Abstract
This chapter aims to provide a summary of different approaches to the payment of pharmaceutical care that have been adopted in selected countries. Each of them is described in brief, with the ultimate goal of highlighting the pros and cons of each approach. The second part of the chapter elaborates on a possible solution to make pharmaceutical care not only a clinical activity which is essential to ensure the patient receives optimal therapy to attain better outcomes , but also to transform this practice into a profitable service. We believe this option is essential for pharmaceutical care to flourish worldwide.
Keywords
The original version of this chapter was revised: The affiliation of editor, Professor Filipa Alves da Costa has been updated. The erratum to this chapter is available at https://doi.org/10.1007/978-3-319-92576-9_41
1 Selected Cases of Remunerated Services Where Different Costing Methods Were Used
Although still not being remunerated, the cost of medication review has been recently estimated for Spain [1]. The approach taken was based on the time-driven activity costing method, an approach that quantifies all costs involved in service delivery. For the estimate, there is a need to time the service delivery, something not routinely done in pharmacy practice. In the model used, named Medication Review with Follow-up (MRF) seven stages were considered: face-to-face interviews; initial assessment of clinical situation; study phase; advanced medication review focusing on the identification of DRPs and negative outcomes ; action plan; delivery of interventions to address the identified DRPs; and the follow-up visits. The mean time spent on service provision was around 6.5 h per provider during 6 months. This included all visits undertaken during that period, which accounted for around 40% of the time estimated. Additional detail is included on the original manuscript referring to the timings allocated to the various stages of the process. The potential service price ranged from 237 to 628 €/patient /year, suggesting that reallocation of tasks so that less expensive staff were involved could be considered, as long as the quality of the service delivery could be sustained.
A similar methodological approach has been taken in Portugal looking at different types of service, including dispensing of medicines, patient counseling and screening programs [2]. According to Gregório and colleagues the cost of these services are, respectively, around 4, 1.3 and 3.5€. It is worth mentioning that none of these three services is currently remunerated in Spain or in Portugal.
One other service currently remunerated in Portugal is the needle exchange program, paid by the Public Health Service at 2.40€. This achievement was a result of a study using a two scenario analysis, considering the existence of the program in pharmacies and its absence, over 5 years. The gains were estimated considering the infections avoided according to the model of Jacobs et al. where epidemiological data were taken into account [3]. The model ascertained that along 5 years (2015–2019), the involvement of community pharmacies would result in a reduction of 22 HIV and 25 HCV new cases. The number of exchanged needles was forecasted at 87,761 in the first year and 169,347 in the following years. As a result, the overall costs per needle exchanged were estimated to be 3.09€ [4].
Another recently published study, yet with no consequences in terms of reimbursement, used a decision model to estimate the social and economic value of the pharmacist. The model used information collected in literature about effectiveness of services, quality of life gains and use of health care resources, which were then adapted to Portugal through an expert panel. The authors estimated that considering all the current pharmacy services result in a quality of life gain of 8.3%, valued at nearly 900 M€. This value was considered to include 342.1 M€ attributed to non-remunerated services and 448.1 M€ in avoided costs due to the use of health care resources [5].
Since 2010, Swiss community pharmacies can offer a ‘Polymedication-Check’ (PMC) to patients on ≥4 prescribed drugs taken over ≥3 months. Referring to the different types of medication reviews, defined by the Pharmaceutical Care Network Europe (PCNE), the PMC is identified as an ‘intermediate’ medication review . Information is available from the medication history, which is mandatorily kept in Swiss community pharmacies, and from a structured patient interview. The check focuses on adherence problems, patients ’ knowledge, and handling problems. At the end of the interview, the patient signs the documentation form and the pharmacy can charge a fee of 40€ to the health insurance irrespective of the time spent. This fee is a result of negotiations with the authorities based on the assumption that this medication review only takes 20 min. After introduction of the service, research showed that the time needed is around 30 min which might be one reason for the very disappointing uptake by Swiss community pharmacies with only about three checks per pharmacy per year and a large majority of pharmacies not offering this service [6].
Through the PMC, pharmacists can evaluate a patient ’s need for a weekly pill organizer (WPO). If the patient agrees and is taking at least three different medicines, the pharmacy can prepare a pill organizer/blister pack. Likewise, the GP can prescribe the provision of a WPO. This service is remunerated by 20€/week. Again, this fee is the same for all pharmacies and is a result of negotiations, which are not based on time requirement or any proof of cost-effectiveness. This service is very well implemented in Swiss community pharmacies reflecting their economic interest in this service [7].
Very recently, new services received remuneration if provided by specialized pharmacies and if the patient voluntarily affects a supplementary insurance. Using the example of asthma , a certified “Air Way Pharmacy” can include patients suffering at least one problem of the asthma control test (ACT) into a comprehensive asthma care program. The service comprises spirometry, individualized counseling on best use of asthma medicines and up to three follow-up visits. The fee of 220€ per patient per year is paid if at least two follow-up visits were reported. Similar services with similar fees paid by supplementary insurances cover, e.g., migraine, musculoskeletal pain, and hypertension.
