Clinical Therapeutics/Volume 32, Number 5, 2010

Editorial Comment

Patient-Centered Services: What Could We Be Doing Right?

With President Obama’s signing into law of the Patient Protection and Affordable Care Act on March 23,1 pharmacists
again have an opportunity to provide patient-centered care.2 Specific provisions of the act encourage the delivery
of medication therapy management (MTM) services by pharmacists, promote integrated care during hospitaliza-
tions, and address issues of health care quality and the health care workforce. However, if we are to get things
right—allowing pharmacists to provide MTM services, something they have been educated to do for almost
20 years3—the terms of MTM provision must be divorced from the dispensing of drug products.
In providing MTM services, the pharmacist partners with patients, caregivers, and other health professionals to
promote the safe and effective use of medications. Medicare Part D plans are required to offer MTM services to
beneficiaries, and eligible beneficiaries receive a comprehensive medication review that includes a personal consul-
tation with a pharmacist, as well as quarterly targeted medication reviews. However, to provide all the analytic,
consultative, educational, and monitoring services needed to help consumers achieve the best results from medica-
tions, pharmacists must be freed from performing distributive functions and their services provided upstream of
the dispensing process. A recent 10-year study of MTM services found that removing pharmacists from the dispens-
ing of prescriptions and reorienting them solely toward the provision of patient-centered services was associated
with safer and more effective medication use.4
The provision of MTM services is based on the recognition that a drug’s safety and effectiveness are not functions
of the molecule alone. Indeed, the promise of efficacy that accompanies many drugs at the time of their approval
fades as their use becomes more widespread. Although we know this, little is actually done across the patient-care
continuum to ensure that the use of drugs is as close to the intended purpose as possible. Pharmacists have the
necessary education and training to follow and systematically monitor how individuals react to newly prescribed
drugs.5 For example, there is a high potential for aging, genetic composition, use of concurrent medications, and
comorbidities to affect a drug’s actions—some of the effects are predictable, while others are not. Although educated
and trained to monitor effectiveness and safety, pharmacists rarely have the opportunity to practice what they have
been prepared to do by their training. Instead, within 6 months of graduation, many pharmacists are functioning
mainly as highly paid technicians and are not viewed as independent practitioners by themselves or by others.
The majority of pharmacy graduates in the United States and Canada are faced with accepting employment that
buries their capabilities beneath the dispensing of drug products; this is how their value is expressed to the world.
Many pharmacists feel their only alternative to this automated drudgery is to move on to get another degree
(medicine) or an administrative position in a hospital or insurance company. There is no reason why those who
stay in the community pharmacy setting should not be valued for their ability to follow up and monitor drug safety
and effectiveness. However, it is difficult for new pharmacists to insist on environments separate from dispensing
that reward the provision of MTM services when their corporate employers hold all the lifelines to financial security
early in their careers, a time when they are faced with paying back student loans and other obligations. Can and
will the majority of pharmacists take advantage of the opportunity being offered by the Patient Protection and
Affordable Care Act? That remains to be seen—some pharmacists working in smaller independent pharmacies did
seize the opportunity to provide MTM services when the Medicare Modernization Act went into effect in January
2006,2 but poor administration of its provisions soured their efforts.6
As with the United States, Canada does not seem to be making much progress toward having pharmacists pro-
vide patient-centered care exclusive of the dispensing function. The provincial government of Ontario has introduced
legislation to make prescription drug pricing more transparent.7 In other words, there are to be no more rewards,
termed professional allowances, paid by pharmaceutical companies to pharmacy corporations for stocking the
range of products within a specific generic brand. Instead, more than $100 million will be made available by the
provincial government to pharmacy corporations to step up and provide follow-up and monitoring services for a

