Payment for Cognitive Services: The Future of the Profession

Working Group Bibliography

Payment for Cognitive Services:

The Future of the Profession TI

e American Pharmaceutical Association believes that patient-oriented pharmacy service is the backbone of pharmacy's future, both professionally and economically. As traditional dispensing responsibilities are increasingly delegated, providing the cognitive services of drug therapy monitoring, patient education and counseling, screening, and other consulting services will become the pharmacist's primary role. Recognizing the need for pharmacists to find out more about the services they can provide, the ClinicallPharmacotherapeutic Section of APhA's Academy of Pharmacy Practice and Management formed the Cognitive Services Working Group in 1988. Members of the group are Kathleen M. Dhhille, PharmD, chairman; Janet P. Engle, PharmD; Janice Gaska, PharmD; Debra Goodman, pharmacist; Branton G. Lachman, PharmD; William F. McGhan, PhD, PharmD; and Margaret C. Yarborough, MS. The group's mission is to document, promote the value of, and secure reimbursement for cognitive services provided by pharmacists. The Cognitive Services Working Group has a fivephase plan to: • Conduct a survey to identify pharmacists who provide cognitive services and how those pharmacists are reimbursed. • Establish a database with information from the survey. • Develop educational materials to provide pharmacists with information on the pharmacist's role in cognitive services. • Promote the value of pharmacists' cognitive services to patients and other health care professionals through the public and trade media. • Actively seek reimbursement for cognitive services from purchasers of health care. As part·of its educational campaign, the group has compiled the following annotated bibliography. This bibliography documents cases in which pharmacists were reimbursed for cognitive services. Many of the articles outline the mechanism used to obtain payment in both community and hospital practice. The bibliography is divided into the following sections: reimbursement guidelines; surveys; how pharmacists were reimbursed in community, inpatient, and ambulatory settings; and articles on a variety of other topics. You are encouraged to pursue this information and explore the options present in your practice area. 34

Cognitive services may be defined as those services provided by a pharmacist to or for a patient or health care professional that are either judgmental or educational in nature rather than technical or informational. Examples of such services are patient education programs, drug level monitoring, hypertension monitoring, diabetes counseling, and home visits for medication consultation.

Reimbursement: Guidelines A Model for Inpatient Clinical Pharmacy Practice and Reim· bursement, Drug Intell Clin Pharm, 20, 989 (1986) . The authors postulate that, as a result of the recent trends in reimbursement to institutions, the reimbursement for clinical pharmacy services will continue in the form of payments from the institution to the pharmacy department rather than directly from third party payers. Pharmacists are encouraged to assume more responsibility for all aspects of drug-use control, because, among other things, this provides an opportunity to identify cost benefits of clinical pharmacy services more readily. ASHP Guidelines for Implementing and Obtaining Compensation for Clinical Services by Pharmacists,AmJ HaspPharm, 42, 1581 (1985).

This article delineates the administrative requirements for im· plementing, documenting the cost of, and obtaining reimbursement for a clinical pharmacy service. It is written primarily for the institutional practitioner, but some aspects may be applicable to independent practitioners. ASHP Statement on Third-Party Compensation for Clinical Services by Pharmacists, Am J Hasp Pharm, 42, 1580 (1985). This statement applies to institutional pharmacy practitioners. It delineates the role ofthe pharmacy administrator in identifying existing institutional reimbursement by third party payers, circumstances under which payment for clinical services may occur, formulation of mechanism for determining costs, and documentation of cost benefit.

Reimbursement: Surveys APhA National Survey: Willingness of Consumers to Pay for Pharmacists' Clinical Services, Am Pharm, NS23, 314 (1983). The survey raised the question, "Are consumers willing to pay?" It did not explore the practicality of these services,just the potential acceptance by patients and their willingness to pay for services. The five services studied were: private consultation about prescription medication; therapeutic drug monitoring (blood pressure); home consultation visits by the pharmacist; consultation advising patient not to take a prescription because the pharmacist felt it would be harmful to the patient; advice regarding the treatment of minor problems with OTC drugs.

