Incentives, trade-offs and changing the game.

Healthcare, like any business or industry, is driven by incentives.

In pharmacy, the business model is volume-based. You charge a dispensing fee for every filled prescription. The more prescriptions you fill, the more revenue you generate. Simple. However, when we examine our values as healthcare providers, our commitment to providing high-quality patient care, and the incentives that drive the business model, things can get complicated.

Let’s examine pharmacy through a few different lenses. If you run your own shop, your priority is prescription volume and maximizing revenue. You carry the burden of providing an essential service to your community, and you have to keep the lights on. No shame in that.

If you’re a staff pharmacist, you’re a dedicated professional, providing clinical care to your community. Your priority is usually providing high-quality care, and taking home a steady paycheck. There’s pride in that.

If you’re a patient, your priority is to get well. Fewer visits to the doctor and pharmacy.

From this perspective, there aren’t many incentives for pharmacies to invest in the health and wellness of their patients. In the end, a patient cured is a customer lost.

The most profitable patients tend to be the sickest. They have a significant pill burden and are on a laundry list of medications. To improve compliance and safety, we can prepare their medications in “blister packs,” conveniently packaging medications and sorting them into different time slots for each day of the week. These patients are golden because instead of the traditional 3 month supply, pharmacies can bill and package blister packs in weekly, biweekly, or monthly intervals. More fees, more revenue. It’s all in the game.

MedsChecks and Expanded Scopes of Practice

This volume-based business model of Apothecary stretches back to ancient Babylon. Fortunately, we’ve diversified our revenue streams and have added a few“professional” services along the way. In my home province of Ontario, the following services are provided by pharmacists and reimbursed by the provincial government:

• Administering vaccinations and injections.
• Minor ailment prescribing (a topic for another day).
• Medication reviews (Medschecks) and pharmaceutical opinions.

Allowing pharmacists to administer vaccines has been an obvious win for all parties. It’s taken a burden off primary care and family medicine clinics, it’s helped patients access flu shots and other injection services, and it’s shifted pharmacists from a role entrenched in treatment and masking symptoms to that of preventative medicine (vaccines are one of our strongest tools in infectious disease prevention).

On the other hand, the Ontario Medscheck program, a government-funded medication review service, is an example of a professional service that’s marred in controversy. The program was introduced in 2007, around the same time the Ministry of Health (MOH) began cracking down on pharmacy rebates and backdoor industry deals, which were a significant source of revenue for pharmacies.

The government took away an essential income stream from pharmacists by “banning” rebates, however, implemented the Medscheck program, gifting pharmacists a chance to flex their clinical muscles, demonstrate their value to patients and earn their (tiny) slice of the MOH funded pie. The Medscheck program was implemented with great intentions. The vision was clear. Pharmacists would take on complex cases and resolve drug therapy problems. The program would significantly impact the overall health of communities and improve clinical outcomes.

It turns out, good intentions don’t always produce good incentives.

Revisiting Medschecks

15 years post-launch, the impact of the Ontario Medscheck program remains elusive. There are some systematic reviews (composed of mainly observational studies) that highlight a few positive clinical outcomes, like reduced hemoglobin A1C or better blood pressure control in select patients. Although comprehensive reviews exist, direct clinical evidence and randomized trials assessing the impact of medication review are scarce. The program’s journey has also been riddled with controversy, from corporate quotas to pharmacies selectively choosing patients for Medschecks.

Conversations with colleagues paint a mixed picture. Many are scarred by the pressure to meet quotas, emphasizing a focus on corporate profits rather than patient care. My friends who own their pharmacies grapple with a tough marketplace, shrinking margins, and an evolving drug reimbursement landscape with political pressures to lower drug expenditure. I empathize with both sides.

In my view, medication reviews can be a powerful tool when used correctly. Recent systematic reviews suggest that around 10% of older adults discharged from hospitals face readmission due to drug-related issues, with roughly 20% of cases being preventable. Those in long-term care, dealing with polypharmacy, or discharged with new medications stand to gain the most from Medschecks.

