- Email: [email protected]
Value of Pharmacy Services
REVIEWED RESEARCH
Value of Pharmacy Services: Perceptions of Consumers, Physicians, and Third Party Prescription Plan Administrators by Jan D. Hirsch, PhD, Jean Paul Gagnon, PhD, and Ruth Camp
Summary A study of patients, physicians, and third party prescription plan administrators was conducted to identify those pharmacy services they believe are important and valuable and to determine whether third party plan administrators would reimburse pharmacists for such services. Patient and physician focus groups indicated that both wanted personalized services related to medications. Physicians believe that pharmacists are talking to patients about their medications, whereas patients want more drug information but report that pharmacists are not always providing such information. A mail survey of 41 third party prescription plan administrators indicated they believe that pharmacy services are important to consumers and that pharmacists are already providing most of the services identified. One-third of the third party administrators said their companies would consider implementing a structured pharmacist incentive plan to improve enrollee satisfaction. Those whose co~panies would not most often gave "increased cost" as the reason. No clear relationship Jan D. Hirsch, PhD, is assistant professor, School ofPharrnacy, University of North Carolina, Chapel Hill, NC 275997360. Jean Paul Gagnon, PhD, is director, pharmacy relations, Marion Merrell Dow Inc., Kansas City, Mo., and Ruth Camp is a fifth-year pharmacy student at the University of North Carolina School of Pharmacy. Submitted November 1989; accepted December 1989.
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was shown between number or type of services and the incentive value offered. Providing administrators with evidence that enhanced pharmacy services will increase overall program cost savings may lead to implementation of pharmacy incentives.
Introduction
D
emand for services by consumer groups historically has not been a driving force in the evolution of pharmacy practice or in health care in general. Traditionally, health care professionals have been viewed as possessing specialized knowl-
edge that society has entrusted to them. Consequently, pharmacists decided what types of pharma"cy services patients needed and what was the fair market value of these services. Today, patients, prescribers, and third party prescription plan administrators are the primary consumer groups actively evaluating and influencing the evolution of pharmacy services. Patients influence the mix of pharmacy services by choosing among competing community pharmacies. When patients have prescription medications dispensed, they may also be consumers of other phar-
American Pharmacy, Vol. NS30, No.3 March 1990/140
macy services such as counseling and drug monitoring. Many studies of patronage have attempted to determine the importance to patients of specific attributes of a community pharmacy.l,2,3 In general, these studies have consistently found that location or convenience of a pharmacy was the most important reason for patronizing a specific pharmacy, followed by prices and personnel characteristics.4 Other studies have focused on the patient's perception of the pharmacist and the pharmacy services provided. 5 ,6 ,7 Counseling on proper use of prescription and nonprescription drugs and on their side effects and drug interactions is important to patients. However, patients generally do not expect more comprehensive health-related services from pharmacists. 7 ,8,9 Physicians are also consumers of drug information provided by pharmacists, and this information can assist them in their prescribing decisions. Physicians influence the provision of pharmacy services by expressing demand through the prescribing process. Physician perceptions of the services provided by pharmacists have also been studied, but to a much lesser degree than patients' perceptions have been studied. A recent survey of physicians revealed that physicians would like pharmacists to inform them of noncompliant patients and of patients possibly experiencing problems with their medications.lO There seems to be little demand by physicians for more clinical functions such as screening and diagnostic procedures. 8 The growth in third party prescription plans has made plan administrators an increasingly important group of consumers of pharmacy services. These administrators influence the mix and evolution of pharmacy services through their reimbursement policies. In 1988, third party prescription plans paid for four out of 10 prescription medications dispensed in community pharmacies.l l Demand for specific types of pharmacy services within third party payer systems has not been systematically investigated to date. Instead, most surveys h ave fo-
cused on cost-containment strategies for drug products and pharmacist fees within third party plans. This paper presents the results of a study designed to determine which pharmacy services three important consumer groups - patients, physicians, and third party prescription plan administrators - believed were important and valuable. The objectives of the study were to: • Identify services that patients and physicians would like pharmacists to provide. • Assess the level of importance that third party prescription plan administrators believe patients and physicians place on selected services.
'Pharmacists offering patient-oriented services consistently would be well positioned to garner an important and growing segment of the prescription drug market.'
• Determine whether third party prescription plan administrators want pharmacists to provide selected pharmacy services to their enrollees. • Determine whether third party prescription plan administrators would be willing to reimburse pharmacists for the services they want pharmacists to provide to their enrollees.
Methods Patient and Physician Focus Groups hree focus group sessions of paT tients and two of physicians were conducted in five North Carolina cities during late 1987 and early 1988. Focus groups are panels of 10 to 12 individuals who provide informal, uncensored dialogue about products or services. The patient focus group members were recruited through random telephone calls to households in the target cities and by placing recruitment flyers in 15
American Pharmacy, Vol. NS30, No.3 March 1990/141
t
to 20 pharmacies in the target cities. Physicians were recruited from actively practicing physicians in the target cities, whose names were provided by pharmacists. In the focus group sessions, patients and physicians were first asked to generate a list of services they associated with pharmacists and pharmacies. After writing each service on an index card, each subject ranked the services by sorting the cards from most important to least important. This procedure yielded an aggregate rank ordering of the pharmacy services identified by the group. Participants also were asked to comment on their pharmacists' performance. Focus group sessions were audiotaped, and transcripts were produced following the sessions. Each subject anonymously completed a questionnaire containing demographic information, including age, sex, and number of years in college. Focus group data are usually examined intuitively, and the transcripts of comments are used to support the researchers' interpretations. In this study a more objective rank ordering of services was also produced.