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Consumer Demand for a Pharmacist Conducted Prescription Counseling Service, Am Pharm, NS23, 321 (1983). This study explored the feasibility and revenue potential of offering a specific health care service. This service involved a fonnal offering to consumers who presented an antibiotic prescription for filling. The serVice was explained to the patient, who had the right to accept or refuse the service. While the technician filled the prescription, the phannacist provided the following in a semiprivate area: a medication history; a review of a brochure of general infonnation on medication use; a review of the monograph for the prescribed drug; a detennination of the individual circumstances of the prescription's use and tailoring the directions accordingly; solicitation of questions from the patient. The value of these services correlated with the charge for the service; too small a charge gave the impression of less value. Two dollars was the charge associated with the greatest utilization and highest value of the service. Greatest acceptance was by individuals aged 36-45; least acceptance was among those aged 66-75. Involvement of a State Society of Hospital Pharmacists in Third-Party Reimbursement for Nondistributive Services, Am J Hosp Pharm, 39, 1937 (1982). A state society of hospital phannacists developed a survey for hospitals in the state of Mississippi. Meetings were held with the third party payers. A statewide approach can facilitate the reimbursement approval for all hospitals in the state. The survey dealt with nondistributive services and reimbursement ofthose services. Payment for Nondistributive Hospital Pharmacy ServicesA Regional Survey, Drug Intell Clin Pharm, 12, 410 (1978). Strandberg et a1. surveyed hospitals in the Pacific Northwest. They detennined the extent of services and actually printed the range of fees charged. Some of the hospitals were paid for their nondistributive services. Professional Fees for Clinical Pharmacy Services, J Am Pharm Assn, 16, 135 (1976). There are many forces in society emphasizing the "bottom cost" of prescription services. Cognitive phannacy services present a more intellectual, professional image ofphannacy and the phannacist, and. give consumers an option to choose phannacies based on quality, not just cost. Clinical fees should be charged and reimbursed as such, not just hidden in the cost of the prescription or lumped in with the routine dispensing activity. The charge for these services must be sufficient to provide a level of remuneration beyond that of strictly a dispensing function. Pharmaceutical Services - Consumer Perceptions, J Am Pharm Assn, 16, 137 (1976). Phannacists are often hesitant to promote "comprehensive pharmaceutical services" due to the lack of a universal definition of the tenn and lack of documentation on consumer receptivity to phannaceutical services and their costs. Using a self-administered questionnaire, this study reports findings suggesting several services rated to be important to consumers and the demographic characteristics of the respondents.

cation histories and patient education (e.g., cardiovascular disease) for reimbursement. The screening service also created a positive public image for the phannacist as a consultant and sets up the opportunity for reimbursement for similar health monitoring functions. Blood Level Testing in a Community Pharmacy: Consumer Demand and Financial Feasibility, Am Pharm, NS28, 188 (1988). This study looked at three small chain phannacies and a larger sample of patients. This study verified the results of the aforementioned paper (Drug Intell Clin Pharm, 22, 45, 1988). It also examined more specifically the costs involved to provide the service and the level of profitability. Theophylline Pharmacokinetic Consultation in a Community Pharmacy, Consult Pharm, January/February, 54 (1988). This paper describes a pilot study for a theophylline consultation service established in a community phannacy. Eighteen patients were tested. Each patient indicated a willingness to pay approximately $25 for perfonnance of a serum theophylline level and a consultation. Medication and medical histories were obtained. Patient acceptance of and satisfaction with the service was high. Clinical Pharmaceutical Services in Retail Practice: Pharmacists' WIllingness and Abilities to Provide Services, Drug I ntell Clin Pharm, 1B, 917 (1984). This paper identified in a statewide survey of registered phannacists two groups of practitioners who were categorized as either currently providing or not providing 18 specific services related to patients' use of medications. Less than 10% of the sample was found to be providing many of the services. Although the study showed a lower mean score of willingness and competency among the nonservice group than among the groups of phannacists who did provide services, the study was not able to prove its hypothesis that a statistically significant difference exists between the two groups. Generally phannacists who provided services considered themselves to be more competent (17/18) compared to the phannacists who were not providing services (8/18). The study also suggests that the willingness to provide services among the service group was less dependent upon economics or the availability of reimbursement. On the other side a lack of willingness by the larger nonservice group was more dependent on factors concerning recognition, demand, and reimbursement by patients, physicians, and third party sources. Patient Willingness to Pay for a Community Pharmacy Based Medication Reminder System, Am Pharm, NS23, 325 (1983). This article describes a study conducted in a community pharmacy with 102 patients. A medication history was obtained and in-depth consultation was provided regarding medications at the initial visit, with follow-up discussions at subsequent visits. For half the patients, a medication reminder card was mailed if the prescriptions were not refilled in a timely manner. A questionnaire was mailed to all of the patients after four months. Overall, 40% of the patients expressed a willingness to pay for the reminder service and to pay $1 or more.

