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Factors Influencing the Delivery of Pharmacy Services
Factors Influencing the Delivery of Pharmacy .s ervices This study explored the link between pharmacy seroices and the percentage ofprescriptions covered by third party plans. Financial incentives are neededfor pharmacies to increase services. by Michael .J. Miller and Brian G. Ortmeier, PhD
Introduction Many factors influence the motivation of community pharmacists to provide pharmacy services. One factor is the level of professional reward derived from their work. On a daily basis, pharmacists provide a special service to patients and other health care professionals that is unique, useful, and held in high esteem. If a pharmacist values such professional fulfillment, the motivation to provide pharmacy services is likely to continue. A second motivating factor is the legal and professional guidelines for what pharmacists can and cannot do. lbis concept is illustrated by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90), which mandated prospective drug use
Abstract This study of 590 community pharmacies examined relationships between prescription payment methods and the number of pharmacy services provided at community pharmacies. Also studied were pharmacists' perceptions regarding: (1) the importance of 24 different pharmacy services, (2) the importance of three motivating factors in providing pharmacy services, (3) satisfaction with three methods of payment for pharmacy services, and (4) agreement with factors cited in the literature as barriers to pharmaceutical care. Results revealed a significant positive relationship (p < 0.05) between the number of pharmacy services provided and the percentage of private-pay prescriptions processed.
Vol. NS35, No. 1 January 1995
review and patient counseling under certain circumstances, beginning January 1, 1993. Private third party contracts also specify rules and guidelines for pharmacists participating in the contract(s). A third factor that motivates pharmacists to provide pharmacy services is the economic benefit linked to the provision of these services. If pharmacists expect a fmancial reward for performing pharmacy services, they will be more likely to provide them. Forces that alter the rewards associated with any of these motivating factors have the potential to affect the development, marketing, and performance of pharmaceutical care services-drug therapy and cognitive services that achieve specific outcomes and improve a patient's quality of life. One concern that may limit a pharmacist's motivation is third party contractual requirements. A significant (p < 0.05) inverse relationship was identified between the number of pharmacy services provided and both the percentage of prescriptions processed for third parties other than Medicaid and the percentage of all third party prescriptions processed . Financial incentives were identified as the most important motivator in providing pharmacy services. Private-pay reimbursement was significantly more satisfactory to respondents than Medicaid reimbursement, and both were more satisfactory than reimbursement by a third party other than Medicaid . The greatest perceived barriers to the provision of pharmacy services involved financial and administrative considerations. Results suggest that financial incentives play a critical role in stimulating the provision of pharmacy services.
AMERICAN PHARMACY
The 1992 Lilly Digest reported that the percentage of third party prescription orders processed (Medicaid and other third parties) had reached 42 .6%, an increase of 12.6% since 1987. 1·2 Validating the Lilly Digest findings is a survey that reported 44.2% of all prescription orders processed in chain pharmacies were paid for by third party pay~ent plans in 1992; this represented a 9. 7% increase over 1991. 3 The survey also found that 31.6% of prescription orders processed at independent pharmacies were paid for by third party payment plans in 1992, a 13.1% increase since 1991. 3 These studies indicate that the percentage of third party payments for prescription drugs in both chain and independent pharmacies is increasing. Furthermore, speculation that health care reform will result in a universal prescription drug benefit may accelerate the rate of increase of third party payment for prescription drugs. Studies have suggested that participation in third party prescription programs can increase short-term profits at community pharmacies; however, over the long-term, profits may decline. 4•5 Also affecting profitability is the growing emphasis on services, but, unfortunately, the focus of third party payment has been on "dispensing fees" as opposed to "service fees. "6 Pharmacists have rated these different plans with varying degrees of favor.7 Executives of both independent and chain pharmacies have perceived third party reimbursement as the biggest challenge facing the community pharmacy. 8 Although payers for health care have recognized the pharmacist's ability to affect costs in the health care system, they have not realized the necessity to compensate for pharmaceutical care.9·10 Rupp et al. stated that "payers remain generally unwilling to compensate pharmacists for most extra distributive professional activities, particularly if these activities were not associated with the distribution of a pharmaceutical product." 11 Many activities that are considered pharmaceutical care services require more patient involvement than do purely distributive functions. Thus, when implementing pharmaceutical care services, a pharmacy may incur additional expenses (e.g., time, renovation, additional personnel, marketing, and training). A reluctance to incur such costs without compensation may adversely affect the motivation to provide pharmaceutical care services. If pharmacists are motivated by financial incentives, and if profits are adversely affected as a result of third party compensation structures, the motivation to provide pharmaceutical care services will decrease. The authors' uncertainty about the relationship between third party reimbursement and the provision of pharmaceutical care services provided the impetus to conduct this study. The study also examined whether a relationship existed between the percentage of prescription orders processed for less favorable third party prescription payment plans and the number of pharmacy services provided at community pharmacies. AMERICAN PHARMACY
Methods A questionnaire was developed and pretested with pharmacy practice academicians and practicing community pharmacists in Tucson, Ariz. After minor modifications, a cover letter and eight-page questionnaire were mailed first-class to 1,504 community pharmacies randomly selected from a listing (owned by the National Council for Prescription Drug Programs) of 56,970 licensed community pharmacies in the United States and its possessions. The listing has been derived from and maintained through state licensing boards, the National Association of Boards of Pharmacy, and third party redemption centers. Both chain and independently owned pharmacies were included in the total population. Each questionnaire was addressed to the owner or manager of the selected individual community pharmacies. To ensure respondent anonymity, no valid identifiers were placed on the instrument or the return envelope. An identical questionnaire and updated cover letter were mailed to all study participants 24 days after the initial mailing. Respondents were instructed to discard the second questionnaire if the first had already been completed and returned. Between mailings, a reminder postcard was sent to the participants, stressing the importance of their responses. The questionnaire was divided into four sections. In the first section, pharmacists indicated how important they believed each of 24 different pharmacy services were to the provision of pharmaceutical care. Responses were given on a five-point Ukert-type scale (1 = "not important"; 5 = "very important"). The services were derived from previously published literature identifying services that are or could be provided in an ambulatory pharmacy setting. 12-18 The respondents were also asked to indicate those services that were provided at their particular practice site. In the second section, pharmacists responded to a series of questions that measured the perceived importance of three motivational factors that may affect the provision of pharmaceutical care services: professional reward, compliance with legal or contractual requirements of third party prescription payment programs, and financial reward. Responses were measured on a five-point likert-type scale (1 = "not important"; 5 ="very important"). In this section, pharmacists also expressed their level of satisfaction with each of the three major types of payment for pharmacy services (private pay, Medicaid, and third party other than Medicaid). Responses were again measured on a five-point Likert-type scale (1 = "very dissatisfied"; 5 = "very satisfied"). The third section of the questionnaire requested information regarding pharmacists' attitudes toward various barriers that may affect the successful implementation of pharmaceutical care services in a community pharmacy setting. Eleven potential barriers, identified in the literature, 19·20 were listed, and respondents were asked to indicate whether or not they January 1995
VoL NS35, No. 1
agreed that each was a barrier to the implementation of new services. Responses were given on a five-point Likert-type scale (1 ="strongly disagree"; 5 = "strongly agree"). The fmal section requested information on demographic characteristics, including type of phannacy, pharmacy location and competition, prescription volume, and payer percentages. Data on respondent age, sex, and year graduated from pharmacy school were also requested. Data analysis was conducted using the Systat (Version 5.0) statistical software. 21 The a priori alpha level was set at 0.05.