Plan Administrator Questionnaire hird party payers must satisfy two primary consumer groups T plan enrollees (patients) and physicians - as well as corporate sponsors. To assess third party prescription administrators' perceptions of pharmacy services, a nationwide mail survey of 60 major third party payers was conducted during the fall of 1988. (The geographic distribution of third party payers required the use of a mail survey rather than focus groups.) This phase of the study built on the results of the focus groups of patients and physicians. The pharmacy services that were included in the questionnaire sent to third party prescription plan administrators were those that patients and/or physicians had rated most important. The targeted respondents were administrators with responsibility for prescription drug programs and/ or pharmacy reimbursement. A random sample was selected from the 21
mailing lists of the 1987 membership listing of the National Council for Prescription Drug Programs and the 1987 Health Maintenance Organizations Directory. There were two follow-up mailings to nonrespondents. Services similar to those judged important by patients and physicians were listed in the first question on the questionnaire sent to third party plan administrators. Administrators were asked to assume the patient or physician perspective, since part of their role as a third party provider involves satisfying these two pharmacy service consumer groups. The Statistical Analysis System (SAS) was used to analyze the data. Since this was a descriptive study, data analysis consisted of calculation of frequencies and means for relevant variables.
Results Patient and Physician Responses emographic data on the members of the patient focus groups D indicated that the mean number of prescription orders processed in the previous year was 17 for themselves and 36 for their families. Sixty percent of the participants patronized one pharmacy, and 71 % patronized a chain pharmacy. The length of time patients had patronized their current pharmacies was evenly distributed from less than one year to 10 years. Most of the participants (88%) picked up their own prescription medications, and most were married females with a high school education. Patients were asked to rank order their top eight pharmacy services. "Providing OTCIRx drug information," "a pamphlet or insert on drugs," "open 24 hours," and "drug expiration date on label" were ranked very important by the patient panel. "Up-to-date about new product," "low prices," "clear directions," "speed," "discusses side effects," "maintains drug records," "dispenses generics," and "refill information" were ranked important. When asked, patients indicated that they were generally pleased with the services offered by their pharmacists, but they had sugges22
tions for improvement. First, they believed that pharmacists should supply more drug information, perhaps a pamphlet or a computergenerated printout. The more experienced users of prescription drugs knew that pharmacists would supply drug information if asked. The inexperienced users, however, said they never asked and therefore often arrived home with a bottle labeled "Take as directed." Some patients believed that pharmacists were intentionally holding back drug information, because patient inserts were given for some drugs and not for others. Another service that patients considered important was the provision of 24-hour coverage. This is a service offered by almost all other health care professionals. The participants suggested that pharmacies could rotate being on call according to a schedule that could be posted weekly in the newspaper. Another suggestion was that pharmacists in a given pharmacy could be on call, with a beeper, on a rotating basis. Patients complained about having to wait for a prescription medication and having to "pretend to shop." Some wondered why there wasn't a waiting room with chairs and health pamphlets or magazines. Finally, patients said they would like the number of renewals recorded on the prescription label. Patients believed this service would save time when they wanted to have a prescription order renewed. In summary, the focus group patients were relatively pleased with their pharmacists and pharmacy services but also had many positive suggestions for fine-tuning a pharmacy's services. The mean age of the physician focus group participants was 39, all were males, and most were in private practice as family practitioners, pediatricians, or internists. They wrote an average of 12 prescription orders a day and talked approximately twice a day to pharmacists. Most ofthe time (69%), the physicians' nurses telephoned in prescription orders to pharmacists. The most important services physicians believed pharmacists could provide were "checks and bal-
ances function," "monitor drug interactions," "clarify dosage directions," and "good pharmacy personnel." Other highly ranked services were "discussing directions," "providing 24-hour service," ''health promotion services," "serving as a source of drug information," and "cost-effective generics." Physicians believed that pharmacists were competent and knowledgeable and should be explaining drugs to patients. In general, they liked the idea that pharmacists serve as checks and balances, and they believed that pharmacists were clarifying dosage and storage directions as well as providing drug product information. Some physicians (and patients) wanted drug expiration dates on prescription labels. Physicians (especially pediatricians) reported they often determine that the patient has on hand a cough syrup or an antibiotic; but because the prescription container has no expiration date, the physician has to call the pharmacist with a new prescription order. A comparison of the physician and patient focus group results reveals a discrepancy with respect to drug information. Physicians believe that pharmacists are talking to patients about their medications, while patients want more drug information but report that pharmacists are not always providing such information to them. Providing more drug information to patients is certainly one service that pharmacists can perform that would increase patient and physician satisfaction.
Administrators' Perceptions f 45 questionnaires returned by third party prescription O plan administrators, four were unusable, yielding a 68% response rate. The respondents represented a wide variety of third party payers, from very small third party plans (35 enrollees, 5,000 prescription medications reimbursed per year, and 20 pharmacy providers) to very large plans (8,300,000 enrollees, 100,000,000 prescription medications reimbursed per year, and 62,000 pharmacy providers).
American Pharmacy, Vol. NS30, No.3 March 1990/142
Table 1. Importance of Pharmacy Services to Patients as Perceived by Third Party Prescription Plan Administrators* ~?ltif19 from " ,Pati,Emt Pe?fgectiY~'k~ 4· ,
Me~n
"
'
S.D.
4.21
PharmaGis,t prpvides written drug information "to the patient.
4.15
0.99
Pharmacist provides physicians with cost data for prescription drugs.
4.07
1.19
Pharmacist provides physicians with periodic new drug updates.
3.77
1.31
Pharmacist advises prescriber of better choice of drug dueto therapeutic reasons.