Reimbursement: Community Pharmacy Practice Establishment and Evaluation of a Serum Cholesterol Monitoring Service in a Community Pharmacy, Drug Intell Clin Pharm, 22,45 (1988). This is a limited three-day single-site study that examined the potential and acceptability of blood cholesterol screening ina community phannacy setting. Study results indicated a positive consumer response to the service and phannacy location and a willingness to pay a fee for the service. This study demonstrated serum cholesterol screenings as a potential reimbursable market for a community phannacy setting. It may create an opportunity to bundle other services with the cholesterol screenings, including medi-

American Phannacy, Vol. NS29, No. 12 December 1989/769

Reimbursement: Ambulatory Hospital Pharmacy Practice Reimbursement of Clinical Pharmacy Services in Community Hospitals and Nursing Homes, Drug Intell Clin Pharm, 21, 64 (1987). This article is the second offour reports by the American College of Clinical Phannacy (AACP) Reimbursement Committee. The paper summarizes available literature on the topic of reimbursement and describes the author's personal experience with reimbursement for clinical phannacy services.

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Reimbursement for Pharmacokinetic Services, Drug Intell Clin Pharm, 21,289 (1987). As the final oHour reports by the AACP Reimbursement Committee, this report provides a very brief general description of reimbursement for pharmacokinetic services. The models at the Medical University of South Carolina and Emory University are described. The two programs are similar and multidisciplinary. The author includes a table of payers of conault charges for clinical pharmacokinetic evaluations in a typical university hospital. Representative charges for clinical pharmacokinetic evaluations in the literature range from $35 to $40 for the evaluation of a new patient and $10 to $15 for each follow-up visit. Reimbursement for Nondistributive Pharmaceutical Services in Hospitals, Am J Hosp Pharm, 39, 594 (1982). This is a literature review conducted in 1982 regarding reimbursement for nondistributive pharmacy services. The authors disCUBS various studies and reiterate the ASHP guidelines for reimbursement. Reimbursement for CUnical Pharmaceutical Services in University Hospitals, Am J Hosp Pharm, 39, 642 (1982). A survey was conducted for teaching hospitals to determine which clinical pharmacy programs had a separate fee for service and who was being reimbursed by third parties. Article gives a list of services provided with percent reporting FFS and third party reimbursement. Developing Reimbursable Clinical Pharmacy Programs: A Goal Oriented Approach, Am J Hosp Pharm, 36, 1548 (1979). This paper describes several approaches to obtain reimbursement by third party payers, including the development of a comprehensive package of pharmaceutical services with a request for aggregate reimbursement for total package. In order to achieve the goal of reimbursement, one must develop clinical service protocols, determine service charges, inform the patient and third party agencies of the availability of the service, and mobilize resources. Reimbursement for Clinical Pharmaceutical Services, Am J Hosp Pharm, 35, 1373 (1978). Patterson and Heuther describe the clinical services at their small hospital covering patient consultation and patient visits. Approval was obtained from the hospital administration to charge for the services, and bills have been paid by third party payers. Third-Party Reimbursement for Pharmacist Instruction About Antihemophilic Factor,AmJ HospPharm, 34, 831 (1977). A pharmacy-based program to teach a 14-year-old hemophilic patient to prepare and self-administer antihemophilic factor is described. The benefits ofthe program included a cost savings of over $20,000 for the first year, decreased hospitalization, and increased school attendance. The results were used to justify third party reimbursement for pharmacist educational services. Third-Party Reimbursement for Clinical Pharmacy Services: Philosophy and Practice, Am J Hosp Pharm, 34, 823 (1977). This article describes an approach for obtaining reimbursement for clinical pharmacy services using a home therapy program as an example. The authors outline the seven steps necessary to obtain reimbursement: 1) hospital management must have a total commitment to the patient's health needs; 2) patient health needs that require a high degree of clinical pharmacy expertise must be identified and communicated to the physician; 3) a training program for the patient needing services from the pharmacist must be developed; 4) a written proposal for review by hospital administration should be developed; 5) the proposal must be presented to third party representatives; 6) a meeting with the hospital fiscal representatives should be arranged to begin charging for clinical services; and 7) provision for a follow-up report to providers on progress should be developed to include the number of patients trained, the number of home therapies involved, an estimate of the number of