Results A total of 590 usable surveys were returned (342 from the first mailing and 245 from the second mailing; three were not identifiable by the date on the cover letter). Questionnaires for 43 pharmacies were returned as undeliverable. Also removed from the analysis were seven questionnaires from owners/managers who were retired or out of business and four owners/managers who believed that their practice settings could not qualify as community pharmacies serving the public; 1,450 potential respondents remained. The overall survey response rate was 40.6%.
organization, department store, grocery store, and home intravenous infusion service). A majority of respondents (57%) indicated that their communities' populations were less than 50,000. A majority (53%) of respondents considered their community pharmacy practice settings to be in an urban environment; the rest considered their practice settings to be rural.
Ranking of Services The first section of the survey assessed the respondents' attitudes toward the perceived importance of various pharmacy services and the number of these services that their pharmacies offered. Services that achieved the highest importance ratings were providing (1) a computerized patient proille, (2) computerized drug allergy screening, (3) computerized drug interaction screening, (4) oral patient counseling, and (5) over-the-<:ounter medication counseling and recommendations (fable 1). Pharmacy services most commonly provided were oral patient counseling, computerized patient profile, computerized drug interaction screening, computerized drug allergy screening, written patient counseling, and over-the-counter medication counseling and recommendations (fable 1).
Ranking of Motivational Factors The next section of the survey assessed the respondents' feci ings about the importance of three different motivational factors
De~nographics
The mean age for all respondents was 44 years. Men respondents' mean age was 46 years; women respondents' mean age was 36 years. A majority of respondents, 80"/o (n = 472), were men; 17% (n = 99) were women; and 3% (n =19) were unidentified. An overwhelming majority, 94.5%, had a BS degree in pharmacy; only 5.5% had a PharmD degree. Ninety-one percent of respondents identified themselves as owners and/or managers of community pharmacies, indicating that the questionnaire was completed by those to whom it was directed. A mean total of 37,650 new and renewed prescription orders were processed by the responding phannacies for calendar year 1992. Private pay customers accounted for a mean of 46.8% of all prescription orders processed, Medicaid customers accounted for a mean of 19.7%, and customers from a third party other than Medicaid accounted for a mean of 33.5%. The percentage of prescription orders processed for all third party plans (Medicaid and third party other than Medicaid) was 53.2%. Although the mean percentage of all third party prescriptions was higher than previously published, 1·3 these results are consistent with trends that suggest a growth in third party payment for phannaceuticals. A majority of respondents (57%) indicated that their pharmactes qualified as independent stores, 38% considered their stores to be chain phannacies, and 5% identified their stores as belonging in another category (e.g., clinic, health maintenance Vol NS35, No. 1 January 1995
Ill
(professional reward, compliance with legal or contractual requirements of third party prescription payment programs, and financial reward) in implementing and providing new, innovative pharmacy services at a community pharmacy. The most important motivating factor was financial incentives, followed by professional reward and legal/contractual requirements of third party payment programs. A one-way repeated-measures analysis of variance (ANOVA), calculated using the three mean scores, revealed a significant difference between the means (f (2, 1090) = 136.78, p < 0.01). A Tukey HSD was calculated; a statistically significant difference existed among all three mean scores (fable 2, page 43). Respondents were most satisfied with private payment for pharmacy services, less satisfied with Medicaid payment, and least satisfied with payment by a third party other than Medicaid. A one-way repeated-measures ANOVA on the three mean scores revealed a significant difference between the means (f (2, 1134) =659.82, p < 0.01). A Tukey HSD was calculated and confirmed that a statistically significant difference existed among all three mean scores (fable 3, page 43). Of this survey's 11 potential barriers that may affect the successful implementation of pharmaceutical care services, the focus of compensation for dispensing a commodity rather than for delivering a cognitive service obtained the highest mean agreement score. This was followed by time spent on performing administrative and technical aspects of prescription dispensing and by capital required to develop, implement, and provide pharmaceutical care services (fable 4, page 44). AMERICAN PHARMACY
Table 1
Perceived Importance of Pharmacy Services
. Importance Score
Pharmacy Service
Pharmacies Providing Service
n
Mean ±SD
n
%
Co~nputerized
patient profile
585
4.73 ± 0.66
496
97.1
Co~nputerized
drug allergy screening
575
4.57 ± 0.76
459
89.7
Co~nputerized
drug interaction screening
575
4.55 ± 0.75
465
90.8
Oral patient counseling
587
4.38 ± 0.80
510
99.6
OTC counseling and recotntnendations
573
4.34 ± 0.76
402
78.8
Written patient counseling
587
3.76 ± 0.95
428
83.8
Prospective tnedication therapy review
581
3.76 ± 0.91
294
57.4
Medication counseling area
587
3.69 ± 1.00
260
50.8
Specialized diabetes education
585
3.66 ± 0.97
114
22.3
Retrospective tnedication therapy revieiiV
586
3.62 ± 0.93
308
60.2
Specialized hotne monitoring devices and education on appropriate use
586
3.46 ± 1.09
164
32.0
Specialty compounding and dosage fortns
574
3.44 ± 1.06
324
63.3
Specialized ostotny education
586
3.27 ± 1.07
46
9.0
Durable tnedical equip~nent and education on proper use
574
3.25 ± 1.02
164
32.1
Consultative nursing hoiTie and long-term care services
583
3.25 ± 1.12
91
17.8
Blood pressure screening
573
3.23 ± 1.10
225
44.0
Health/liVeliness education for the community through nei!Vsletters, talk shoiiVs, etc.
570
3.17 ± 1.05
120
23.4
573
3.13 ± 1.13
63
12.4
24-hour etnergency prescription and infortnation service
585
3.07 ± 1.22
228
44.5
Therapy cotnpliance tnonitoring through broiiVn-bag sessions
565
3.03 ± 0.99
80
15.7
Blood-glucose screening
574
2.98 ± 1.12
69
13.5
HoiTie intravenous therapy
584
2.97 ± 1.18
34
6.6
Serutn cholesterol screening
572
2.78 ± 1.05
64
12.5
Telephone folloiiV-up on neiiV prescriptions dispensed
584
2.64 ± 1.06
60
11.7
Therapeutic drug level
~nonitoring
n =number of respondents; OTC =over the counter; SD =standard deviation. * Scale: 1 ="not important" to 5 ="very important."