3.46
1.52
Pharmacist offers health promotion programs in pharmacy (e.g., free blood pressure monitoring~ cholesterol checks}.
3.41
1.16
Pharmacist provides a periodic neV\lS[etler gn health issues and new drug therapy for patients~
2.85
1.25
* n = 41 * * Scale range: 1 = UnImportant; 5 = Important. Question stated as "In your opinion, how important are the following pharmacy services to PATIENTS?"
Respondents were asked, "In your opinion, how important are the following pharmacy services to patients?" Importance was rated on a 5-point Likert-type scale ranging from "important" (5) to "unimportant" (1). Two spaces were provided for respondents to enter and rate "other" services of their choice. The services are listed in order of their mean importance rating from the patient perspective in Table 1. The two services that administrators perceived as having the greatest importance to patients were "pharmacist personally counsels each patient with a new prescription" (x=4.56) and "pharmacist provides counseling on proper dosage and choice of OTC products" (x=4.52). Furthermore, the smallest standard deviations (S.D.) were observed for these services, an indication of agreement among respondents on the importance of these services to patients. ''Advising pre-
scribers of better choice of drug due to lower cost" (x=4.21) and "providing physicians with cost data for prescription drugs" (x = 4.07) were rated important to patients. Less traditional roles involving provision of therapeutic or health-related information to patients or physicians (e.g., providing physicians with new drug updates or advising of better drug choices due to therapeutic reasons, and health promotion activities or newsletters for consumers) were rated neutral to slightly unimportant. Pharmacy services that were written in by administrators and perceived as important to patients were as follows: • "Classes for patients: Pharmacist teaches patients about medications for specific conditions (e.g., diabetes)." • "Pharmacist supplies patients with cost of prescription if prescription is a third party prescription."
American Pharmacy, Vol. NS30, No. 3 March 1990/143
• "Pharmacist checks for utilization (i.e., overuse and noncompliance)." • "Pharmacist is actively involved in monitoring compliance with drug therapy." • "Pharmacist monitors patientspecific drug profiles and informs physician of inappropriate drug use." • "Pharmacist advises patient a generic equivalent drug is available." • "Pharmacist consults physician on use of generic drugs." Differences in third party administrators' perceptions of the value of pharmacy services to patients vs. the value to physicians could influence their assessment of the overall value of pharmacy services. Therefore, the questionnaire also asked for the prescription plan administrators' perceptions of which pharmacy services physicians would rate as the three most important for pharmacists to provide to patients (enrollees). The rankings for perceived importance to physicians generally paralleled those for perceived importance to patients. The majority (56%) of administrators believed that the "pharmacist personally counseling patients with new prescriptions" was the most important pharmacy service to physicians. Approximately one-quarter of the administrators indicated "providing counseling in proper dosage and choice of OTC products" and "providing written drug information to the patient" would be second most important to physicians. Providing nonprescription drug counseling ranked as the third most important service for almost one-quarter of the respondents. After rating the importance to patients and physicians of the listed services, administrators were asked to indicate which services they believed pharmacists were currently providing for their enrollees (Table 2). The majority of administrators believed that pharmacists were offering the four services rated most important to patients and physicians: "new prescription counseling" (60.5%), "OTC counseling" (70%), "advising prescribers of better drug choice due to cost" (55%), and "providing written information 23
Table 2. Third Party Prescription Plan Administrators' Perception of What Pharmacy Services Are Currently Offered*
No.
%
23
60.5
21
52.5
PharmaCist advises prescriber of better choice of drug due to therapeutic reasons.
15
37.5
Pharmacistadvises prescriber of better choice of drug due to lower cost.
22
55.0
Pharma ffers health promotiqn programs in .g., free blood pressure monitoring, pharrna cholesterol Oi"ecks).
19
47.5
Pharmacist provides counseling on proper dosage and choice of OTe products.
28
70.0
Pharmacistprovides a periodic nevvsletter on healtq issues ~md new drug therapy for patients.
6
15.0
Pharm Rr-evides physicians with cost data for prescrl en drugs.
7
17.5
Pharmacist provides physicians with periodic new drug updates.
