What is the future of pharmacy? It seems to be a hot topic no matter where you look, and I've written about it a lot, as you know. My argument has been that pharmacists must get into the digital health/medicine space before it's too late and that there are myriad ways for us to transition from a product-based model to a value-based/service-based model. I am still actively looking for that one start-up that will do it, and a few I am quite interested in as possibly crossing that Rubicon. Nonetheless, several papers and pieces have come out that I think are worth addressing as I believe they reaffirm some of my beliefs but also leave some trepidation.

Deloitte's 'The Future of Pharmacy'

Now, this is a fascinating read. The perspective highlights the technology changes coming to the market, which I thought was right, though I think cutting it closer to pharmacy and pharmacists would have been a bit nicer to show relevance. Demonstrating tech is happening is all and good, but how pharmacists can leverage it is key. But to be honest, I do not think that was their objective. They highlight how the pharmacy can serve the continuum of patient care, with wearables and sensors identifying key issues, and where (very futuristically I would say) a pharmacy could 3D print a medication which a drone would then drop off. Now, who prints the drug? Is that a pharmacist or tech? I do envision a 3D personalized medicine approach to drug molecule therapy at some point, and how we train pharmacists for that is daunting. Goodbye mortar and pestle, hello 3D drug printer.

Now, Deloitte talks about the future of the pharmacist, and some of their key concepts were:

• Pharmacists are underutilized resource (really appreciate that affirmation)

• "Pharmacists may find themselves at a professional crossroads: either grow their role's scope and value or face potential disintermediation." Now, this is quite interesting. They posit that the change in technology advancement will dictate the level of care or services -- with AR contact lenses worn by a pharmacy technician to verify medications. To be honest, we don't need the AR; we already see this done with techs verification of dispensed drugs. The bigger question to me is the verification of prescriptions legally conducted by a pharmacist. 

• The perspective highlights (again by everyone) that a growing need for physicians and lack of supply leaves an open door for pharmacists to fulfill that PCP burden. They see three areas for pharmacists:

  • Digital - Help patients and providers select, implement, and manage DTx and non-drug solutions. I get that, and I have been pushing that. Preferably though, I think we should just skip being the guides and just jump into doing it ourselves. 

  • Medical - Specialize in the treatment and management of complex chronic diseases with an understanding of genetics. That's already been done, but not executed, I would say very well.

  • Behavioral - Focus on mental health and SDoH. Again, similar to medical, we are already doing that.

• I would say that their conclusions on what pharmacists can do are still limited, and really are the same conversations that have been occurring for the past 20 -30 years. Yes, pharmacists are in trouble with tech, so what can we do with technology and build a business around our clinical service and not just dispensing medications and pulling ourselves up with our bootstraps.

Finally, the perspective talks about outside disruptors and allies for the current and future ecosystem of pharmacy. These are good questions. I would love to see some pharmacy researchers and analysts take it on. But the problem for me is if it's focused on the pharmacy profession or the pharmacy business. Overall, I liked this piece, but I think a follow-up would be interesting to address some of my concerns.

JAMA Study Demonstrates Patients Visit their Pharmacy more than their PCP

Now this study is likely to be used by multiple pharmacy researchers as an 'Aha!' reference. I know I will, but with caveats. We know that 9 out of 10 Americans live close to a pharmacy, and often, they serve as a health hub, especially in health deserts. But how often do they actually see the pharmacy (keep this in mind, its pharmacy, not pharmacist)?

So Dr. Berenbrok and colleagues from UPitt did an interesting analysis I have not seen before and really applaud. I think their work should be followed up - and I hope they do. So what did they do here? They essentially conducted a cross-sectional study of a random 5% selection of 2016 medicare beneficiaries and looked at the claims data. Specifically, they were evaluating the number of encounters with a PCP and community pharmacy. The PCP data is rather accessible, as likely the billing would have occurred due to a direct touchpoint, but... pharmacy is a bit more tricky. They had to account for a 13-day window where patients may have bought their prescription and billed medicare and thus have been at the pharmacy. Now, this means they are excluding mail-order patients, and may not account for prescriptions picked up by someone else. Now, this would be very interesting during the current pandemic, what with telemedicine from PCPs now offered, and patients getting mailed medications directly from a community pharmacy or even using services like DoorDash. I'm pretty sure no one is going to use 2020-2022 data for this reason (haha). Nonetheless, the inference is based on their methodology, which I cannot fault based on their dataset.