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hospital and clinic visits avoided (cost avoidance), and a benefit-cost analysis. Reimbursement: Inpatient Hospital Pharmacy Practice Evaluation ofthe Contribution of Clinical Pharmacists: Inpatient Care and Cost Reduction, Drug Intell Clin Pharm, 22,252 (1988). This article documents the contribution of clinical pharmacists in increasing the quality of care and avoiding costs. While this article does not address reimbursement directly, the information presented is useful in justifying clinical pharmacy services. Obtaining Reimbursement for Clinical Pharmacokinetic Monitoring, Am J Hosp Pharm, 39, 1662 (1982). This article describes a method for obtaining reimbursement for clinical pharmacokinetic monitoring at the Hamot Medical Center, Erie, Pa. Audit of records indicated that reimbursement was obtained from third party programs, insurance companies, and private patients. Blue Cross reimbursement criteria for pharmacokinetic monitoring are outlined in the article. An inclusive charge of $10 per patient day was chosen. Cost-effectiveness of Clinical Pharmaceutical Services: A Follow-up Report, Am J Hosp Pharm, 36, 1527 (1979). The cost-effectiveness of pharmacist-conducted training programs for patients administering at-home antihemophilic factor, calcitonin, cytarabine, parenteral nutrition, and injectable analgesics was studied and described at the Ohio State University hospitals. A table in the article lists payment method, estimated hospitalization cost savings for patients trained to self-administer their medications, etc. Developing Reimbursable Clinical Pharmacy Programs: Pharmacokinetic Dosing Service, Am J Hosp Pharm, 36, 1523 (1979). This article describes the development, operation, and evaluation of a pharmacy-conducted pharmacokinetic dosing service at the Department of Pharmacy at Ohio State University hospitals. The authors state that their pharmacokinetic dosing service was the first nonteaching, nonproduct-oriented pharmaceutical service in which cost-effectiveness has been recognized by a third party payer. The pharmacokinetic dosing service fee of $20 was reimbursed by Blue Cross of Central Ohio. Charging for Hospital Pharmaceutical Services: Product Cost, Per Diem Fees and Fees for Special Clinical Services, Am J Hosp Pharm, 36, 355 (1979). This paper describes a method for charging for clinical pharmacy services in a hospital. The following pharmacy services were separately charged for and charges were reimbursed by third parties: hemogram drug report, drug liver function report, aminoglycoside dosing guidelines, heparin IV infusion guidelines, oral anticoagulants, drug history, TPN evaluation, pharmacokinetic levels, and pharmacokinetic consultation.

Reimbursement: Miscellaneous Cardiac Risk Screening Gets Florida Pharmacy Test, Drug Topics, February 15, 12 (1988). This article describes two community pharmacies in Florida that have initiated a comprehensive cardiac risk screening program. Separate charges ($35) were made for the laboratory values and assessment of cardiovascular risk factors. Appropriate referrals were made to a physician for patients identified to be at significant risk. A pharmacist provides patient education regarding diet and other methods available for controlling cholesterol for a separate $10 fee. This was a pilot program supported by a college of pharmacy with little marketing that saw four to six patients per week. This article suggests that by working with other health care professionals in the community for referral and follow-up of patients identified, a strong network can be established at the community phar-

