.s and 47% of those in the suburbs. Geographically, pharmacists in the East are least likely to give OTC advice often (35%), compared with those in the South (52%), West (53%), and Midwest (58%).

Offering OTC recommendations is one thing, but just how often do patients take their pharmacist's advice? For all respondents, patients follow pharmacists' OTC recommendations 68% of the time. Neither gender of the R.Ph. nor pharmacy setting affects how often patients follow their pharmacists' suggestions. Region of the country does make a difference, however. Those in the Midwest take the R.Ph.'s advice the least, and Easterners are most likely to do what the pharmacist advises.

Taking the generic option

Pharmacists also have considerable clout when it comes to controlling drug costs, particularly through generic and therapeutic substitutions. And they said they use that authority often. Respondents indicated that, on average, seven out of 10 Rxs they receive are written for generic drugs or permit substitution. This percentage is higher in retail settings (chains, 78%; supermarkets/mass merchants, 73%; and independents, 70%) than in hospitals (65%). Prescriptions for generics are less common in urban communities (67%) than in suburban (72%) and rural (75%) areas.

When they can, most pharmacists choose to make the substitution. Overall, 80% said they always substitute generics when possible. Again, this varies by type of setting and region. Nearly nine of 10 (89%) R.Ph.s in supermarkets/mass-merchandiser settings said they always substitute a generic when allowed. In contrast, only 70% of chain R.Ph.s, 76% of independents, and 81% of hospital R.Ph.s always substitute when they can.

Regionally, pharmacists in the East substitute more often than others; 88% of them said they substitute all the time, compared with 84% in the Midwest, 77% in the West, and only 73% in the South. In addition, more rural pharmacists said they always substitute (84%) than did urban (82%) and suburban (73%) R.Ph.s.

Therapeutic substitution is another critical role for pharmacy, but one that is exercised mostly in hospitals. More than half (57%) of all pharmacists said they practice therapeutic substitution. Fully 79% of hospital R.Ph.s practice therapeutic substitution, however, compared with only 33% of independents, 32% of supermarket/mass-merchandiser R.Ph.s, and 47% of chain pharmacists. Female R.Ph.s are also significantly more likely to substitute (65% versus 51% for males), undoubtedly because more female respondents work in hospitals (52%) compared with males (31%). Those in practice for fewer years are also more likely to substitute than are R.Ph.s who've been practicing longer.

Among R.Ph.s who practice therapeutic substitution, 25% of the Rxs they dispense are substituted. The top three categories for substitution are antihypertensives (cited by 63% as one of the top three drugs for substitution), followed by antibiotics (62%) and analgesics (44%).

The main reason given for not substituting is potential liability, cited by 40% of those who do not make therapeutic substitutions. This is followed by time constraints (19%) and reluctance to antagonize doctors (16%). A number of pharmacists also noted that therapeutic substitution is not allowed in their state.

Although many pharmacists are allowed by law to offer immunization programs to the public, it is not a common practice, according to those surveyed. Almost half (46%) said their state allows them to immunize, but 89% of those permitted to do so said they do not provide this service.

The right to immunize varies remarkably by region, cited by only 5% in the East, 57% in the South, 63% in the Midwest, and 56% in the West. Among those who do provide immunizations, the most common types of programs offered are flu (supplied by 100%), pneumonia (70%), and hepatitis (50%). For these R.Ph.s, the average number of immunizations provided per year is 56, and the average fee per immunization is $11.40. Nearly half (44%) said they receive no compensation for the immunizations they provide, however, which may help explain the general lack of interest in offering the programs to patients.

Overall, more pharmacists believe they have gained authority in most aspects of drug therapy decision-making over the past two years than believe they have lost authority or maintained the status quo (see Table 2).

Table 2
Are pharmacists losing ground or gaining power?

Most R.Ph.s cited drug therapy management as the area where they have gained the greatest strength. More than half (53%) said their power has waxed in this area, while nearly one-third said their clout remains the same, and 12% believe they have lost ground. Those most upbeat on the question are female R.Ph.s and hospital pharmacists. Nearly one-fifth of independents said they have lost authority in the area of drug therapy management.

The next most-cited advance is in drug product selection, seen as a gain by half of the pharmacists surveyed. Nonetheless, nearly one in five said R.Ph.s have lost authority in this area, and 31% said their power over this type of decision remains unchanged.

Although one-third of respondents said their authority in drug administration has increased, nearly half reported a status quo on this issue, and 8% believe they have lost ground in this area. Again, hospital R.Ph.s feel most strongly that they have expanded their profile in this area, while R.Ph.s in the East see the least gain.