They found that overall visits to a pharmacy outnumbered visits to a PCP based on billing codes by almost 2 to 1. Interestingly, this varied depending on the state, but the south and midwest saw more touchpoints with a pharmacy than the northeast USA. I do not find that surprising, given a look at PCP shortages in certain parts of the US are similar, so wait times must be higher. 

Now, I did find their discussion most interesting. They made the logical leap that this demonstrates patients may see a pharmacist more often than a PCP... "the frequency of visits estimated by our analysis suggests that community pharmacists have frequent opportunities to deliver patient-centered services in community-based locations." Now that makes sense, right? You have specific areas where pharmacists may be the most accessible health professional (and you don't have to pay them to make a consultation or a call!). So it's logical that they could provide clinical services for disease management.

Until... you get to the issue that it's likely most interactions did not occur with a pharmacist and was a purchase by a family member or patient with a pharmacy tech running the cash register who declines they have any questions for the pharmacist because you know they are overworked and understaffed at this point. And I'm not saying the authors did not recognize that this was limitation three and four that cognitive services cannot be established in this dataset analysis, nor infer what is said and done at a PCP or pharmacy locale. To be frank, I don't know how you could do that without some massive mechanic that I do not know who would fund at this point. But I think this really hurts their conclusion that community pharmacists are really an accessible health professional resource. I think their paper actually establishes that the pharmacy (i.e., locale, business, etc.) is an excellent potential for businesses to serve the patient community. And you'll see my personal thoughts on this at the bottom why that is an issue. This study lends more credit in my mind for the business potential rather than the pharmacist's potential at this point, and that may be an unintended outcome of how this paper will be used that the authors may not have intended. THough post-COVID would be interesting to compare, I'd say. Someone do that.

Lastly, I really liked one section they had, and I want to quote it:

"It is also important to note that pharmacists cannot capitalize on accessible and frequent encounters at community pharmacies without further practice change and transformation. The need to recognize pharmacists as providers of billable services, integrate pharmacists in emerging delivery and payment models, and enhance collaborative relationships... To further capitalize on the uniqueness of the pharmacist as an accessible health care professional, pharmacy and health care organizations must consider how community pharmacy practice will adapt to transformed pharmacist roles, including changes to business models, workflows, and staffing."

I'm just gonna throw that whole thing on a slide at my next presentation about the need for digital health transformation for pharmacists. Thanks to the authors!

How Pharmacy can conduct a 24-Hour Blood Pressure Monitoring Service 

Now, I was working on this article with the first two papers above, when I saw an interesting tweet by Dr. Dave Dixon from VCU. 

Ugh, I mean, this just reinforces my view that if anything, pharmacists will have too many hurdles to climb and that if making alliances doesn't work, then maybe we should steamroll ahead.

In any event, his paper actually really fits into this piece! You see, Dr. Dixon and colleagues have done what I think emphasizes what pharmacy/pharmacists can do and actually transforms the model of care currently. Now I am not going to go crazy detailing the paper, but primarily at two independent (always the independents most innovative I say for academics) offered ABPM after referral by a provider or self-referred for HTN monitoring requiring confirmation of HTN. Now, if you are not familiar with this process, it sucks. You can spend days or weeks waiting to get a device to continuously track your BP, and I often think pharmacy (especially with digital health products!) could just make up for this logistical nightmare. In any event, 52 participants were enrolled, with 46 having successful ABPM with mixed results confirming or canceling the potential HTN diagnosis (e.g., white coat HTN). And 88% of the patients agreed that they were satisfied with the service! For further information, Dr. Dixon also has a presentation exploring some other aspects that you can see here. Now, if only a follow-up study was done to have the pharmacist, then manage the patient... Dave get on that.

