THE CURE …
It was meant to be a simple pre-election news conference, replete with wide-eyed pharmacy students who clapped dutifully as Alberta's Health Minister praised their profession.
Pharmacists are a pillar of patient care, Fred Horne told the crowd, and will play an ever-larger role as provinces allow them greater powers, such as renewing prescriptions and ordering lab tests.
By taking on these roles, pharmacists will help ease clogs throughout the overstretched health system, the minister said. Applause rang out in the University of Alberta atrium as students leaned out over railings to watch from several floors above.
But behind the cheers, a battle is brewing as the patchwork regulation of Canada's pharmacy profession is overhauled. Pharmacists are indeed being handed more powers, but they are also seeing, in many cases, their lucrative funding model whittled away.
… BECAME THE PROBLEM …
It's all a murky system tucked away behind the tall counters and white coats, but it boils down to this: Governments want your pharmacist to play a much larger role in routine care, but are making cuts pharmacists say will instead force them to roll back services. The new funding models also tend to attach government money strictly to prescription counts, not to consultation, meaning pharmacists only earn more money by handing out more pills, whether they're needed or not.
Foremost among the cuts is a clampdown on subsidies paid to pharmacies by drug companies. It goes like this: Mr. Horne announced on Feb. 13 that Alberta would save $85-million annually by lowering its cap on generic drug prices, thereby lowering what it pays to cover the cost of those drugs for certain groups, such as seniors. Other provinces, including Ontario, have also lowered their caps.
The moves will, however, slash drug-company profit margins and, as such, reduce the "rebates" those companies send back to pharmacies – effectively, bonuses for selling their drug. Those rebates form a pillar of pharmacy income, with much of the rest coming from a dispensing fee of about $10 per prescription.
… AND THE PATIENT PUSHED BACK.
Although the complex changes sailed over the heads of many, they raised the ire of pharmacy owner-operators. In the atrium, Kit Poon stood up when Mr. Horne asked whether students had questions. But Mr. Poon wasn't a student. Instead, he's a 32-year-old pharmacy owner who had a bone to pick.
Mr. Poon told Mr. Horne, a veteran health-care consultant who entered politics four years ago, that pharmacy owners would be out tens of thousands of dollars because of the changes. ("I'm not an expert on how this is going to affect individual pharmacists," Mr. Horne replied.) Mr. Poon thinks he'll have to lay people off.
The standoff is a sign of the broader battle being waged nationally in quiet meetings over the fate of the profession. Alberta pharmacist Jody Shkrobot, who serves as the head of the Canadian Pharmacists Association, called Mr. Horne's announcement a "slap in the face." But other provinces are in the midst of similar changes.
Ever more, pharmacists say they have become a front line of health care, spending more time on routine cases than a doctor. They say they often catch errors in prescriptions and refer patients back to a doctor's office. Pharmacies have been able to hire staff, who spend more time with patients, because they were rolling in cash - one of Alberta's richest men, after all, is billionaire Rexall Drugs mogul Daryl Katz. A first-year pharmacist can command $90,000 annually in Alberta.
Now, some warn services will have to be cut and the future of the industry remains unclear. The new Alberta system will also not encourage pharmacists to be front-line health professionals – it pays them only to dispense pills, and not to consult with patients. Pharmacists say they should be paid for assessments, not prescriptions.
TAKE MR. POON, FOR EXAMPLE …
"If this is the end result, the end point of what they're announcing, it really diminishes the role of the pharmacist," Mr. Poon said of the Alberta system. "It's actually a step back."
A half-hour drive from Edmonton, the main drag of Stony Plain, Alta., has clung to a distinctly small-town feel. Parking is free and traffic moves at a snail's pace as citizens, mainly seniors, run their daily errands.
In the heart of it all is Mr. Poon's Mainstreet Home Health Pharmacy, which he opened two years ago. It's one of a dying breed of independent shops.
Inside, he knows many patient files by name – a young girl with concussion-like symptoms, a dog in need of a powdery medication, a suicidal person hoarding pills. In each of his cases during a winter Monday afternoon, he did more than fill a pill bottle. He identified symptoms, referred patients to doctors, talked at length with customers and flagged incorrect prescriptions. All without being paid by the system for it.
