Unfortunately, these four advantages are not being fully leveraged today, owing to a number of constraints. One set of constraints is regulatory. The range of services that pharmacists (and clinic-based nurse practitioners) are allowed to perform is limited, and it varies by state. One historical reason for this constraint is the concern for patient safety, but in many cases political pressure from physician groups also plays a role.
Other constraints are structural. For example, because health-care providers in the U.S. are typically reimbursed based on the number of visits rather than on outcomes, physicians and hospitals have limited incentive to collaborate with pharmacists and other stakeholders to address issues such as patient compliance with drug regimens.
Another obstacle to integrating pharmacies more closely into the health-care delivery system has been technological. Although pharmacies, insurers, and physicians are moving toward establishing better electronic records, many of these systems remain independent of one another and often provide only partial information about a patient. Without a full clinical record and a physician interface, the pharmacist is limited in his or her ability to advise or refer the patient appropriately.
Finally, some of the constraints are self-imposed. Pharmacy companies have been hesitant to expand their range of services for fear of alienating prescribing physicians. They also face some growing pains in making the transition from the traditional pharmacy business to new formats. Pharmacy-based retail clinics have not yet proven profitable. In addition, a substantial investment will be required for pharmacies to upgrade technology, facilities, and staff to be able to offer a broader range of services. Many pharmacies are also not set up to bill insurance companies for providing services because medication benefits are typically handled by different systems and agreements than are services.
Fortunately, many of these obstacles may be minimized or removed as the economic and regulatory environment evolves. The structural barriers, for example, may be addressed through the adoption of pay-for-performance reimbursement schemes for providers. Under this model, providers are compensated for results rather than number of visits, thus increasing the incentive for physicians and hospitals to collaborate with pharmacists on improving patient compliance.
Expanded use of electronic medical records (EMRs) was a critical element of the U.S. government’s Health Information Technology stimulus package and could have a powerful impact on the operation of pharmacies as they address the technological barrier. The government has created incentives and a regulatory framework for adoption of a portable, interoperable EMR. These records will make it easier for pharmacists to work with physicians, hospitals, and insurers to make the overall system more convenient and cost effective, while improving health outcomes overall. Other new forms of technology — such as expert systems that provide information about disease and treatments, more portable and affordable diagnostic equipment, and telemedicine — will also enable pharmacists to perform a larger number of screenings and consultations in retail clinics more conveniently and at a lower cost than traditional medical facilities can.
Finally, the pharmacy itself might become more tightly integrated into the health-care delivery system and relax some of its self-imposed barriers as the new care-delivery model emerges. This model is likely to be more patient-centric and integrated, relying on a medical team to deliver care. In such a model, the patient would be steered toward the most appropriate clinician and location depending on the nature of the health problem. Most pilot programs currently providing team-based care include a pharmacist as part of the team. For smaller physician practices — which make up a significant segment of providers — the pharmacist could be involved virtually, perhaps working at a nearby retail pharmacy and accessible via telemedicine.