American Phannacy, Vol. NS29, No. 12 December 1989n70

macy level to link the pharmacist to the appropriate health care professional. A Study of the Monetary Impact of Clinical Pharmacy Interventions, Pharm Times, 8, 101 (1988). This study at Pacific Presbyterian Medical Center was intended to demonstrate cost savings from clinical pharmacist intervention, identify therapeutic areas in which clinical pharmacists are intervening, determine if drug cost savings justify these services, and assess the methods of documenting cost savings. Unfortunately, economics are based on cost savings rather than reimbursement for improved patient care. It could be anticipated that once the clinical service has made the distribution component efficient, without emphasis on patient outcomes there would be no mechanism for further justification. Also, the service as described does not seem realistic for non-hospital-based programs. Evaluation of Prescribing Errors and Pharmacist Interventions in Community Practice: An Estimate of "Value Added," Am Pharm, NS28, 766 (1988). Nine community pharmacies in Indiana documented prescribing errors over a two-week period. Thirty-eight errors were identified that might have resulted in patient harm without pharmacist intervention. The cost of pharmacist time for the intervention was $1.75 vs. a savings of $7.15 in medical care avoided, indicating that nondistributive professional activities added significaI\t value to the dispensing process. Increasing Patient Compliance Through Tracking Systems, Calif Pharm, 35, 54, (1987). This article describes a six-month hypertension medication compliance project in a community pharmacy. Printed medication refill reminders resulted in 100 (65%) of the 154 people in the intervention group having a high level of compliance, compared to 70 (46%) of the 152 people in the control group. A 41 % increase in compliance in the treatment group leads to 41% additional revenue due to more refills of cardiovascular drugs. This extrapolates to $882 in additional revenue per week in the average pharmacy. Two For-Fee Pharmacist Consulting Services Begin Operations, Consult Pharm, 2, 369 (1987). This article presents two different innovative fee-for-service pharmacist consulting services in a community pharmacy setting. The practices differ in both their structure and their marketing approaches. One is based on a self-care concept in which the pharmacist charges $3 for an on-demand service taking about three minutes. The other program is structured to be initiated on physician referral for a comprehensive clinical evaluation of the patient's therapeutic regimen. The pharmacist reports his recommendations directly to the physician, for which the patient pays the pharmacist approximately $50. While both of these innovative pharmacists report their efforts are rewarding, utilization of the service is disappointing. They conclude that success of these programs will depend on the public's education and third party realization of the cost-effectiveness/value of the pharmacist's services. Fee-Paid Cholesterol Screening Program Introduced, Am Pharm, NS27, 662 (1987). In late 1987, patients paid $3 , which was reimbursable under the state's Blue Cross program, for a family history, medication and dietary profile, and a cholesterol test. The aim was to improve compliance and offer comprehensive patient counseling. Impact of Federal Reimbursement Changes on Clinical Pharmacy Education and Training, Am J Hosp Pharm, 43, 1773 (1986). This is a report of an AACP-sponsored invitational conference on the impact of federal reimbursement changes on undergraduate and postgraduate clinical pharmacy education and training held February 25-26, 1986, in Washington, D.C. The conference traced the negative and positive incentives that are affecting pharmacy

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practice and education. These incentives are affected by federal reimbursement policies for hospitals and private initiatives to control the rising costs of health care. The immediate impact on pharmaceutical education will be through clerkship, externship, and residency training. Recent Developments in Organizing and Financing HealthCare Services, Am J Hosp Pharm, 43, 2436 (1986). This is an article expanding on the changes in financing health care. It seems to aim at hospital practice, but it does not touch on home health, long-term care, and physician reimbursement. Application of Cost-Benefit Analysis to Community Pharmacy Practice, Bootman, J .L. (1985 presentation in Toronto, Canada). Assuming limited health care dollars and resources, the application of cost-benefit analyses (CBA) or cost-effectiveness analyses (CEA) to proposed pharmacy programs becomes important. A CBA applied to community pharmacy practice may compare the cost of a program with outcome benefits such as therapy compliance, adverse drug effects, rate of generic substitution, dosage errors, use ofOTC drugs, or frequency of physician visits. Different CBAs may be sought for different purposes; for example, interest in a new program would be different from the perspectives of patient, provider, third party payer, or employer. This article summarizes three CBA studies performed at the University of Arizona, all of which suggest that the following programs may be cost-effective: prescription counseling services, pharmacokinetics services, and pharmacist prescribing of medications in a long-term geriatric facility. Other reports of CBA studies on pharmacy services are mentioned. These examples show the usefulness of CBA as a tool to obtain data to assist policy makers in their decisions regarding the financial support of health care programs competing for the same health care dollar. Reimbursement Dilemma Regarding Home Health-Care Products and Services, Am J Hosp Pharm, 41, 1548 (1984). This article is somewhat outdated due to recent changes in the Medicare guidelines; however, some points are relevant. First is that services and products are reimbursed differently; services are usually covered 100% but products (DME, oxygen, etc.) are covered only 80% with patient responsibility for the rest. The rationale for this is unclear and not reviewed. Second, this article does not mention nondispensing pharmacy professional services in its review and there is no direct coverage for pharmacist consultative services even though Medicare-certified HHAs can obtain reimbursement under administrative expenses for such. Finally, it is noted that government administrators are concerned about potential spending growth at a time of balloon deficits, and private health insurers are uncertain about coverage criteria. Fiscal and Clinical Evaluation of Home Parenteral Nutrition, Am J Hosp Pharm, 41, 285 (1984). This article describes a nonphysician clinical management team of a home parenteral nutrition program that included pharmacists and was hospital based. Product and service costs were documented, and savings for 13 patients managed at home were $651,6511patienUyear in 1984 dollars. Since product costs were based on hospital contract prices, an equivalent non-hospital-based program would probably project lesser though still significant savings. DRG's and Medicare Reimbursement for Outpatient Intravenous Antibiotic Programs, A m J H osp Pharm, 41, 1310 (1984). This letter notes the inequities between prospective pricing systems (DRGs) with respect to long-term antibiotic therapy for osteomyelitis and endocarditis, which encourages early discharge and home administration. Clinical Services in an Independent Community Pharmacy, NARD Foundation Grant Report, 1984. A one-year study was undertaken to identify patient-oriented,