A statistically significant positive correlation (r (386) = + 0.148, p = 0.003) was found between the number of pharmacy services provided and the percentage of prescription orders processed for private pay customers. Conversely, a statistically significant inverse correlation (r (386) = - 0.149, AMERICAN PHARMACY
p = 0.003) was found between the percentage of prescription orders processed for all third party payment plans (Medicaid and third party other than Medicaid) and the number of pharmacy services provided. A statistically significant inverse correlation (r (382) = - 0.122, p = 0.017) was found between the January 1995
Vol. NS35, No.1
percentage of prescription orders processed for patients with third party prescription programs other than Medicaid and the number of pharmacy services provided. No statistically significant correlation (r (382) = - 0.052, p = 0.312) was detected between the number of services provided and the percentage of prescription orders processed for Medicaid patients.
Discussion This research was conducted to determine the pharmaceutical care services currently being provided by community pharmacies and to examine factors that may potentially influence the implementation of such services at community pharmacies. The results suggest that at community pharmacies an inverse relationship exists between the percentage of prescription orders processed for third party prescription payment plans and the number of pharmacy services provided. These fmdings are consistent with previous research that has identified fewer pharmacist/prescriber interactions associated with capitation and third part{payment for prescription medications. 22 The results suggest that third party programs other than Medicaid were least satisfactory to respondents in terms of payment. They also suggest that fewer services were offered when the percentage of processed prescriptions paid for by this method was the highest. Such a fmding is especially important when considering that the percentage of prescription orders processed for third party prescription programs has been steadily increasing over recent years and will probably continue to increase. Of the barriers to the provision of pharmaceutical care services evaluated in this research, those receiving the highest mean agreement scores focused on fmancial and administrative concerns. A multitude of third party benefit management organizations, each with unique rules, procedures, and reimbursement schedules, has given rise to an extremely complex and often confusing approach to community pharmacist compensation. The development of a unique and consistent documentation format linked to a standardized payment schedule for cognitive pharmacy services would facilitate the process. It would also shift the pharmacy paradigm closer to the universal provision of pharmaceutical care. Because the goal of pharmaceutical care is the achievement of defmite outcomes that positively affect patient care and quality of life, 2 3 incentives for the pharmacist to implement pharmaceutical care services must be established. The most important motivating factor, according to our study results, was fmancial. The need for capital also ranked as one of the three primary barriers to developing, implementing, and providing new services. Third party reimbursement has been cited as the biggest challenge facing community pharmacy. 8 This is understandVol. NS35, No. 1
January 1995
Table 2
Perceived Importance of Motivating Factors to Performing Pharmaceutical Care Services Motivating Factor
Importance Score (Mean± SO)*
Financial incentives
4.15 ± 0.99
547
Professional reward
3.65 ± 1.09
573
Legal/Contractual requirements of third party payn1ent programs
3.17 ± 1.28
574
Number of Respondents
SD =standard deviation. * Scale: 1 ="not important" to 5 ="very important." All importance scores significantly differ from each other at P< 0.01.
able; Carroll indicated that participation in third party payment programs could be detrimental to long-term pharmacy profits. 4 The results of this study suggest that fmancial incentives linked to the provision of pharmaceutical care services may serve as the greatest motivator to implementing new, innovative pharmacy services.
Limitations This study has limitations. First, the data were selfreported; it must be assumed that the information was reported honestly and accurately. Second, although statistically significant relationships were identified, a large sample size allows the detection of very small differences, and the practicality of the fmdings can be questioned. Also, the data collection instrument had not been used previously; further experi-
Table 3
Perceived Satisfaction vvith Prescription Payment Methods Number of Respondents
Method of Payment
Satisfaction Score (Mean± SO)*
Private pay
4.01 ± 0.95
576
Medicaid
2.54± 1.14
572
Third party other than Medicaid
2.05 ± 1.06
578
SD =standard deviation. * Scale: 1 ="very dissatisfied" to 5 ="very satisfied." All satisfaction scores significantly differ from each other at p < 0.01.
A 1ERJCA PHARi'VIACY
Table 4
Perceived Agreement with Existence
of Barriers to Pharn1aceutical Care Services Agreement Score *
Potential Barrier
Mean±SD
Number of Respondents
Focus of compensation for pharmacy services on dispensing a conunodity as opposed to delivering a cognitive service
3.87 ± 1.09
578
Time spent on administrative and technical aspects of prescription dispensing
3.80 ± 1.04
580
Capital required to develop, implement, and provide services that represent pharmaceutical care
3.57 ± 1.02
582
Lack of a means to document the provision of cognitive services
3.51 ± 1.04
580
Limited access to other health care professionals to address therapy discrepancies
3.50± 1.07
579
Limited access to pertinent medical information required to provide pharmaceutical care
3.46± 1.08
580
Varying patient demand for pharmaceutical care
3.21 ± 0.99
581
Current /ega/limitations and restrictions on pharmacy technician functions and responsibilities
3.05 ± 1.13
581
Insufficient knowledge or training necessary to provide pharmaceutical care services
2.94± 1.16
581
Conflicts between the pharmacist and other health care professionals regarding appropriate drug therapy
2.86± 1.08
570
Focus of the pharmacy profession on technical aspects such as compounding and dispensing
2.77 ± 1.14
581
SD =standard deviation. *Scale: 1 = "strongly disagree" to 5 ="strongly agree."
personal sense of profession. al reward but also equitabl compensation for the perfor mance of such tasks. At a time when the pharmaq profession is moving towar providing more pharmacy services and pharmaceutica care to the benefit of it patients, fewer services ar being provided by individual pharmacies as third part} involvement increases. To increase the provision of new, innovative pharmacy services, both pharmacists and payers must work together. If pharmacists document their services and payers offer financial incen· tives to encourage their provision, we can move in a positive direction to change these trends. Without ade· quate financial incentives, legislative and contractual requirements will most like· ly fail to achieve the level of motivation necessary to develop pharmacy services that have a positive impact on patient well-being and to decrease overall health care costs. Ultimately, if these trends are reversed, the win· ners will be the patients.
ence with it is needed to assess its validity and reliability. Although it is possible that the same pharmacy returned the survey twice, respondents were instructed in the second mailing to discard the survey if they had already responded. Finally, the respondent sample differed from the population in terms of the distribution of types of pharmacies; a bias toward independent pharmacy respondents may be present.
Michael j Miller is an MS candidate in the Department ofPharmacy Practice, College ofPhar· macy, the University ofArizona, Tucson. At the time of this study, Brian G. Ortmeier, PhD, was assistant professor, Department of Pharmacy Practice, the University ofArizona. He is now manager, pharmacoeconomics, Hoechst-Roussel Pharmaceuticals Inc.