Professional influence mixed

Pharmacists reported both losses and gains in the past two years when it comes to their professional influence (see Table 2). Overall, pharmacists seemed to say they have seen advances in patient and physician influence but continue to lose ground when it comes to drug manufacturers, legislators, and, in particular, pharmacy benefit managers, and insurers.

More than two-thirds of respondents believe they have gained influence with patients, 26% said nothing has changed, and nearly one in 10 said R.Ph.s' influence with patients has diminished.

Pharmacists in the middle of their careers, with 11 to 20 years of experience, are less convinced of gains in this area compared with newer pharmacists and those in practice more than 30 years. In addition, more male pharmacists than female pharmacists see an upturn in patient influence. Pharmacists in the Midwest are also considerably more positive about their influence over patients than are those in other areas. Responses across settings were similar, with slightly more chain and independent R.Ph.s reporting increased patient influence.

Respondents also saw progress in their influence with physicians, although less so than with patients. More than half of them (54%) reported increased physician influence, but more than one-third (38%) said this has remained the same. A retail pharmacist from Newburgh, Ind., commented that R.Ph.s have also gathered more influence with nurses and other healthcare providers.

In terms of practice setting, hospital pharmacists saw the greatest increase in influence over physicians, with 67% saying they have gained influence with physicians, compared with 47% in supermarkets and mass-merchandisers, 43% in independent pharmacies, and only 32% for chains.

Pharmacists are far less satisfied when it comes to their influence with drug manufacturers, third parties, and legislators. Indeed, a supermarket pharmacist from New Jersey said R.Ph.s have lost influence with every group, and he puts the blame largely on insurers.

Nearly nine in 10 pharmacists believe they have lost ground or remained static in their influence with PBMs and insurers, and 52% said they have less pull with these companies. Hospital and supermarket/ mass-merchandiser R.Ph.s are far more positive on this topic than independents and chains; 21% of those who practice in hospitals and 14% of those in supermarkets or mass merchants see a gain in their influence with insurers, compared with 2% for independents and 3% for chains. As in most questions of influence, the Midwest is the most upbeat and the East is the least: Only 3% of Easterners reported a gain in influence, compared with 19% in the Midwest, and 12% in both the South and West.

As far as pharmacists' sway over drug manufacturers and legislators, the results are nearly identical: About one in five said R.Ph.s have gained influence with these two entities in the past two years, and about four in 10 said their influence remains the same. Slightly more R.Ph.s believe they have lost some clout with manufacturers than with legislators (36% versus 28%), however.

Newer pharmacists are far more positive about their influence with drug manufacturers than are other pharmacists; 32% of those in practice for fewer than 10 years said they have gained influence with manufacturers, compared with lower percentages for R.Ph.s who have been in practice longer. Also, pharmacists in the East make an uncharacteristic showing, reporting that they see the most gain in influence with drugmakers, while R.Ph.s in the West appear particularly downbeat; 50% of them said they have lost influence with drug companies, while 28% of those in the East see an increase in R.Ph.s' influence.

Less pull with legislators

Many pharmacists were undoubtedly mindful of Sept. 11 and the many challenges facing America and its lawmakers when they were asked in February 2002 if they have lost or gained influence with Congress in the past two years. Despite the many changes in our national priorities, as well as a shift in political parties in both the White House and the House of Representatives, four out of 10 pharmacists believe their influence with Congress remains the same compared with two years ago. One in five said R.Ph.s have actually gained ground with lawmakers, while 28% believe they have lost influence.

Mid-career R.Ph.s were twice as likely to report a decline in influence with Congress, compared with newer R.Ph.s. In addition, only hospital pharmacists were more likely to see a gain than a loss with lawmakers; 28% of them said they gained in influence and 18% saw a loss. However, 12% of both independent and chain R.Ph.s reported a gain, and 33% of independents and 49% of chain R.Ph.s said they've lost influence with Congress. Supermarket and mass-merchandiser R.Ph.s also went with the majority, with only 17% reporting a gain in influence and 29% seeing a loss.

All four regions of the country were unanimous: More R.Ph.s in each area said pharmacy has lost influence with Congress than said they had gained in favor with lawmakers. There were highly mixed feelings within areas of the country, however. For instance, 30% of Western pharmacists said they gained ground with legislators, while 41% believe they have lost influence. A mere 8% of pharmacists in the East believe pharmacy has won favor with lawmakers, compared with 25% in the South and 21% in the Midwest.

From practice setting to practice setting and region to region, respondents showed a wide variation when asked about the power of the pharmacist. One simple fact emerged clearly, however: Pharmacists believe that theirs is a profession with room for improvement when it comes to authority and influence.

Debbie Epstein

The author is a writer based in New Jersey.

Debbie Epstein. THE POWER OF THE PHARMACIST.

Drug Topics

2002;9:58.