7
17.5
* n = 40 Question stated as "Please place a check under 'Offer Now' for services you believe pharmacists curre\1tly provide to your enrollees. 'I
to patients" (52.5%). A large proportion also believed that pharmacists were performing two informationrelated services that received lower importance ratings: "offering health promotion programs" (47.5%) and "advising prescriber of better drug choice due to therapeutic reasons" (37.5%). If administrators believed that pharmacists were not currently offering one of the listed services, they were asked to indicate whether their company would be willing to pay pharmacists to offer the service to their enrollees. This question was presented only to the subset of respondents who believed pharmacists were not currently providing a service, because it was thought unlikely that administrators who believed pharmacists were already performing a service would begin to pay pharmacists for the service. Approximately one-third of respondents who did not believe phar-
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macists currently "advised prescribers of better drug choices due to lower cost" or "counseled patient with a new prescription" would pay pharmacists to do so. Almost 20% of respondents who did not believe pharmacists ''provided patients with written drug information" or "provided physicians with cost data for prescription drugs" would pay pharmacists to do so. Two respondents wrote in a service they would be willing to pay pharmacists to provide their enrollees: "dispensing generics when physician writes 'dispense as written' " and "monitoring patient compliance (e.g., antihypertensive therapy)." (The legal ramifications of the first write-in service will vary by state.) In addition to identifying which services they would be willing to pay for, administrators were asked to indicate "how much of an incentive your company would be willing to pay pharmacists (in aggregate)
to perform the desired services." They were given the option of phrasing their incentive in terms of unit of service, time, or patient (e.g., $x.xx per prescription order, $xx.xx per hour, $xx.xx per enrollee). Only eight respondents answered this question. The stated incentives ranged from $0.10 to $3.00 per prescription order. Only one respondent phrased the incentive as a rate per enrollee ($5.00). The relationship between number or type of services and incentive value offered was not clear from the data. There was no obvious rationale that could correlate the number of services or time required to provide service(s) with the incentive value. Two administrators suggested another type of incentive for pharmacists: providing pharmacy services (not specified) through an exelusive business contract with the third party payer. Administrators were asked if their companies would consider implementing a structured pharmacist incentive plan to improve enrollee satisfaction. Slightly more than one-third of the respondents said yes. Three primary reasons were given for not implementing a pharmacist incentive plan: • The plan would be too costly. • Pharmacists should already be providing such services as part of their professional responsibilities. • Enrollee satisfaction is already high. Four respondents indicated they would implement an incentive plan only if it would decrease total plan costs. Cost concerns were paramount, while reasons for implementing a pharmacist incentive plan were less clear (e.g., "pharmacists have something to offer," "would increase commitment to HMO," "strive for customer satisfaction"). In a related question, administrators were asked to rank proposed mechanisms for monitoring patient! enrollee satisfaction on an ongoing basis if a pharmacist incentive plan based on enrollee satisfaction were implemented. Since only a small portion of the administrators perceived a need for such an incentive plan, it was not surprising that only 16 respondents answered this question.
American Pharmacy, Vol. NS30, No.3 March 1990/144
When asked to rank ideas for monitoring patient satisfaction, administrators most frequently ranked conducting a periodic survey of a sample of enrollees (31.3%) and sending trained observers posing as "shoppers" into a random selection of member pharmacies (37.5%) as the best ideas. However, an equal number of respondents ranked enrollee surveys as the worst idea. Providing enrollees and physicians with complaint forms was rated the second best idea by almost half (46.7%) of the respondents to this question.
Discussion Patient and Physician Need for Services he results of this study indicated T that the patients and physicians wanted personalized services related to their medications. Evidence of growing patient demand for information is apparent in today's society. Pharmacists offering patient-oriented services consistently would be well positioned to garner an important and growing segment of the prescription drug market.
Plan Administrator Perceptions of Need here is also a demand by third T party prescription plan administrators for specific pharmacy services. The results of the third party survey indicated that administrators believed patient counseling on both prescription and nonprescription products, providing cost data about drugs to physicians, and providing written drug information to patients are pharmacy services that are important to consumers. Since third party payers must satisfy their corporate sponsors by satisfying corporate enrollees (patients) and, to a large extent, the prescribers (physicians), it would be logical to assume that third party payers would value these services in monetary terms. However, overall, third party payers did not appear to be willing to translate perceived importance into incentives for pharmacists to provide specific services or any array of services listed in the survey. Most of the respondents believed
that pharmacists were already providing the majority of services listed. Therefore, it is unlikely that third party payers will begin to pay for a service their enrollees are already receiving. In addition, for those respondents who did not believe pharmacists were providing a service, only a small percentage were willing to pay for the service. Only two of the listed services could be construed to be candidates for pharmacist payment: "advising prescriber of better choice of drug due to lower cost" and "personally counseling each patient with a new prescription." When the administrators were asked about their companies' intentions for implementing a pharmacist incentive plan, the most frequently reported reason for not implementing such a plan was increased cost. Thus, it appears that providing administrators with evidence that enhanced pharmacy services will increase overall program cost savings as well as patient satisfaction may be a more productive step toward implementing pharmacy incentives than promoting only the potential of increased patient satisfaction. Although the results of this study do not appear to be encouraging to pharmacy as it seeks to gain specific reimbursement for services, a limitation of the third party survey tempers the conclusions drawn: third party respondents were provided with a list of specific services based on the results of the patient and physician focus groups. To the extent that the listed services were not comprehensive, perceived value of pharmacy services by third party prescription plan administrators has not been fully assessed. In fact, the number of services written in by administrators suggests that the listing was not complete. Two areas revealed in the writeins that appear to be potentially of demonstrable value to a third party payer were the pharmacist's role in monitoring drug therapy and the pharmacist's role as patient educator. The perceived value of these and other similar services to third party payers should be explored' and studies demonstrating
American Pharmacy, Vol. NS30, No. 3 March 19901145
the impact of these services need to be conducted before administrators will perceive them to be truly "value added" services. With sound experimental data as supporting evidence, these types of services could be perceived by third party prescription plan administrators as being more likely to result in savings than in additional cost.® Note: This study was supported by the North Carolina Task Force on Pharmacy. The authors and task force members invite comments from all interested parties regarding the issue of third party reimbursement for pharmacy services or the specific results of this study.