A pharmacist's secret is simple: The more time to spend with patients, one on one, the better. "It allows us to pick up the person who falls through the cracks," he says.
Mr. Poon is precisely the type of pharmacist that provinces across Canada hope to empower, with the goal of freeing up a doctor's time from routine visits. Pharmacists can now renew routine medications, such as those for blood pressure, but not narcotics, such as codeine. Such routine prescription visits will only increase in frequency as baby boomers age.
… WHO IS CAUGHT IN A CLASH OF IDEALS …
Only three provinces, however, actually pay pharmacists to take on the new roles. Alberta will, beginning this year, pay a $20 fee each time a pharmacist does a routine prescription renewal, compared with $36 it pays a doctor for the same service. B.C. pays pharmacists $10 per renewal, while Saskatchewan pays $6 per consultation.
That difference – renewals versus consultations – is the crux of the ideological conflict in the field, torn between its pill-producing past and its ambitions of being broad health-care providers. They want to be paid for consultations instead of piecing together lucrative incomes with drug-company subsidies, dispensing fees and prescription-renewal fees.
"The renewal is still based on, 'Here, there's drugs. We'll put it into a little bottle and here you go.' It doesn't talk about, 'Hey, go to your pharmacist and get assessed,' " Mr. Poon says.
Pharmacy is a four-year program at the University of Alberta, and students can apply after just one earlier year of post-secondary schooling. Though far less schooling than doctors, pharmacists argue their education is sufficient to handle basic cases. But doctors across the country have balked at handing over certain powers.
"I guess I wonder what criteria pharmacists will use to renew prescriptions when they were not the original prescriber. How will they know it's reasonable to do so?" Alberta College of Physician and Surgeons registrar Dr. Trevor Theman said in an e-mail.
Alberta isn't the only province lowering the cap on what drug companies can charge for generic drugs -- 20 million prescriptions a year in Alberta alone. The system of drug-company subsidies, meanwhile, is considered ethically dicey by some pharmacists. "No one likes this, but it's the only way that pharmacies have been able to provide services," Mr. Poon says.
Cutting the rebates will put many pharmacies into the red, forcing them to lay off staff or close.
"Over the years, generic drug pricing has changed in a way that it actually supplemented the ways pharmacies were able to provide services," said Anjli Acharya, president of the Alberta College of Pharmacists. Pharmacists used to make money only by a dispensing fee, but those have stayed mostly stable as costs grew – opening the door to drug-company money.
"If you pull that funding out, it's not like it was just going anywhere," Ms. Acharya says.
… THAT YOUR LOCAL PHARMACIST WILL LIKELY FACE SOON …
Alberta says the changes are just one piece of the puzzle, and pharmacists indeed hope that's the case. "If this [a renewal]is the only thing I'm being reimbursed for, it's actually bad for patients. It's counterproductive," said Edmonton-area pharmacist Hugo Leung, who also attended Mr. Horne's announcement.
Each province takes a different approach. For instance, Quebec allows pharmacists to bill for being on call, while Saskatchewan has a minor-ailments program that allows pharmacists to be paid for treating minor ailments, such as rash.
In Ontario, talks are under way over how to overhaul the funding method after a similar cut in generic-drug pricing. Pharmacists there can renew prescriptions but have to try to ask a doctor first, and aren't paid.
"We should have been doing this years ago," says Dennis Darby, CEO of the Ontario Pharmacists' Association. He frames the broader powers as a way to ease up the health-system congestion caused by routine prescription renewals.
"It's not uncommon to see someone lined up in an emergency department trying to get their prescription to be renewed," he notes, a scenario that's "very, very cost inefficient."
Each province is watching the others closely as the changes roll forward. The students at Alberta's news conference have banked on the industry remaining lucrative, but there's no clear sign of where the changes – in roles and in funding – will take Canadian pharmacists.
"The real key message is pharmacists need to be able to provide care," Ms. Acharya says. "And the care they provide should be funded."
Editor's Note: In Saskatchewan, both physicians and pharmacists can treat certain minor ailments. Incorrect information appeared in an earlier version of this article.