Conclusions
References
The results of this study reinforce much of what has been cited in previous publications on the topic. Providing new, innovative pharmacy services not only requires the appropriate training and knowledge to perform such services and a AMERICAN PHARMACY
This study was funded by NARD Foundation, Alexandria, Va.
1. Hargis JR, ed. Lilly Digest. 1992. Indianapolis, lnd: Eli Lilly and Company;1992:3. 2. Third party payer Rxs hit 40% of all Rxs filled. Pharmacy Times. 1989;55( 12):72-4. 3.
Prescription trends survey. American Druggist. 1993;208(1):31-4.
4. Carroll NV. Forecasting the impact of participation in third party pre· scription programs on pharmacy profits. Journal of Research and Pharmaceutical Economics. 1991 ;3(3):3-23. January 1995
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5. Glaser M. As Medicaid rolls swell, so does cost of Rx benefit. Drug Topics. 1991;135:52,55,56. 6. Martin S. Revamping how pharmacists are paid. Am Pharm . 1993;NS33(2):62-5. 7. Glaser M. How pharmacists rate third party plans. Drug Topics. 1991;135(18):48--52. 8. Conlan M. Insurance reimbursement biggest challenge in '93. Drug Topics. 1992;136(23):88,90. 9. Department of Health and Human Services. Medicaid program; drug use review program and electronic claims management system for outpatient drug claims. Federal Register. 1992; 57(212):49397-412. 10. Gebhart F. HCFA tells pharmacy to do more for same compensation. Drug Topics. 1991;135(18):14. 11 . Rupp MT, et al. Prescribing problems and pharmacist interventions in community practice. Med Care. 1992;30(10):926-40. 12. The ACCP Clinical Practice Affairs Committee, 1990--1991. Clinical pharmacy practice in the noninstitutional setting: a white paper from the American College of Clinical Pharmacy. Pharmacotherapy. 1992; 12( 4):358--64. 13. Abramowitz PW, Mansur JM. Moving toward the provision of comprehensive ambulatory-care pharmaceutical services. Am J Hosp Pharm. 1987;44(5):1155-63. 14. Engle JP. Innovative community and ambulatory pharmacy services. Drug Topics. 1992;136(1):78--80,82-9. 15. Martin S. Making cholesterol screening work in small town America. Am Pharm. 1990;NS30(8):42-3. 16. Meade V. Conducting at-home medication reviews. Am Pharm. 1992;NS32(6):37-9. 17. Meade V. New services emerge in chain pharmacy. Am Pharm. 1993;NS33(2):23-7. 18. Malone DC, Rascati KL, Gagnon JP. Consumers' evaluation of value-added pharmacy services. Am Pharm. 1993;NS33(3):48-56. 19. Penna RP. Pharmaceutical care: pharmacy's mission for the 1990s. Am J Hasp Pharm. 1990;47:543-9. 20. Kusserow RP. The Clinical Role of the Community Pharmacist. Washington:Office of the Inspector Generai;November 1990:10--17. OEI-01-89-89160. 21. Wilkinson L. SYSTAT: The System for Statistics. Version 5.0. Evanston,III:SYSTAT, lnc.;1990. 22. Raisch DW. Relationships among prescription payment methods and interactions between community pharmacists and prescribers. Ann Pharmacother. 1992;26(8):902-6. 23. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care services. Am J Hosp Pharm. 1990;47:533-43.
Postpartum continued from p. 38 34. Meares R, Grimwade J, Wood C. A possible relationship between anxiety in pregnancy and puerperal depression. J Psychosom Res. 1976;20:605-1 0. 35. Gordon RE, Gordon KK. Social factors in prevention of postpartum emotional problems. Obstet Gynecol. 1960;15:433-8. 36. Vandenbergh RL. Postpartum depression. Clin Obstet Gynecol. 1980;23:1105. 37. Brown CS, Bryant SG. Major depression. In: Koda-Kimble MA, Young LV, eds. Applied Therapeutics: The Clinical Use of Drugs. 5th ed. Vancouver: Applied Therapeutics Inc.; 1991:57-7. 38. Misri S, Sivertz K. Tricyclic drugs in pregnancy and lactation: a preliminary report. lnt J Psychiatry Med. 1991;21:157-71. 39. Robinson GE, Stewart DE, Flak E. The rational use of psychotropic drugs in pregnancy and postpartum. Can J Psychiatry. 1986;31: 183-90. 40. Buist A, Norman TR, Dennerstein L. Breastfeeding and the use of psychotropic medication: a review. J Affective Disord. 1990;19:197-206. 41. Briggs, GG, Freeman RK, Yaffe SJ, eds. Drugs in Pregnancy and Lactation. 4th ed. Baltimore: Williams & Wilkins; 1994. 42. Lawrence RA, ed. Breastfeeding. 3rd ed. St. Louis: CV Mosby Co; 1989.
Vol. NS35, No. 1
January 1995
APhA Annual Meeting Focuses on Counseling As more and more phannacists
incorporate patient-centered care components into their practices, specialized education will be needed-education that is focused on phannaceutical care delivery skills. The American Pharmaceutical Association (APhA) is designing educational programs to meet these needs of contemporary pharmacy practitioners. The APhA l4ZnJ Annual & I• xposiuon \larch 1»-22, 1<.195 142nd Annual Meeting & Exposition, March 18-22, in Orlando, Fla., will offer pharmacists an excellent opportunity to learn from innovative practitioners and patient care experts. Communicating with patients, caregivers, and other health care providers is the foundation of high-quality patient care. Several continuing education sessions planned for the Annual Meeting will focus on overcoming barriers to communicating effectively with patients. Experts in the communications field will teach pharmacists how to overcome barriers and enhance counseling experiences for both patients and themselves. You will not want to miss these sessions: • "Bolstering Your Communication Effectiveness." • "Counseling Techniques: Integrating Assessment and Intervention. " • "Facilitating Patient-Pharmacist Consultation: Focus on OTCs. " • "A Matter of Trust: A Program in Pharmacist/Patient Relationships. " In addition to these sessions, APhA will launch a new innovative educational opportunity-the APhA/United States Pharmacopeia/ Convention, Inc., (USP) Assessment, Communication & Evaluation (ACE) Program-at the Annual Meeting. TIIis program will help pharmacists better understand the primary elements-assessment, communication, and evaluation-of effective patient counseling. Through these sessions, pharmacists will learn innovative patient care strategies and enhance their understanding of basic pharmaceutical care principles. Issues such as counseling in busy practice settings, considerations for special patient populations, and conducting patient intetviews will be explored. The ACE program will include a case-based educational session on "Effective Patient Counseling: An Integral Component of Pharmaceutical Care." Following the session, interested pharmacists can practice what they learned in private, videotaped patient counseling sessions, which will be evaluated by experts. For additional information on the educational programs scheduled for the APhA Annual Meeting & Exposition, contact Linda Eakin, education program coordinator, at (800) 237-APhA, ext. 7578. \let:tin~
AMERICA PHARMACY
Introduction Many factors influence the motivation of community pharmacists to provide pharmacy services. One factor is the level of professional reward derived from their work. On a daily basis, pharmacists provide a special service to patients and other health care professionals that is unique, useful, and held in high esteem. If a pharmacist values such professional fulfillment, the motivation to provide pharmacy services is likely to continue. A second motivating factor is the legal and professional guidelines for what pharmacists can and cannot do. lbis concept is illustrated by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90), which mandated prospective drug use
Abstract This study of 590 community pharmacies examined relationships between prescription payment methods and the number of pharmacy services provided at community pharmacies. Also studied were pharmacists' perceptions regarding: (1) the importance of 24 different pharmacy services, (2) the importance of three motivating factors in providing pharmacy services, (3) satisfaction with three methods of payment for pharmacy services, and (4) agreement with factors cited in the literature as barriers to pharmaceutical care. Results revealed a significant positive relationship (p < 0.05) between the number of pharmacy services provided and the percentage of private-pay prescriptions processed.