References 1. Gagnon JP. Factors affecting pharmacy patronage motives - a literature review. J Am Pharm Assoc. 1977;NS17:557-59. 2. Gagnon Jp, Carroll NY A strategy for marketing pharmacy services. Am Pharm. 1982;NS22:53--56. 3. Newcomb JM. Consumer attitudes about pharmacists and their services. Md Pharm. 1979:8-19. 4. Joyce G, Hubbard cw. Consumer patronage for pharmaceutical services: a comparative analysis of upper income households in urban areas. J Pharm Marketing Management. 1988;3:3-17. 5. Yellin AK, Norwood GJ. The public's attitude toward pharmacy. J Am Pharm Assoc. 1974;NS14:6165. 6. Stewart JE, Kabat HF, Purohit A. Consumer-pharmacist congruence - understanding consumer wants and needs. J Am Pharm Assoc. 1977;NS17:358-61. 7. Gagnon Jp. Pharmacist services consumer perceptions. J AmPharm Assoc. 1976;NS16:137-42, 162. 8. Norwood GJ, SiebertJJ, GagnonJP. Attitudes of rural consumers and physicians toward expanded roles for pharmacists. J Am Pharm A ssoc. 1976;NS16:551-54. 9. Carroll NV, Gagnon JP. Consumer demand for patient-oriented pharmacy services. Am J Public Health. 1984;74:609-11. 10. Glaser M. What today's doctors think about pharmacists. Drug Top. October 17, 1988:32---34,38,40. 11. Prescription dispensing costs $1.12 more per Rx for patients covered by insurance plans, survey finds . Technology Reimbursement Reports. September 8, 1989:10-11.
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Value of Pharmacy Services: Perceptions of Consumers, Physicians, and Third Party Prescription Plan Administrators by Jan D. Hirsch, PhD, Jean Paul Gagnon, PhD, and Ruth Camp
Summary A study of patients, physicians, and third party prescription plan administrators was conducted to identify those pharmacy services they believe are important and valuable and to determine whether third party plan administrators would reimburse pharmacists for such services. Patient and physician focus groups indicated that both wanted personalized services related to medications. Physicians believe that pharmacists are talking to patients about their medications, whereas patients want more drug information but report that pharmacists are not always providing such information. A mail survey of 41 third party prescription plan administrators indicated they believe that pharmacy services are important to consumers and that pharmacists are already providing most of the services identified. One-third of the third party administrators said their companies would consider implementing a structured pharmacist incentive plan to improve enrollee satisfaction. Those whose co~panies would not most often gave "increased cost" as the reason. No clear relationship Jan D. Hirsch, PhD, is assistant professor, School ofPharrnacy, University of North Carolina, Chapel Hill, NC 275997360. Jean Paul Gagnon, PhD, is director, pharmacy relations, Marion Merrell Dow Inc., Kansas City, Mo., and Ruth Camp is a fifth-year pharmacy student at the University of North Carolina School of Pharmacy. Submitted November 1989; accepted December 1989.
20
was shown between number or type of services and the incentive value offered. Providing administrators with evidence that enhanced pharmacy services will increase overall program cost savings may lead to implementation of pharmacy incentives.
Introduction
D
emand for services by consumer groups historically has not been a driving force in the evolution of pharmacy practice or in health care in general. Traditionally, health care professionals have been viewed as possessing specialized knowl-
edge that society has entrusted to them. Consequently, pharmacists decided what types of pharma"cy services patients needed and what was the fair market value of these services. Today, patients, prescribers, and third party prescription plan administrators are the primary consumer groups actively evaluating and influencing the evolution of pharmacy services. Patients influence the mix of pharmacy services by choosing among competing community pharmacies. When patients have prescription medications dispensed, they may also be consumers of other phar-
American Pharmacy, Vol. NS30, No.3 March 1990/140
macy services such as counseling and drug monitoring. Many studies of patronage have attempted to determine the importance to patients of specific attributes of a community pharmacy.l,2,3 In general, these studies have consistently found that location or convenience of a pharmacy was the most important reason for patronizing a specific pharmacy, followed by prices and personnel characteristics.4 Other studies have focused on the patient's perception of the pharmacist and the pharmacy services provided. 5 ,6 ,7 Counseling on proper use of prescription and nonprescription drugs and on their side effects and drug interactions is important to patients. However, patients generally do not expect more comprehensive health-related services from pharmacists. 7 ,8,9 Physicians are also consumers of drug information provided by pharmacists, and this information can assist them in their prescribing decisions. Physicians influence the provision of pharmacy services by expressing demand through the prescribing process. Physician perceptions of the services provided by pharmacists have also been studied, but to a much lesser degree than patients' perceptions have been studied. A recent survey of physicians revealed that physicians would like pharmacists to inform them of noncompliant patients and of patients possibly experiencing problems with their medications.lO There seems to be little demand by physicians for more clinical functions such as screening and diagnostic procedures. 8 The growth in third party prescription plans has made plan administrators an increasingly important group of consumers of pharmacy services. These administrators influence the mix and evolution of pharmacy services through their reimbursement policies. In 1988, third party prescription plans paid for four out of 10 prescription medications dispensed in community pharmacies.l l Demand for specific types of pharmacy services within third party payer systems has not been systematically investigated to date. Instead, most surveys h ave fo-
cused on cost-containment strategies for drug products and pharmacist fees within third party plans. This paper presents the results of a study designed to determine which pharmacy services three important consumer groups - patients, physicians, and third party prescription plan administrators - believed were important and valuable. The objectives of the study were to: • Identify services that patients and physicians would like pharmacists to provide. • Assess the level of importance that third party prescription plan administrators believe patients and physicians place on selected services.
'Pharmacists offering patient-oriented services consistently would be well positioned to garner an important and growing segment of the prescription drug market.'
• Determine whether third party prescription plan administrators want pharmacists to provide selected pharmacy services to their enrollees. • Determine whether third party prescription plan administrators would be willing to reimburse pharmacists for the services they want pharmacists to provide to their enrollees.