In any event, this work I think is key for pharmacists to explore to engage in tech developments, model what pharmacists are doing around the world, and to look towards business expansions and capabilities not necessarily tied with a drug product. If pharmacy turns into the home base for clinical services leveraging hardware of software, pharmacists are likely in the right position to regard them as a formulary of products to evaluate for patients to use on a clinical case by case model and achieve a level of care not seen before.

Some Personal Thoughts

Now, these items really got me thinking about several aspects that I think are worth addressing.

• All of this was done pre-COVID, and I think taking a post-COVID outlook is critical. Things will change fast, and patients as consumers of health will be key, as I've mentioned in a previous article about how the pandemic will impact pharmacy. I really think testing can be taken on by pharmacy and will be, and vaccinations we will conduct at a large scale. But the tele space we are still lacking, and we need to leverage RPM abilities now.

• Pharmacy does not mean pharmacists. Lets really talk about the elephant in the room. Even the JAMA piece highlighted their work was focused on pharmacy, but not pharmacists, and every paper talks about what a pharmacy (as a business and locale) can offer patients. But that doesn't mean it's a pharmacist doing that work or getting paid for it. Look at Walgreens with their new push for primary care with their partnership with VillageMD. Do you really think that if they are going to attach directly primary providers with a pharmacy, they will have pharmacists provide clinical services? Maybe some service expansion may occur, but I don't see it exploding as a possibility, to be honest. Even the CVS HealthHubs I haven't seen much work on involving the pharmacist. So, in the end, the business model focuses on the brick-and-mortar building as a center of care, but the status quo of a pharmacist doesn't change. This is perhaps the most troublesome topic at hand that really needs a change in the dynamic of terminology change. We need to stop saying pharmacy and put the pharmacist first if we want to develop the profession.

• Philosophically, I have always struggled with the concept of can a pharmacist exist without a pharmacy. In certain circles, you'll hear this discussion, and for those that take a topical view of pharmacy (by which they generally mean the actual business and building), the answer is no. But taking a look at the profession, its a bit of a class struggle, with 'clinical' pharmacists separated for their services, and 'staff' or dispensing pharmacists relegated directly to their roles getting medications out the door. I would say that this is a huge issue that most in the tech world and, in general, do not recognize. I hear some clinical pharmacists saying dispensing will be automated, and that sector of pharmacists destroyed at large or relegated to remote call centers for prescription verification. They think their clinical jobs are safe, but I would argue probably not, just further downstream the technology advances and digital health will hit them too, just like the medical field at large. So we really need to have a good hard look at professional duties and remuneration aside from dispensing or clinical knowledge, which brings me to my next point.

• This pandemic is a strategic issue that will haunt us or help us. We are so focused on surviving. Pharmacy is getting hammered, and we are seeing hours being cut across the country. There is a big focus on PBMs and dispensing fees, which need to be addressed but shouldn't consume us. Focusing on drug dispensing for the profession is flawed and is a tactical thought process for the problems now and not later. The pharmacy will continue to exists one way or another, but what pharmacists do is another matter. So, we know testing and vaccinations will be a massive gig for us soon. We need to leverage other capabilities, such as getting into RPM and teleservices for chronic conditions. This can work, and we have evidence for it (see this small sample of collated studies, for instance). We have other evidence on what happens if a pharmacy closes and impact on public health and that pharmacists' interventions if we can prescribe, can be beneficial. That should be an area to focus on, and I'd like to see that have more discussions.

In summary, we see a lot of people questioning the value and business potential of pharmacy. Little I think hits on the pharmacists themselves and needs to be addressed. Is the future bright for pharmacy? Yes. I have no doubt it will be a business that will see a massive transformation. But will pharmacists drive that change or be taken along for the ride is my most considerable concern. We have all this tangential information that gets us right along the razor's edge to demonstrate we should be paid as providers. But we're not there yet and for all so many different reasons. My take? Get with the technology before others do it for us.