Vol. NS35, No. 1 January 1995
review and patient counseling under certain circumstances, beginning January 1, 1993. Private third party contracts also specify rules and guidelines for pharmacists participating in the contract(s). A third factor that motivates pharmacists to provide pharmacy services is the economic benefit linked to the provision of these services. If pharmacists expect a fmancial reward for performing pharmacy services, they will be more likely to provide them. Forces that alter the rewards associated with any of these motivating factors have the potential to affect the development, marketing, and performance of pharmaceutical care services-drug therapy and cognitive services that achieve specific outcomes and improve a patient's quality of life. One concern that may limit a pharmacist's motivation is third party contractual requirements. A significant (p < 0.05) inverse relationship was identified between the number of pharmacy services provided and both the percentage of prescriptions processed for third parties other than Medicaid and the percentage of all third party prescriptions processed . Financial incentives were identified as the most important motivator in providing pharmacy services. Private-pay reimbursement was significantly more satisfactory to respondents than Medicaid reimbursement, and both were more satisfactory than reimbursement by a third party other than Medicaid . The greatest perceived barriers to the provision of pharmacy services involved financial and administrative considerations. Results suggest that financial incentives play a critical role in stimulating the provision of pharmacy services.
AMERICAN PHARMACY
The 1992 Lilly Digest reported that the percentage of third party prescription orders processed (Medicaid and other third parties) had reached 42 .6%, an increase of 12.6% since 1987. 1·2 Validating the Lilly Digest findings is a survey that reported 44.2% of all prescription orders processed in chain pharmacies were paid for by third party pay~ent plans in 1992; this represented a 9. 7% increase over 1991. 3 The survey also found that 31.6% of prescription orders processed at independent pharmacies were paid for by third party payment plans in 1992, a 13.1% increase since 1991. 3 These studies indicate that the percentage of third party payments for prescription drugs in both chain and independent pharmacies is increasing. Furthermore, speculation that health care reform will result in a universal prescription drug benefit may accelerate the rate of increase of third party payment for prescription drugs. Studies have suggested that participation in third party prescription programs can increase short-term profits at community pharmacies; however, over the long-term, profits may decline. 4•5 Also affecting profitability is the growing emphasis on services, but, unfortunately, the focus of third party payment has been on "dispensing fees" as opposed to "service fees. "6 Pharmacists have rated these different plans with varying degrees of favor.7 Executives of both independent and chain pharmacies have perceived third party reimbursement as the biggest challenge facing the community pharmacy. 8 Although payers for health care have recognized the pharmacist's ability to affect costs in the health care system, they have not realized the necessity to compensate for pharmaceutical care.9·10 Rupp et al. stated that "payers remain generally unwilling to compensate pharmacists for most extra distributive professional activities, particularly if these activities were not associated with the distribution of a pharmaceutical product." 11 Many activities that are considered pharmaceutical care services require more patient involvement than do purely distributive functions. Thus, when implementing pharmaceutical care services, a pharmacy may incur additional expenses (e.g., time, renovation, additional personnel, marketing, and training). A reluctance to incur such costs without compensation may adversely affect the motivation to provide pharmaceutical care services. If pharmacists are motivated by financial incentives, and if profits are adversely affected as a result of third party compensation structures, the motivation to provide pharmaceutical care services will decrease. The authors' uncertainty about the relationship between third party reimbursement and the provision of pharmaceutical care services provided the impetus to conduct this study. The study also examined whether a relationship existed between the percentage of prescription orders processed for less favorable third party prescription payment plans and the number of pharmacy services provided at community pharmacies. AMERICAN PHARMACY
Methods A questionnaire was developed and pretested with pharmacy practice academicians and practicing community pharmacists in Tucson, Ariz. After minor modifications, a cover letter and eight-page questionnaire were mailed first-class to 1,504 community pharmacies randomly selected from a listing (owned by the National Council for Prescription Drug Programs) of 56,970 licensed community pharmacies in the United States and its possessions. The listing has been derived from and maintained through state licensing boards, the National Association of Boards of Pharmacy, and third party redemption centers. Both chain and independently owned pharmacies were included in the total population. Each questionnaire was addressed to the owner or manager of the selected individual community pharmacies. To ensure respondent anonymity, no valid identifiers were placed on the instrument or the return envelope. An identical questionnaire and updated cover letter were mailed to all study participants 24 days after the initial mailing. Respondents were instructed to discard the second questionnaire if the first had already been completed and returned. Between mailings, a reminder postcard was sent to the participants, stressing the importance of their responses. The questionnaire was divided into four sections. In the first section, pharmacists indicated how important they believed each of 24 different pharmacy services were to the provision of pharmaceutical care. Responses were given on a five-point Ukert-type scale (1 = "not important"; 5 = "very important"). The services were derived from previously published literature identifying services that are or could be provided in an ambulatory pharmacy setting. 12-18 The respondents were also asked to indicate those services that were provided at their particular practice site. In the second section, pharmacists responded to a series of questions that measured the perceived importance of three motivational factors that may affect the provision of pharmaceutical care services: professional reward, compliance with legal or contractual requirements of third party prescription payment programs, and financial reward. Responses were measured on a five-point likert-type scale (1 = "not important"; 5 ="very important"). In this section, pharmacists also expressed their level of satisfaction with each of the three major types of payment for pharmacy services (private pay, Medicaid, and third party other than Medicaid). Responses were again measured on a five-point Likert-type scale (1 = "very dissatisfied"; 5 = "very satisfied"). The third section of the questionnaire requested information regarding pharmacists' attitudes toward various barriers that may affect the successful implementation of pharmaceutical care services in a community pharmacy setting. Eleven potential barriers, identified in the literature, 19·20 were listed, and respondents were asked to indicate whether or not they January 1995
VoL NS35, No. 1
agreed that each was a barrier to the implementation of new services. Responses were given on a five-point Likert-type scale (1 ="strongly disagree"; 5 = "strongly agree"). The fmal section requested information on demographic characteristics, including type of phannacy, pharmacy location and competition, prescription volume, and payer percentages. Data on respondent age, sex, and year graduated from pharmacy school were also requested. Data analysis was conducted using the Systat (Version 5.0) statistical software. 21 The a priori alpha level was set at 0.05.