Methods Patient and Physician Focus Groups hree focus group sessions of paT tients and two of physicians were conducted in five North Carolina cities during late 1987 and early 1988. Focus groups are panels of 10 to 12 individuals who provide informal, uncensored dialogue about products or services. The patient focus group members were recruited through random telephone calls to households in the target cities and by placing recruitment flyers in 15
American Pharmacy, Vol. NS30, No.3 March 1990/141
t
to 20 pharmacies in the target cities. Physicians were recruited from actively practicing physicians in the target cities, whose names were provided by pharmacists. In the focus group sessions, patients and physicians were first asked to generate a list of services they associated with pharmacists and pharmacies. After writing each service on an index card, each subject ranked the services by sorting the cards from most important to least important. This procedure yielded an aggregate rank ordering of the pharmacy services identified by the group. Participants also were asked to comment on their pharmacists' performance. Focus group sessions were audiotaped, and transcripts were produced following the sessions. Each subject anonymously completed a questionnaire containing demographic information, including age, sex, and number of years in college. Focus group data are usually examined intuitively, and the transcripts of comments are used to support the researchers' interpretations. In this study a more objective rank ordering of services was also produced.
Plan Administrator Questionnaire hird party payers must satisfy two primary consumer groups T plan enrollees (patients) and physicians - as well as corporate sponsors. To assess third party prescription administrators' perceptions of pharmacy services, a nationwide mail survey of 60 major third party payers was conducted during the fall of 1988. (The geographic distribution of third party payers required the use of a mail survey rather than focus groups.) This phase of the study built on the results of the focus groups of patients and physicians. The pharmacy services that were included in the questionnaire sent to third party prescription plan administrators were those that patients and/or physicians had rated most important. The targeted respondents were administrators with responsibility for prescription drug programs and/ or pharmacy reimbursement. A random sample was selected from the 21
mailing lists of the 1987 membership listing of the National Council for Prescription Drug Programs and the 1987 Health Maintenance Organizations Directory. There were two follow-up mailings to nonrespondents. Services similar to those judged important by patients and physicians were listed in the first question on the questionnaire sent to third party plan administrators. Administrators were asked to assume the patient or physician perspective, since part of their role as a third party provider involves satisfying these two pharmacy service consumer groups. The Statistical Analysis System (SAS) was used to analyze the data. Since this was a descriptive study, data analysis consisted of calculation of frequencies and means for relevant variables.
Results Patient and Physician Responses emographic data on the members of the patient focus groups D indicated that the mean number of prescription orders processed in the previous year was 17 for themselves and 36 for their families. Sixty percent of the participants patronized one pharmacy, and 71 % patronized a chain pharmacy. The length of time patients had patronized their current pharmacies was evenly distributed from less than one year to 10 years. Most of the participants (88%) picked up their own prescription medications, and most were married females with a high school education. Patients were asked to rank order their top eight pharmacy services. "Providing OTCIRx drug information," "a pamphlet or insert on drugs," "open 24 hours," and "drug expiration date on label" were ranked very important by the patient panel. "Up-to-date about new product," "low prices," "clear directions," "speed," "discusses side effects," "maintains drug records," "dispenses generics," and "refill information" were ranked important. When asked, patients indicated that they were generally pleased with the services offered by their pharmacists, but they had sugges22
tions for improvement. First, they believed that pharmacists should supply more drug information, perhaps a pamphlet or a computergenerated printout. The more experienced users of prescription drugs knew that pharmacists would supply drug information if asked. The inexperienced users, however, said they never asked and therefore often arrived home with a bottle labeled "Take as directed." Some patients believed that pharmacists were intentionally holding back drug information, because patient inserts were given for some drugs and not for others. Another service that patients considered important was the provision of 24-hour coverage. This is a service offered by almost all other health care professionals. The participants suggested that pharmacies could rotate being on call according to a schedule that could be posted weekly in the newspaper. Another suggestion was that pharmacists in a given pharmacy could be on call, with a beeper, on a rotating basis. Patients complained about having to wait for a prescription medication and having to "pretend to shop." Some wondered why there wasn't a waiting room with chairs and health pamphlets or magazines. Finally, patients said they would like the number of renewals recorded on the prescription label. Patients believed this service would save time when they wanted to have a prescription order renewed. In summary, the focus group patients were relatively pleased with their pharmacists and pharmacy services but also had many positive suggestions for fine-tuning a pharmacy's services. The mean age of the physician focus group participants was 39, all were males, and most were in private practice as family practitioners, pediatricians, or internists. They wrote an average of 12 prescription orders a day and talked approximately twice a day to pharmacists. Most ofthe time (69%), the physicians' nurses telephoned in prescription orders to pharmacists. The most important services physicians believed pharmacists could provide were "checks and bal-
ances function," "monitor drug interactions," "clarify dosage directions," and "good pharmacy personnel." Other highly ranked services were "discussing directions," "providing 24-hour service," ''health promotion services," "serving as a source of drug information," and "cost-effective generics." Physicians believed that pharmacists were competent and knowledgeable and should be explaining drugs to patients. In general, they liked the idea that pharmacists serve as checks and balances, and they believed that pharmacists were clarifying dosage and storage directions as well as providing drug product information. Some physicians (and patients) wanted drug expiration dates on prescription labels. Physicians (especially pediatricians) reported they often determine that the patient has on hand a cough syrup or an antibiotic; but because the prescription container has no expiration date, the physician has to call the pharmacist with a new prescription order. A comparison of the physician and patient focus group results reveals a discrepancy with respect to drug information. Physicians believe that pharmacists are talking to patients about their medications, while patients want more drug information but report that pharmacists are not always providing such information to them. Providing more drug information to patients is certainly one service that pharmacists can perform that would increase patient and physician satisfaction.
Administrators' Perceptions f 45 questionnaires returned by third party prescription O plan administrators, four were unusable, yielding a 68% response rate. The respondents represented a wide variety of third party payers, from very small third party plans (35 enrollees, 5,000 prescription medications reimbursed per year, and 20 pharmacy providers) to very large plans (8,300,000 enrollees, 100,000,000 prescription medications reimbursed per year, and 62,000 pharmacy providers).