2 The Lean Management of Pharmaceutical Services: How Can We Boost Service Provision and Make It Profitable?
In order to provide pharmaceutical care services in a cost-efficient way and to reduce the workload of pharmacists while service provision is enhanced, different approaches can be considered:
First , we should organize the workforce in our institutions. Pharmacy technicians are able to take on a larger role in pharmacy practice. For illustration, performing medication reviews comprises distinct activities within a structured process. Initially, a best possible medication history is needed which often involves a reconciliation of medicines prescribed currently versus in the past. Often, a brown bag analysis of the medicines in the hand of the patient is additionally performed. These preparatory tasks could be delegated to pharmacy technicians [8, 9]. Eventually, patient interviews focusing on adherence and handling problems could be delegated as well. On the other hand, the clinical assessment of potential and manifest drug-related problems associated with efficacy and safety issues need a clinical judgement by a pharmacist. Thus, medication reviews could be performed in the pharmacy setting in collaboration and with support by a technician. Similarly, all kind of screening services including point of care testing and smoking cessation counseling are feasible tasks for pharmacy technicians if adequately trained [10]. Overall, increasing staff productivity is the highest priority with respect to the delivery of cost effective pharmaceutical care .
Second, prioritizing of patients served and of their problems is key in order to achieve outcomes with a reasonable effort. For prioritizing of pharmaceutical care delivery at ward level, a simple self-assessment questionnaire to screen for hospitalized patients at risk for drug-related problems has been developed, enabling targeted pharmaceutical care during the hospital stay and upon discharge [11]. More challenging is the priority setting during a medication review of polypharmacy . Multiple DRPs become evident and a clinical judgement is needed to address the most relevant problem for intervention. Again, a collaborative approach could be used with delegation of interventions to the best-suited health care professional. Likewise, a lot of follow-up activities can be delegated as well, e.g., to a pharmacy technician.
Third, short and easy to use checklists, standard operating procedures and validated tools can be supportive in daily practice. Such tools need to be tailored for practice (and not only retrieved from research) and must be adapted to local situations. The NHS Medicines Use Review service worksheet can be cited as a good example [12].
Fourth, technology can assist with delivery of pharmaceutical care . The question is how we could better use ehealth (or ePharmacy). Not only to support dispensing and administrative/logistic processes but also for patient care. However, little information is available concerning the implementation of clinical decision support software in community pharmacy practice [13]. Fortunately, ehealth will push on traditional practices. Information systems and technologies will have an important role in shaping future health care provision. And, online pharmaceutical services will emerge such as ePharmacare [14].
Fifth, training is essential. Moreover, the best training only can result in efficient service provision if the service is frequently provided to become at least weekly routine. Therefore, a kind of specialization within a team of pharmacists might be a solution, but only feasible in large community pharmacies.
In short, through optimized organization of both, the workforce and the processes in the pharmacy the imperative target of lean management of pharmaceutical care services can be achieved.
3 Conclusion
We have provided some examples of services being remunerated in different countries, briefly explaining the grounds for the fee estimate. So far, in pharmacy practice, we have identified four major approaches to estimate the fee of a service:
-
(1)
based on the time spent to provide the service, irrespective of the result;
-
(2)
based on the results achieved, which depending on the disease or the setting could be cases of disease prevented, controlled, or cured;
-
(3)
fixed fee based on meeting a minimum set of quantity and/or quality requirements; and
-
(4)
negotiations with the payer with no solid grounds (these may be market research, for instance, where the cost results from what is “normal” in other countries or when the service is provided in other venues or by other healthcare providers).
Each of these approaches has advantages and disadvantages, and highly dependent on the functioning of the health care system and also on the culture in place. Some services might benefit from one way of remuneration in an initial phase and then an adaption into a different model of payment. One possible evolution is to start with model 1 (to foster adoption), then evolve into model 4 (to improve quality), and finalize with model 2 (to ensure patients and payers indeed benefit from the service).
Change history
02 November 2018
Correction to: F. Alves da Costa et al. (eds.), The Pharmacist Guide to Implementing Pharmaceutical Care, https://doi.org/10.1007/978-3-319-92576-9 The original version of the book was published with the affiliation “Ordem dos Farmacêuticos (Portuguese Pharmaceutical Society), Lisbon, Portugal” of the editor, Professor “Filipa Alves da Costa” in the frontmatter and in chapters 5, 14, 35, 37 and 38, which has now been changed to “Instituto Universitário Egas Moniz (IUEM), Monte da Caparica, Portugal”.
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Alves da Costa, F., Hersberger, K.E. (2019). Paying for Pharmaceutical Care. In: Alves da Costa, F., van Mil, J., Alvarez-Risco, A. (eds) The Pharmacist Guide to Implementing Pharmaceutical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-92576-9_38
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