Use Your Voice: Pharmacists as Patient Advocates
From expanding vaccination coverage to battling with PBMs, the community pharmacist has the ability to promote change like never before.
Medication affordability is one of the most pressing issues for patients who regularly visit their local pharmacies to pick up prescriptions. But exactly how can independent pharmacists advocate for this? Is this the most important issue to address first? And how does advocacy play out in real time?
Ask pharmacists and patients to name one of the most pressing issues they’re facing; the answer—medication affordability—likely isn’t that surprising. But when it comes to advocating for patients, what is the role of independent pharmacists and how does that advocacy play out in real time?
The role of the pharmacist as an advocate isn't new. In a 2015 article published in Canadian Pharmacists Journal, Jason Perepelkin, PhD, and colleagues explained, “With the profession of pharmacy changing dramatically in recent years, it has become more and more apparent that pharmacists are being placed in the driver’s seat when it comes to promoting new skills and services to patients. Not only have these changes begun to emphasize a less technical role for pharmacists, but they have also opened up many diverse opportunities for pharmacists willing to step outside their comfort zone. But the question that is being asked by many pharmacists is, ‘How?’ The answer…can be summed up in one key word: advocacy…. Advocacy in its most basic form is simply promotion…of your skills and education as a health care provider.”1
When it comes to the pharmacist-patient relationship, advocacy for patients includes self-advocating on the part of the pharmacists. | image credit: buraratn / stock.adobe.com
To Advocate and Educate
When it comes to the pharmacist-patient relationship, advocacy for patients includes self-advocating on the part of the pharmacists. As Perepelkin and colleagues noted, “Patients cannot take advantage of pharmacy services such as medication assessments or pharmacist prescribing unless they are aware of the value that these provide. Currently, patients may be confused about what pharmacists can do for them and so have low expectations, requiring little more from pharmacists than friendly and timely service. It is for this reason that pharmacists must advocate for themselves and promote their abilities and the services they can provide for patients.”1
This is especially true since the COVID-19 pandemic, when pharmacists’ roles quickly expanded. For many, pharmacists became the go-to health care provider for COVID-19 vaccines and boosters. Today, pharmacists continue to be these go-to providers—not only for the newest COVID-19 vaccines but for vaccines for influenza, shingles, and respiratory syncytial virus.
Creating stronger relationships with other health care providers is another area where pharmacists can advocate for themselves. “Physicians and other health care professionals are an important group on whom pharmacists need to focus advocacy efforts,” Perepelkin and colleagues explained. “This group is the key to developing solid interprofessional relationships and can support our profession when advocating both for and to patients.” This can be done as simply as emailing, calling, or visiting the offices of the health care providers of patients as well as local hospitals, explaining your array of services and encouraging more collaboration.1
In a 2019 position paper, the American Society of Health-System Pharmacists wrote that “pharmacists have a professional obligation to advocate on behalf of patients and the profession.”2 In the paper, the authors emphasized the importance of influencing physicians, nurses, pharmacy technicians, support staff, and other health care workers in matters such as medication safety and positive patient outcomes. Additionally, the paper highlights the importance of pharmacists playing a role in developing or changing health care policies, urging that “pharmacists participate with policy makers and stakeholders in the development of health-related policies at the national, state, and community levels.”2
To educate patients, advocacy of skills and services can be disseminated in a variety of ways, including posters or pamphlets in the waiting area of pharmacy and/or general community outreach. For the latter, this can include offering presentations about your role in the community at high schools, senior centers, and community events.2
The PBM Fight
Today, the No. 1 advocacy issue for pharmacists and their patients is pharmacy benefit managers (PBMs). Jessi Stout, PharmD, owner of Table Rock Pharmacy & Compounding in Morganton, North Carolina, said, “PBMs are squeezing independent pharmacies out of business. In 2023, nearly 1 independent pharmacy closed every day. CVS Health, on the other hand, saw an almost 11% increase in profits (they generated approximately $357.8 billion in revenue in 2023, which is the highest ever registered).”3,4
“PBMs are continuing to grow their profits at the expense of everyone else in the health care system. If they are not regulated, patients will ultimately suffer, as they will no longer have access to the quality care they are used to receiving at their community pharmacies,” Stout added.
Carter High, PharmD, RPh, co-owner of Best Value Pharmacies, Inc, in Rhome, Texas, agrees. “Pricing transparency within the PBM space is hugely important right now, as it affects the overall spend for patients in terms of their out-of-pocket costs and how their premiums are determined and such. That is something that, as pharmacists, we need to advocate so patients can get back to their employer to say, ‘Hey, there [are] cheaper options for us out there.’”
A recent article from an Ohio news station, ominously titled “PBMs Pushing Independent Pharmacies to the Brink of ‘Starvation Event,’” reports, “PBMs were designed to bring down health care costs. Drugmakers want their drugs on PBMs’ formularies, which determine which drugs are covered by insurance and thus more often purchased. Pharmacies want to be listed in network, which gives them access to more patients. In exchange, both agree to o er discounts on drug prices. A growing chorus of pharmacists, patients, and lawmakers claim instead of passing on those savings, PBMs have instead sought to maximize their own profits.”5
The article goes on to explain how pharmacists are “in effect forced to sign contracts with the 3 largest PBMs—CVS Caremark, Express Scripts, and Optum—which together control 79% of the market share. The contracts are nonnegotiable and often reimburse pharmacies less than the cost of a drug. The practice is called spread pricing, in which PBMs charge insurers a higher amount for a drug than is reimbursed to the pharmacy. Then the PBM keeps the ‘spread,’ or difference.”5
“There’s a lot of opportunity for those entities to take advantage of their market power, and they do so at the detriment of our members and the patients whom they serve,” Matt Seiler, RN, CIPM, general counsel for the National Community Pharmacists Association, said.5
Other Issues in Advocacy
Although both High and Stout agree that the battle of the PBMs is the most important current fight when it comes to advocating for patients, there is still other advocacy work to be done. “Unrelated to PBM reform, an issue affecting patients in our community is access to medications for opioid use disorder [MOUD],” Stout said. “Battling the opioid epidemic is multifaceted and includes fighting stigma, improving access to MOUD, and ensuring wraparound services are available for those released from prison. Not enough primary care providers treat [opioid use disorder], and there is no treatment offered in our local prison, where a majority of defendants are incarcerated for some kind of drug charge.”