American Pharmacy, Vol. NS30, No.3 March 1990/142
Table 1. Importance of Pharmacy Services to Patients as Perceived by Third Party Prescription Plan Administrators* ~?ltif19 from " ,Pati,Emt Pe?fgectiY~'k~ 4· ,
Me~n
"
'
S.D.
4.21
PharmaGis,t prpvides written drug information "to the patient.
4.15
0.99
Pharmacist provides physicians with cost data for prescription drugs.
4.07
1.19
Pharmacist provides physicians with periodic new drug updates.
3.77
1.31
Pharmacist advises prescriber of better choice of drug dueto therapeutic reasons.
3.46
1.52
Pharmacist offers health promotion programs in pharmacy (e.g., free blood pressure monitoring~ cholesterol checks}.
3.41
1.16
Pharmacist provides a periodic neV\lS[etler gn health issues and new drug therapy for patients~
2.85
1.25
* n = 41 * * Scale range: 1 = UnImportant; 5 = Important. Question stated as "In your opinion, how important are the following pharmacy services to PATIENTS?"
Respondents were asked, "In your opinion, how important are the following pharmacy services to patients?" Importance was rated on a 5-point Likert-type scale ranging from "important" (5) to "unimportant" (1). Two spaces were provided for respondents to enter and rate "other" services of their choice. The services are listed in order of their mean importance rating from the patient perspective in Table 1. The two services that administrators perceived as having the greatest importance to patients were "pharmacist personally counsels each patient with a new prescription" (x=4.56) and "pharmacist provides counseling on proper dosage and choice of OTC products" (x=4.52). Furthermore, the smallest standard deviations (S.D.) were observed for these services, an indication of agreement among respondents on the importance of these services to patients. ''Advising pre-
scribers of better choice of drug due to lower cost" (x=4.21) and "providing physicians with cost data for prescription drugs" (x = 4.07) were rated important to patients. Less traditional roles involving provision of therapeutic or health-related information to patients or physicians (e.g., providing physicians with new drug updates or advising of better drug choices due to therapeutic reasons, and health promotion activities or newsletters for consumers) were rated neutral to slightly unimportant. Pharmacy services that were written in by administrators and perceived as important to patients were as follows: • "Classes for patients: Pharmacist teaches patients about medications for specific conditions (e.g., diabetes)." • "Pharmacist supplies patients with cost of prescription if prescription is a third party prescription."
American Pharmacy, Vol. NS30, No. 3 March 1990/143
• "Pharmacist checks for utilization (i.e., overuse and noncompliance)." • "Pharmacist is actively involved in monitoring compliance with drug therapy." • "Pharmacist monitors patientspecific drug profiles and informs physician of inappropriate drug use." • "Pharmacist advises patient a generic equivalent drug is available." • "Pharmacist consults physician on use of generic drugs." Differences in third party administrators' perceptions of the value of pharmacy services to patients vs. the value to physicians could influence their assessment of the overall value of pharmacy services. Therefore, the questionnaire also asked for the prescription plan administrators' perceptions of which pharmacy services physicians would rate as the three most important for pharmacists to provide to patients (enrollees). The rankings for perceived importance to physicians generally paralleled those for perceived importance to patients. The majority (56%) of administrators believed that the "pharmacist personally counseling patients with new prescriptions" was the most important pharmacy service to physicians. Approximately one-quarter of the administrators indicated "providing counseling in proper dosage and choice of OTC products" and "providing written drug information to the patient" would be second most important to physicians. Providing nonprescription drug counseling ranked as the third most important service for almost one-quarter of the respondents. After rating the importance to patients and physicians of the listed services, administrators were asked to indicate which services they believed pharmacists were currently providing for their enrollees (Table 2). The majority of administrators believed that pharmacists were offering the four services rated most important to patients and physicians: "new prescription counseling" (60.5%), "OTC counseling" (70%), "advising prescribers of better drug choice due to cost" (55%), and "providing written information 23
Table 2. Third Party Prescription Plan Administrators' Perception of What Pharmacy Services Are Currently Offered*
No.
%
23
60.5
21
52.5
PharmaCist advises prescriber of better choice of drug due to therapeutic reasons.
15
37.5
Pharmacistadvises prescriber of better choice of drug due to lower cost.
22
55.0
Pharma ffers health promotiqn programs in .g., free blood pressure monitoring, pharrna cholesterol Oi"ecks).
19
47.5
Pharmacist provides counseling on proper dosage and choice of OTe products.
28
70.0
Pharmacistprovides a periodic nevvsletter on healtq issues ~md new drug therapy for patients.
6
15.0
Pharm Rr-evides physicians with cost data for prescrl en drugs.
7
17.5
Pharmacist provides physicians with periodic new drug updates.