Results A total of 590 usable surveys were returned (342 from the first mailing and 245 from the second mailing; three were not identifiable by the date on the cover letter). Questionnaires for 43 pharmacies were returned as undeliverable. Also removed from the analysis were seven questionnaires from owners/managers who were retired or out of business and four owners/managers who believed that their practice settings could not qualify as community pharmacies serving the public; 1,450 potential respondents remained. The overall survey response rate was 40.6%.
organization, department store, grocery store, and home intravenous infusion service). A majority of respondents (57%) indicated that their communities' populations were less than 50,000. A majority (53%) of respondents considered their community pharmacy practice settings to be in an urban environment; the rest considered their practice settings to be rural.
Ranking of Services The first section of the survey assessed the respondents' attitudes toward the perceived importance of various pharmacy services and the number of these services that their pharmacies offered. Services that achieved the highest importance ratings were providing (1) a computerized patient proille, (2) computerized drug allergy screening, (3) computerized drug interaction screening, (4) oral patient counseling, and (5) over-the-<:ounter medication counseling and recommendations (fable 1). Pharmacy services most commonly provided were oral patient counseling, computerized patient profile, computerized drug interaction screening, computerized drug allergy screening, written patient counseling, and over-the-counter medication counseling and recommendations (fable 1).
Ranking of Motivational Factors The next section of the survey assessed the respondents' feci ings about the importance of three different motivational factors
De~nographics
The mean age for all respondents was 44 years. Men respondents' mean age was 46 years; women respondents' mean age was 36 years. A majority of respondents, 80"/o (n = 472), were men; 17% (n = 99) were women; and 3% (n =19) were unidentified. An overwhelming majority, 94.5%, had a BS degree in pharmacy; only 5.5% had a PharmD degree. Ninety-one percent of respondents identified themselves as owners and/or managers of community pharmacies, indicating that the questionnaire was completed by those to whom it was directed. A mean total of 37,650 new and renewed prescription orders were processed by the responding phannacies for calendar year 1992. Private pay customers accounted for a mean of 46.8% of all prescription orders processed, Medicaid customers accounted for a mean of 19.7%, and customers from a third party other than Medicaid accounted for a mean of 33.5%. The percentage of prescription orders processed for all third party plans (Medicaid and third party other than Medicaid) was 53.2%. Although the mean percentage of all third party prescriptions was higher than previously published, 1·3 these results are consistent with trends that suggest a growth in third party payment for phannaceuticals. A majority of respondents (57%) indicated that their pharmactes qualified as independent stores, 38% considered their stores to be chain phannacies, and 5% identified their stores as belonging in another category (e.g., clinic, health maintenance Vol NS35, No. 1 January 1995
Ill
(professional reward, compliance with legal or contractual requirements of third party prescription payment programs, and financial reward) in implementing and providing new, innovative pharmacy services at a community pharmacy. The most important motivating factor was financial incentives, followed by professional reward and legal/contractual requirements of third party payment programs. A one-way repeated-measures analysis of variance (ANOVA), calculated using the three mean scores, revealed a significant difference between the means (f (2, 1090) = 136.78, p < 0.01). A Tukey HSD was calculated; a statistically significant difference existed among all three mean scores (fable 2, page 43). Respondents were most satisfied with private payment for pharmacy services, less satisfied with Medicaid payment, and least satisfied with payment by a third party other than Medicaid. A one-way repeated-measures ANOVA on the three mean scores revealed a significant difference between the means (f (2, 1134) =659.82, p < 0.01). A Tukey HSD was calculated and confirmed that a statistically significant difference existed among all three mean scores (fable 3, page 43). Of this survey's 11 potential barriers that may affect the successful implementation of pharmaceutical care services, the focus of compensation for dispensing a commodity rather than for delivering a cognitive service obtained the highest mean agreement score. This was followed by time spent on performing administrative and technical aspects of prescription dispensing and by capital required to develop, implement, and provide pharmaceutical care services (fable 4, page 44). AMERICAN PHARMACY
Table 1
Perceived Importance of Pharmacy Services
. Importance Score
Pharmacy Service
Pharmacies Providing Service
n
Mean ±SD
n
%
Co~nputerized
patient profile
585
4.73 ± 0.66
496
97.1
Co~nputerized
drug allergy screening
575
4.57 ± 0.76
459
89.7
Co~nputerized
drug interaction screening
575
4.55 ± 0.75
465
90.8
Oral patient counseling
587
4.38 ± 0.80
510
99.6
OTC counseling and recotntnendations
573
4.34 ± 0.76
402
78.8
Written patient counseling
587
3.76 ± 0.95
428
83.8
Prospective tnedication therapy review
581
3.76 ± 0.91
294
57.4
Medication counseling area
587
3.69 ± 1.00
260
50.8
Specialized diabetes education
585
3.66 ± 0.97
114
22.3
Retrospective tnedication therapy revieiiV
586
3.62 ± 0.93
308
60.2
Specialized hotne monitoring devices and education on appropriate use
586
3.46 ± 1.09
164
32.0
Specialty compounding and dosage fortns
574
3.44 ± 1.06
324
63.3
Specialized ostotny education
586
3.27 ± 1.07
46
9.0
Durable tnedical equip~nent and education on proper use
574
3.25 ± 1.02
164
32.1
Consultative nursing hoiTie and long-term care services
583
3.25 ± 1.12
91
17.8
Blood pressure screening
573
3.23 ± 1.10
225
44.0
Health/liVeliness education for the community through nei!Vsletters, talk shoiiVs, etc.
570
3.17 ± 1.05
120
23.4
573
3.13 ± 1.13
63
12.4
24-hour etnergency prescription and infortnation service
585
3.07 ± 1.22
228
44.5
Therapy cotnpliance tnonitoring through broiiVn-bag sessions
565
3.03 ± 0.99
80
15.7
Blood-glucose screening
574
2.98 ± 1.12
69
13.5
HoiTie intravenous therapy
584
2.97 ± 1.18
34
6.6
Serutn cholesterol screening
572
2.78 ± 1.05
64
12.5
Telephone folloiiV-up on neiiV prescriptions dispensed
584
2.64 ± 1.06
60
11.7
Therapeutic drug level
~nonitoring
n =number of respondents; OTC =over the counter; SD =standard deviation. * Scale: 1 ="not important" to 5 ="very important."