Stout cites a few successful programs that use pharmacists as clinical pharmacy practitioners who enter under a collaborative practice agreement with a provider so that they can write prescriptions for MOUD and provide follow-up care, but the problem with dispensing medication and treating these patients remains. Stout added, “We need guidance from regulators that dispensing controlled drugs to treat MOUD will not be a source of litigation or punishment.”6
For High, who works in Texas, expanding vaccine administration for pharmacists is another challenge: “Let’s face it: Practitioners are overwhelmed. They’re understaffed. You know they don’t want to see those influx of patients for something that they know we can do, and most of the general physicians want us to do this.”
An opinion paper published on the website Governing.com states, “An overwhelming number of adult patients in the US receive their vaccinations at pharmacies. The research led to state efforts to expand and enhance pharmacists’ authority to immunize, similar to the authority enjoyed by their physician peers.”7 Recently, an immunization bill that would expand vaccination abilities for pharmacists in Texas “died in the senate,” High said.8 And so that fight remains.
Ways to Advocate in Government
“The best way to advocate is to reach out to your federal and state representatives, join and donate to the PAC [political action committee] of your national and state pharmacy associations, and educate patients on issues that ultimately impact them. It’s also important to be persistent,” Stout said. “You can’t send one email and think your job is done; the squeaky wheel gets the oil. When CVS Caremark, which is the PBM for our state health plan employees, partnered with GoodRx earlier this year, I sent emails to anyone I could think of. I followed up every couple of weeks. Eventually, I got to the right person and our state health plan board of trustees invited me to come speak at their quarterly meeting about the issues community pharmacies are facing.”
High added, “Independent pharmacists need to be part of their state association. It’s a voice that’s going to be the true voice of the profession within their state. I have had considerable influence with my [state] board with how legislation is worded, because one little word in a piece of legislation can mean a lot of different things to a lot of people. There’s a lot of ambiguity in that. The devil is in the details.”
High encourages other community pharmacists to not only get involved in a similar manner but also to not be intimidated by the often wordy and complex world of writing to state legislature. “For the average pharmacist who doesn’t typically delve into state associations and legislation, don’t be scared simply because you don’t understand it. There are mechanisms and avenues, such as your associations, to help you digest [this complicated wording of bills] to help you understand what the phrasings mean and how it will impact your practice.”
The bottom line? Whether it is for PBMs, opioid drugs, transparency in pricing, or other key issues, getting involved at the state level is crucial for community pharmacists. As Stout said, “It is this grassroots movement for change that will drive the profession forward.”
References
1. Boechler L, Despins R, Holmes J, et al. Advocacy in pharmacy: changing “what is” into “what should be”.Can Pharm J (Ott). 2015;148(3):138-141. doi:10.1177/1715163515577693
2. Little J, Ortega M, Powell M, Hamm M. ASHP statement on advocacy as a professional obligation. American Society of Health-System Pharmacists. 2019. Accessed June 3, 2024. https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/advocacy-as-a-professional-obligation.ashx
3. Cash crunch pushes independents to the brink, data says. National Community Pharmacists Association. February 27, 2024. Accessed June 12, 2024. https://ncpa.org/newsroom/qam/2024/02/27/cash-crunch-pushes-independents-brink-data-shows
4. CVS Health’s revenue from 2005 to 2023. Statista. February 12, 2024. Accessed June 11, 2024. https://www.statista.com/statistics/241536/total-revenues-of-cvs-caremark-since-2005/
5. Leigh H. PBMs pushing independent pharmacies to the brink of ‘starvation event’. Spectrum News 1. April 5, 2024. Accessed June 11, 2024. https://spectrumnews1.com/oh/columbus/news/2024/04/05/pbm-independent-pharmacy-ohio
6. Model state law to improve access to medications for opioid use disorder from pharmacists. American Society of Health-System Pharmacists. Accessed June 12, 2024. https://www.ashp.org/advocacy-and-issues/key-issues/opioids/model-moud-prescribing-legislation?loginreturnUrl=SSOCheckOnly
7. Patel A, Popovian R, Tewary V. Pharmacists’ crucial role in getting vaccines into arms. Governing. April 16, 2024. Accessed June 11, 2024. https://www.governing.com/policy/pharmacists-crucial-role-in-getting-vaccines-into-arms
8. Relating to Preventative Health Care and Public Health, Including Prohibited Immunization and Face-Covering Requirements, Private Business or School Closures, and the Ordering and Administration of Immunizations by a Pharmacist, HR 1105, 88th Leg (Tex 2023). LegiScan. Accessed June 12, 2024. https://legiscan.com/TX/bill/HB1105/2023
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