7
17.5
* n = 40 Question stated as "Please place a check under 'Offer Now' for services you believe pharmacists curre\1tly provide to your enrollees. 'I
to patients" (52.5%). A large proportion also believed that pharmacists were performing two informationrelated services that received lower importance ratings: "offering health promotion programs" (47.5%) and "advising prescriber of better drug choice due to therapeutic reasons" (37.5%). If administrators believed that pharmacists were not currently offering one of the listed services, they were asked to indicate whether their company would be willing to pay pharmacists to offer the service to their enrollees. This question was presented only to the subset of respondents who believed pharmacists were not currently providing a service, because it was thought unlikely that administrators who believed pharmacists were already performing a service would begin to pay pharmacists for the service. Approximately one-third of respondents who did not believe phar-
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macists currently "advised prescribers of better drug choices due to lower cost" or "counseled patient with a new prescription" would pay pharmacists to do so. Almost 20% of respondents who did not believe pharmacists ''provided patients with written drug information" or "provided physicians with cost data for prescription drugs" would pay pharmacists to do so. Two respondents wrote in a service they would be willing to pay pharmacists to provide their enrollees: "dispensing generics when physician writes 'dispense as written' " and "monitoring patient compliance (e.g., antihypertensive therapy)." (The legal ramifications of the first write-in service will vary by state.) In addition to identifying which services they would be willing to pay for, administrators were asked to indicate "how much of an incentive your company would be willing to pay pharmacists (in aggregate)
to perform the desired services." They were given the option of phrasing their incentive in terms of unit of service, time, or patient (e.g., $x.xx per prescription order, $xx.xx per hour, $xx.xx per enrollee). Only eight respondents answered this question. The stated incentives ranged from $0.10 to $3.00 per prescription order. Only one respondent phrased the incentive as a rate per enrollee ($5.00). The relationship between number or type of services and incentive value offered was not clear from the data. There was no obvious rationale that could correlate the number of services or time required to provide service(s) with the incentive value. Two administrators suggested another type of incentive for pharmacists: providing pharmacy services (not specified) through an exelusive business contract with the third party payer. Administrators were asked if their companies would consider implementing a structured pharmacist incentive plan to improve enrollee satisfaction. Slightly more than one-third of the respondents said yes. Three primary reasons were given for not implementing a pharmacist incentive plan: • The plan would be too costly. • Pharmacists should already be providing such services as part of their professional responsibilities. • Enrollee satisfaction is already high. Four respondents indicated they would implement an incentive plan only if it would decrease total plan costs. Cost concerns were paramount, while reasons for implementing a pharmacist incentive plan were less clear (e.g., "pharmacists have something to offer," "would increase commitment to HMO," "strive for customer satisfaction"). In a related question, administrators were asked to rank proposed mechanisms for monitoring patient! enrollee satisfaction on an ongoing basis if a pharmacist incentive plan based on enrollee satisfaction were implemented. Since only a small portion of the administrators perceived a need for such an incentive plan, it was not surprising that only 16 respondents answered this question.
American Pharmacy, Vol. NS30, No.3 March 1990/144
When asked to rank ideas for monitoring patient satisfaction, administrators most frequently ranked conducting a periodic survey of a sample of enrollees (31.3%) and sending trained observers posing as "shoppers" into a random selection of member pharmacies (37.5%) as the best ideas. However, an equal number of respondents ranked enrollee surveys as the worst idea. Providing enrollees and physicians with complaint forms was rated the second best idea by almost half (46.7%) of the respondents to this question.
Discussion Patient and Physician Need for Services he results of this study indicated T that the patients and physicians wanted personalized services related to their medications. Evidence of growing patient demand for information is apparent in today's society. Pharmacists offering patient-oriented services consistently would be well positioned to garner an important and growing segment of the prescription drug market.
Plan Administrator Perceptions of Need here is also a demand by third T party prescription plan administrators for specific pharmacy services. The results of the third party survey indicated that administrators believed patient counseling on both prescription and nonprescription products, providing cost data about drugs to physicians, and providing written drug information to patients are pharmacy services that are important to consumers. Since third party payers must satisfy their corporate sponsors by satisfying corporate enrollees (patients) and, to a large extent, the prescribers (physicians), it would be logical to assume that third party payers would value these services in monetary terms. However, overall, third party payers did not appear to be willing to translate perceived importance into incentives for pharmacists to provide specific services or any array of services listed in the survey. Most of the respondents believed
that pharmacists were already providing the majority of services listed. Therefore, it is unlikely that third party payers will begin to pay for a service their enrollees are already receiving. In addition, for those respondents who did not believe pharmacists were providing a service, only a small percentage were willing to pay for the service. Only two of the listed services could be construed to be candidates for pharmacist payment: "advising prescriber of better choice of drug due to lower cost" and "personally counseling each patient with a new prescription." When the administrators were asked about their companies' intentions for implementing a pharmacist incentive plan, the most frequently reported reason for not implementing such a plan was increased cost. Thus, it appears that providing administrators with evidence that enhanced pharmacy services will increase overall program cost savings as well as patient satisfaction may be a more productive step toward implementing pharmacy incentives than promoting only the potential of increased patient satisfaction. Although the results of this study do not appear to be encouraging to pharmacy as it seeks to gain specific reimbursement for services, a limitation of the third party survey tempers the conclusions drawn: third party respondents were provided with a list of specific services based on the results of the patient and physician focus groups. To the extent that the listed services were not comprehensive, perceived value of pharmacy services by third party prescription plan administrators has not been fully assessed. In fact, the number of services written in by administrators suggests that the listing was not complete. Two areas revealed in the writeins that appear to be potentially of demonstrable value to a third party payer were the pharmacist's role in monitoring drug therapy and the pharmacist's role as patient educator. The perceived value of these and other similar services to third party payers should be explored' and studies demonstrating
American Pharmacy, Vol. NS30, No. 3 March 19901145
the impact of these services need to be conducted before administrators will perceive them to be truly "value added" services. With sound experimental data as supporting evidence, these types of services could be perceived by third party prescription plan administrators as being more likely to result in savings than in additional cost.® Note: This study was supported by the North Carolina Task Force on Pharmacy. The authors and task force members invite comments from all interested parties regarding the issue of third party reimbursement for pharmacy services or the specific results of this study.
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