A statistically significant positive correlation (r (386) = + 0.148, p = 0.003) was found between the number of pharmacy services provided and the percentage of prescription orders processed for private pay customers. Conversely, a statistically significant inverse correlation (r (386) = - 0.149, AMERICAN PHARMACY
p = 0.003) was found between the percentage of prescription orders processed for all third party payment plans (Medicaid and third party other than Medicaid) and the number of pharmacy services provided. A statistically significant inverse correlation (r (382) = - 0.122, p = 0.017) was found between the January 1995
Vol. NS35, No.1
percentage of prescription orders processed for patients with third party prescription programs other than Medicaid and the number of pharmacy services provided. No statistically significant correlation (r (382) = - 0.052, p = 0.312) was detected between the number of services provided and the percentage of prescription orders processed for Medicaid patients.
Discussion This research was conducted to determine the pharmaceutical care services currently being provided by community pharmacies and to examine factors that may potentially influence the implementation of such services at community pharmacies. The results suggest that at community pharmacies an inverse relationship exists between the percentage of prescription orders processed for third party prescription payment plans and the number of pharmacy services provided. These fmdings are consistent with previous research that has identified fewer pharmacist/prescriber interactions associated with capitation and third part{payment for prescription medications. 22 The results suggest that third party programs other than Medicaid were least satisfactory to respondents in terms of payment. They also suggest that fewer services were offered when the percentage of processed prescriptions paid for by this method was the highest. Such a fmding is especially important when considering that the percentage of prescription orders processed for third party prescription programs has been steadily increasing over recent years and will probably continue to increase. Of the barriers to the provision of pharmaceutical care services evaluated in this research, those receiving the highest mean agreement scores focused on fmancial and administrative concerns. A multitude of third party benefit management organizations, each with unique rules, procedures, and reimbursement schedules, has given rise to an extremely complex and often confusing approach to community pharmacist compensation. The development of a unique and consistent documentation format linked to a standardized payment schedule for cognitive pharmacy services would facilitate the process. It would also shift the pharmacy paradigm closer to the universal provision of pharmaceutical care. Because the goal of pharmaceutical care is the achievement of defmite outcomes that positively affect patient care and quality of life, 2 3 incentives for the pharmacist to implement pharmaceutical care services must be established. The most important motivating factor, according to our study results, was fmancial. The need for capital also ranked as one of the three primary barriers to developing, implementing, and providing new services. Third party reimbursement has been cited as the biggest challenge facing community pharmacy. 8 This is understandVol. NS35, No. 1
January 1995
Table 2
Perceived Importance of Motivating Factors to Performing Pharmaceutical Care Services Motivating Factor
Importance Score (Mean± SO)*
Financial incentives
4.15 ± 0.99
547
Professional reward
3.65 ± 1.09
573
Legal/Contractual requirements of third party payn1ent programs
3.17 ± 1.28
574
Number of Respondents
SD =standard deviation. * Scale: 1 ="not important" to 5 ="very important." All importance scores significantly differ from each other at P< 0.01.
able; Carroll indicated that participation in third party payment programs could be detrimental to long-term pharmacy profits. 4 The results of this study suggest that fmancial incentives linked to the provision of pharmaceutical care services may serve as the greatest motivator to implementing new, innovative pharmacy services.
Limitations This study has limitations. First, the data were selfreported; it must be assumed that the information was reported honestly and accurately. Second, although statistically significant relationships were identified, a large sample size allows the detection of very small differences, and the practicality of the fmdings can be questioned. Also, the data collection instrument had not been used previously; further experi-
Table 3
Perceived Satisfaction vvith Prescription Payment Methods Number of Respondents
Method of Payment
Satisfaction Score (Mean± SO)*
Private pay
4.01 ± 0.95
576
Medicaid
2.54± 1.14
572
Third party other than Medicaid
2.05 ± 1.06
578
SD =standard deviation. * Scale: 1 ="very dissatisfied" to 5 ="very satisfied." All satisfaction scores significantly differ from each other at p < 0.01.
A 1ERJCA PHARi'VIACY
Table 4
Perceived Agreement with Existence
of Barriers to Pharn1aceutical Care Services Agreement Score *
Potential Barrier
Mean±SD
Number of Respondents
Focus of compensation for pharmacy services on dispensing a conunodity as opposed to delivering a cognitive service
3.87 ± 1.09
578
Time spent on administrative and technical aspects of prescription dispensing
3.80 ± 1.04
580
Capital required to develop, implement, and provide services that represent pharmaceutical care
3.57 ± 1.02
582
Lack of a means to document the provision of cognitive services
3.51 ± 1.04
580
Limited access to other health care professionals to address therapy discrepancies
3.50± 1.07
579
Limited access to pertinent medical information required to provide pharmaceutical care
3.46± 1.08
580
Varying patient demand for pharmaceutical care
3.21 ± 0.99
581
Current /ega/limitations and restrictions on pharmacy technician functions and responsibilities
3.05 ± 1.13
581
Insufficient knowledge or training necessary to provide pharmaceutical care services
2.94± 1.16
581
Conflicts between the pharmacist and other health care professionals regarding appropriate drug therapy
2.86± 1.08
570
Focus of the pharmacy profession on technical aspects such as compounding and dispensing
2.77 ± 1.14
581
SD =standard deviation. *Scale: 1 = "strongly disagree" to 5 ="strongly agree."
personal sense of profession. al reward but also equitabl compensation for the perfor mance of such tasks. At a time when the pharmaq profession is moving towar providing more pharmacy services and pharmaceutica care to the benefit of it patients, fewer services ar being provided by individual pharmacies as third part} involvement increases. To increase the provision of new, innovative pharmacy services, both pharmacists and payers must work together. If pharmacists document their services and payers offer financial incen· tives to encourage their provision, we can move in a positive direction to change these trends. Without ade· quate financial incentives, legislative and contractual requirements will most like· ly fail to achieve the level of motivation necessary to develop pharmacy services that have a positive impact on patient well-being and to decrease overall health care costs. Ultimately, if these trends are reversed, the win· ners will be the patients.
ence with it is needed to assess its validity and reliability. Although it is possible that the same pharmacy returned the survey twice, respondents were instructed in the second mailing to discard the survey if they had already responded. Finally, the respondent sample differed from the population in terms of the distribution of types of pharmacies; a bias toward independent pharmacy respondents may be present.
Michael j Miller is an MS candidate in the Department ofPharmacy Practice, College ofPhar· macy, the University ofArizona, Tucson. At the time of this study, Brian G. Ortmeier, PhD, was assistant professor, Department of Pharmacy Practice, the University ofArizona. He is now manager, pharmacoeconomics, Hoechst-Roussel Pharmaceuticals Inc.
Conclusions
References
The results of this study reinforce much of what has been cited in previous publications on the topic. Providing new, innovative pharmacy services not only requires the appropriate training and knowledge to perform such services and a AMERICAN PHARMACY
This study was funded by NARD Foundation, Alexandria, Va.