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nondistributive services that may be provided in a community pharmacy setting, and to evaluate consumer satisfaction with those services. The services included OTC and/or prescription counseling, written drug information materials, availability of a private consultation area, medication histories, drug interaction screening, answering drug information questions, provision of primary care (e.g., treating skin abrasion), and/or consulting with health care practitioners concerning identified problems. Direct or personal services by the pharmacist ranked highest (checking with physician, checking for interactions, and medication counseling). Sixty-one percent of the respondents reported that a pharmacist's consultation had saved a physician office visit. Pharmacy location and pharmacist consultation ranked higher than the financial considerations of prescription price or availability of charge accounts. This study examined the perceived value of the clientele of a community pharmacy to selected clinical services; it did not attempt to determine if or how much consumers would be willing to pay for them.

Task and Cost Analysis of Integrated Clinical Pharmacy Services in Private Family Practice Centers, J Fam Prac, 16, m (1983). This study analyzed the costs and activities necessary for provision of clinical pharmacy services in three centers in South Carolina. The study concluded that 51% of general job activities were clinical in nature and that clinical costs averaged $1.47/prescription or $1.65/patient center visit. The authors concluded that integration of these costs into the prescription fee is viable and a competitive prescription pricing policy is possible. Changing the Rules of the Reimbursement Game, Am J Hasp Pharm, 39, 1975 (1982). The implications of the transition from cost-based reimbursement to a rate-based reimbursement for hospital services are discussed. The author states that "clinical pharmacy programs will survive only to the extent that hospital administrators can be convinced that clinical pharmacy services are effective in controlling the use of expensive medications, reducing the incidence of drug

interactions and adverse reactions, optimizing drug therapy through more appropriate dosing, conducting prospective drug-use review and prescribing studies, and intensifying patient care and reducing the average length of stay." Final Report of the Task Force on Payment for Pharmacy Services, ASHp, 1979. This report served as the basis of the more recent ASHP guidelines related to reimbursement for clinical pharmacy services. It is of historical interest and also notable for its selected bibliography on the "Justification of Clinical Services."

Communicating the Value of Comprehensive Pharmaceutical Services to the Consumer, The Dichter Institute for Motivational Research, Inc., 1973. This report determined mechanisms for communicating the value ofpharmacy services to consumers to increase demand. Utilizing interviews, psychological tests, and projective techniques, the investigators found that communication between the community pharmacist and the patient is lacking and needs to be improved. Results indicate that the public is not aware of the many services provided by pharmacists. The report offers suggestions to improve this situation on a local community pharmacy level. The Face of Pharmacy's Future, Florida Pharmacy Today, 52, 5 (1988). This article describes the results of a pilot project that studied an independent medication consultation service. This service was set up as a "stand alone" practice whereby the patient did not receive hislher drugs from the pharmacist. The pharmacist obtained a medication history from each study patient. A computerized screening checking for interactions, duplications, etc., was performed on the data gathered from the interview. The computer-generated report as well as a letter explaining the results was then given to the patient. The patients who participated in the study indicated that they were impressed with the service and would definitely recommend it to a friend or relative. The patients also indicated that they would be willing to pay for the service. ®

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American Pharmacy, Vol. NS29, No. 12 December 1989n72