962 Volume 32 Number 5

 Editorial Comment

professional fee; for providing such services, they will be allowed to increase their dispensing fees. However, an
earlier (2006) version of this policy that provided $50 million for medication consulting8 resulted in these same
pharmacy corporations leaving more than $38 million on the table. Furthermore, after an audit, it was found that
70% of professional allowances went toward fringe benefits, bonuses, overhead costs, and the boosting of profits
rather than to salaries and benefits for providing patient services.9
Providing professional services such as MTM is a messy business—it is a largely unstandardized process that
cannot be tabulated as easily as sales of tobacco or health and beauty aids. Prescription dispensing is more stan-
dardized and can literally be counted on to add to the bottom line of the corporation—the more prescriptions
dispensed, the better the economies of scale and the net profits realized. However, the body of work produced by
the originators of the Peters Institute of Pharmaceutical Care in Minneapolis has dispelled most of the perceived
unprofitability of offering professional pharmacist services.10 Investigators from this institute reported a 30%
return on investment associated with offering pharmacist services that did not involve the dispensing of drugs.4
Based on numbers provided by Kozyrskyj et al11 and the framework and strata for matching need with service and
price developed by Cipolle et al,10 I estimated the costs of applying a model of pharmacist (MTM) services in
Manitoba, Canada. I found that a mere 4% of the provincial drug budget would be needed to pay half of the
province’s pharmacists $90,000 annually to do what they are trained and educated to do, and should be valued
for—helping people to use their medicines better. The savings to the provincial government would be substantial,
and the pharmacist’s value would be priceless, particularly when a life is saved, for example, because of better
warfarin monitoring.
One could assign value to the provision of MTM services by pharmacists simply by examining the papers in
this month’s Pharmaceutical Economics & Health Policy section of the journal. After reading the article by Guénette
and Gaudet12 examining the impact of prior authorization for asthma medications on the use of emergency health
services, one is left wondering whether prior authorization policies would be necessary if pharmacists were allowed
to fulfill their societal responsibility. If pharmacists were actively participating in patient care, would asthma con-
tinue to be inadequately controlled, as the article states, or would patients instead be enjoying a better quality
of life?
In an article describing their study in outpatients with type 2 diabetes mellitus (DM) in the Jiangsu province of
China, Bi et al13 report that making a pharmacist available to assist patients with glycemic control and general DM
education was associated with improvements in patients’ health status at tertiary care hospitals. These authors con-
clude that “future research should investigate structural interventions and policies to improve DM care in primary
and secondary hospitals.”
To improve medication use, perhaps the best course for pharmacists would be to accept the challenge and agitate
for a different structure within which to practice what they have learned. Both dispensing and professional services
are probably integral to a successful pharmacy practice. However, pharmacists do not work in practices, they work
for corporations that have little incentive to offer MTM services separate from dispensing. Pharmacists could have
positive effects on the topics and issues discussed in this section of the journal. However, as long as it is a matter
of corporate pharmacy fighting for profitable dispensing rather than pharmacists fighting for their duty to provide
MTM services—incorporating the pharmacist’s expertise in the provision of patient-centered care seems to be beyond
the collective reach of the profession and beyond legislation. Doing it right would begin with shifting the perception
of pharmacists from something akin to shopkeepers to the health care providers and experts in the use of medications
that they are. We need more pharmacists helping people manage their medications on a fee-for-service basis, letting
technology and technicians do the job of drug dispensing.

Colleen J. Metge, BSc(Pharm), PhD

Associate Professor and Senior Scholar
Faculty of Pharmacy
University of Manitoba
Winnipeg, Manitoba
Canada

May 2010 963

 Clinical Therapeutics

REFERENCES
1. H.R. 3590: Patient Protection and Affordable Care Act. http://www.govtrack.us/congress/bill.xpd?bill=h111-3590&tab=summary.
Accessed May 10, 2010.
2. Public Law 108-173—December 8, 2003. Medicare Prescription Drug, Improvement, and Modernization Act of 2003. http://
www.ustreas.gov/offices/public-affairs/hsa/pdf/pl108-173.pdf. Accessed May 10, 2010.
3. Hepler CD, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–543.
4. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 Years of experience in a large integrated
health care system. J Manag Care Pharm. 2010;16:185–195.
5. McKnight AG, Thomason AR. Pharmacists’ advancing roles in drug and disease management: A review of states’ legislation.
J Am Pharm Assoc (2003). 2009;49:554–558.
6. Roberts BT. A community pharmacy success in Medicare Part D plan. http://ncpanet.wordpress.com/2010/01/28/a-community-
pharmacy-success-in-medicare-part-d-plan/. Accessed May 10, 2010.
7. Notice of proposed regulations to amend Regulation 935 under the Drug Interchangeability and Dispensing Fee Act and
Ontario Regulation 201/96 under the Ontario Drug Benefit Act. http://www.health.gov.on.ca/english/public/legislation/
drugs/regulation_935.pdf. Accessed May 10, 2010.
8. Legislative Assembly of Ontario. 38:2 Bill 102, Transparent Drug System for Patients Act, 2006. http://www.ontla.on.ca/web/
bills/bills_detail.do?locale=en&BillID=412&isCurrent=false&ParlSessionID=. Accessed May 10, 2010.
9. Ontario Ministry of Health and Long-Term Care. Drug system reforms. Our plan: Fairer prices for drugs. http://www.health.
gov.on.ca/en/public/programs/drugreforms/our_plan.aspx#1. Accessed May 10, 2010.
10. Cipolle R, Strand L, Morley P. Pharmaceutical Care Practice: The Clinician’s Guide. 2nd ed. New York, NY: McGraw-Hill Medical;
2004.
11. Kozyrskyj A, Lix L, Dahl M, Soodeen RA. High-cost users of pharmaceuticals: Who are they? http://mchp-appserv.cpe.umanitoba.
ca/reference/high-cost.pdf. Accessed May 7, 2010.
12. Guénette L, Gaudet M. Impact of prior authorization for asthma medications on the use of emergency health services: A retro-
spective cohort study among newly diagnosed patients with asthma. Clin Ther. 2010;32:965–972.
13. Bi Y, Zhu D, Cheng J, et al. The status of glycemic control: A cross-sectional study of outpatients with type 2 diabetes mellitus
across primary, secondary, and tertiary hospitals in the Jiangsu province of China. Clin Ther. 2010;32:973–983.

doi:10.1016/j.clinthera.2010.05.009

964 Volume 32 Number 5