1. Hargis JR, ed. Lilly Digest. 1992. Indianapolis, lnd: Eli Lilly and Company;1992:3. 2. Third party payer Rxs hit 40% of all Rxs filled. Pharmacy Times. 1989;55( 12):72-4. 3.
Prescription trends survey. American Druggist. 1993;208(1):31-4.
4. Carroll NV. Forecasting the impact of participation in third party pre· scription programs on pharmacy profits. Journal of Research and Pharmaceutical Economics. 1991 ;3(3):3-23. January 1995
Vol. NS35, No. 1
5. Glaser M. As Medicaid rolls swell, so does cost of Rx benefit. Drug Topics. 1991;135:52,55,56. 6. Martin S. Revamping how pharmacists are paid. Am Pharm . 1993;NS33(2):62-5. 7. Glaser M. How pharmacists rate third party plans. Drug Topics. 1991;135(18):48--52. 8. Conlan M. Insurance reimbursement biggest challenge in '93. Drug Topics. 1992;136(23):88,90. 9. Department of Health and Human Services. Medicaid program; drug use review program and electronic claims management system for outpatient drug claims. Federal Register. 1992; 57(212):49397-412. 10. Gebhart F. HCFA tells pharmacy to do more for same compensation. Drug Topics. 1991;135(18):14. 11 . Rupp MT, et al. Prescribing problems and pharmacist interventions in community practice. Med Care. 1992;30(10):926-40. 12. The ACCP Clinical Practice Affairs Committee, 1990--1991. Clinical pharmacy practice in the noninstitutional setting: a white paper from the American College of Clinical Pharmacy. Pharmacotherapy. 1992; 12( 4):358--64. 13. Abramowitz PW, Mansur JM. Moving toward the provision of comprehensive ambulatory-care pharmaceutical services. Am J Hosp Pharm. 1987;44(5):1155-63. 14. Engle JP. Innovative community and ambulatory pharmacy services. Drug Topics. 1992;136(1):78--80,82-9. 15. Martin S. Making cholesterol screening work in small town America. Am Pharm. 1990;NS30(8):42-3. 16. Meade V. Conducting at-home medication reviews. Am Pharm. 1992;NS32(6):37-9. 17. Meade V. New services emerge in chain pharmacy. Am Pharm. 1993;NS33(2):23-7. 18. Malone DC, Rascati KL, Gagnon JP. Consumers' evaluation of value-added pharmacy services. Am Pharm. 1993;NS33(3):48-56. 19. Penna RP. Pharmaceutical care: pharmacy's mission for the 1990s. Am J Hasp Pharm. 1990;47:543-9. 20. Kusserow RP. The Clinical Role of the Community Pharmacist. Washington:Office of the Inspector Generai;November 1990:10--17. OEI-01-89-89160. 21. Wilkinson L. SYSTAT: The System for Statistics. Version 5.0. Evanston,III:SYSTAT, lnc.;1990. 22. Raisch DW. Relationships among prescription payment methods and interactions between community pharmacists and prescribers. Ann Pharmacother. 1992;26(8):902-6. 23. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care services. Am J Hosp Pharm. 1990;47:533-43.
Postpartum continued from p. 38 34. Meares R, Grimwade J, Wood C. A possible relationship between anxiety in pregnancy and puerperal depression. J Psychosom Res. 1976;20:605-1 0. 35. Gordon RE, Gordon KK. Social factors in prevention of postpartum emotional problems. Obstet Gynecol. 1960;15:433-8. 36. Vandenbergh RL. Postpartum depression. Clin Obstet Gynecol. 1980;23:1105. 37. Brown CS, Bryant SG. Major depression. In: Koda-Kimble MA, Young LV, eds. Applied Therapeutics: The Clinical Use of Drugs. 5th ed. Vancouver: Applied Therapeutics Inc.; 1991:57-7. 38. Misri S, Sivertz K. Tricyclic drugs in pregnancy and lactation: a preliminary report. lnt J Psychiatry Med. 1991;21:157-71. 39. Robinson GE, Stewart DE, Flak E. The rational use of psychotropic drugs in pregnancy and postpartum. Can J Psychiatry. 1986;31: 183-90. 40. Buist A, Norman TR, Dennerstein L. Breastfeeding and the use of psychotropic medication: a review. J Affective Disord. 1990;19:197-206. 41. Briggs, GG, Freeman RK, Yaffe SJ, eds. Drugs in Pregnancy and Lactation. 4th ed. Baltimore: Williams & Wilkins; 1994. 42. Lawrence RA, ed. Breastfeeding. 3rd ed. St. Louis: CV Mosby Co; 1989.
Vol. NS35, No. 1
January 1995
APhA Annual Meeting Focuses on Counseling As more and more phannacists
incorporate patient-centered care components into their practices, specialized education will be needed-education that is focused on phannaceutical care delivery skills. The American Pharmaceutical Association (APhA) is designing educational programs to meet these needs of contemporary pharmacy practitioners. The APhA l4ZnJ Annual & I• xposiuon \larch 1»-22, 1<.195 142nd Annual Meeting & Exposition, March 18-22, in Orlando, Fla., will offer pharmacists an excellent opportunity to learn from innovative practitioners and patient care experts. Communicating with patients, caregivers, and other health care providers is the foundation of high-quality patient care. Several continuing education sessions planned for the Annual Meeting will focus on overcoming barriers to communicating effectively with patients. Experts in the communications field will teach pharmacists how to overcome barriers and enhance counseling experiences for both patients and themselves. You will not want to miss these sessions: • "Bolstering Your Communication Effectiveness." • "Counseling Techniques: Integrating Assessment and Intervention. " • "Facilitating Patient-Pharmacist Consultation: Focus on OTCs. " • "A Matter of Trust: A Program in Pharmacist/Patient Relationships. " In addition to these sessions, APhA will launch a new innovative educational opportunity-the APhA/United States Pharmacopeia/ Convention, Inc., (USP) Assessment, Communication & Evaluation (ACE) Program-at the Annual Meeting. TIIis program will help pharmacists better understand the primary elements-assessment, communication, and evaluation-of effective patient counseling. Through these sessions, pharmacists will learn innovative patient care strategies and enhance their understanding of basic pharmaceutical care principles. Issues such as counseling in busy practice settings, considerations for special patient populations, and conducting patient intetviews will be explored. The ACE program will include a case-based educational session on "Effective Patient Counseling: An Integral Component of Pharmaceutical Care." Following the session, interested pharmacists can practice what they learned in private, videotaped patient counseling sessions, which will be evaluated by experts. For additional information on the educational programs scheduled for the APhA Annual Meeting & Exposition, contact Linda Eakin, education program coordinator, at (800) 237-APhA, ext. 7578. \let:tin~
AMERICA PHARMACY