The challenge lies in the complexity of these cases. Reviewing medication history, confirming indications, monitoring efficacy, and coordinating care demand significant time and resources. Yet, pharmacies are handed a mere one-time annual fee of $60, hardly a carrot enticing enough for the extensive work involved.

It all comes back to incentives. Staff pharmacists do the bulk of the work and see none of the profit, as pharmacies bill the government for the service. For pharmacy owners, it simply becomes a numbers game—more Medschecks, more revenue. Again, it’s all in the game.

What about checks and balances for Medschecks’ quality?

If the Ontario Drug Benefit (the provincial drug program that reimburses Medschecks) decides to conduct an audit, for the Medscheck to remain eligible for reimbursement, the criteria is comical. The patient must be on 3 or more chronic medications. The medications listed on the review must have an indication, the patient must sign a consent form, and there has to be proof that the pharmacy faxed the report to the family physician.

Working in a clinic alongside family doctors, I’ve seen many Medscheck reports from other pharmacies, and some are laughable. Rudimentary indications (cardio meds always have the indication as “BP”), futile patient notes (everyone is stable, or ‘“doing well on the medication”), and a never-ending pile of reports. Most of the physicians I work with barely read the reports, it just adds to their administrative headache.

The sad reality is that clinical outcomes are usually ignored when it comes to Medschecks, even though the program was designed and implemented to improve patient care. Imagine, if somehow, we could tie the reimbursement of medication reviews to clinical outcomes. Perhaps only then, could we begin moving in the right direction.

Deprescribing, MedsChecks and Changing The Rules.

In my attempt at solving the complex problem of fixing Medschecks, fighting polypharmacy, and reducing preventable hospitalizations or medication-related injuries, I think of a quote I came across from the venerable American economist, Thomas Sowell.

“There are no solutions. There are only trade-offs.”

– Thomas Sowell

Part of me truly believes we should scrap the Medscheck program. However, in reconsidering the role of Medschecks and envisioning a more impactful future for pharmacy, deprescribing emerges as a potential solution. If executed correctly, Medschecks should serve as a natural springboard for deprescribing, identifying unnecessary medications, addressing side effects and neutralizing complex drug interactions. However, deprescribing is quite antithetical to the traditional business model of pharmacy. Remember, the game is rigged to focus solely on the script count.

But maybe, we can evolve the Medschecks program to become a platform for fostering patient engagement, offering follow-up support and potential coaching programs for patients. By coupling Medschecks with deprescribing programs, we could empower patients to implement lifestyle interventions and chart a path toward reversing underlying conditions and reducing dependency on medications.

For this to become a reality, we need a few paradigm shifts in how we think about pharmacy. First, rather than pharmacies billing OHIP, it should be the individual pharmacist billing for their clinical services. By taking the power away from pharmacy owners, most of whom are driven by profitability, we can place it back in the hands of clinical pharmacists.

Just as physicians have billing codes, we could implement similar models for pharmacists, asserting their autonomy in providing patient care. This could incentivize pharmacists to participate in more clinical services and focus more on patient care services. Moreover, this could help revolutionize the business of pharmacy, letting more pharmacists create business models centred around clinical services, allowing pharmacists the opportunity to finally divorce the dispensary.

Second, we need to identify methods, build the right systems, and leverage technology and data to track real clinical outcomes. One way to track the effectiveness of deprescribing programs could be to utilize the concept of churn rates. It’s a concept used by tech companies to determine the number of customers lost versus the total number of customers over a certain period of time. Pharmacy software systems and insurance companies already have the infrastructure and capability to track this data.

By shifting the reimbursement model to one that tracks and rewards positive clinical outcomes, all the money spent on poor-quality Medschecks (which is a lot, I may add) could be used to fund deprescribing programs, chronic disease prevention initiatives and clinical services that aim to improve health outcomes and patient well-being.

Bottom Line

As we contemplate the future of our profession, questions surrounding the scope of practice and government-funded professional services need honest exploration. While there may not be a one-size-fits-all solution, trade-offs are inevitable.

Many industry experts envision future pharmacies as community health hubs, where you get your medications, but also participate in an array of preventative medicine services. This all hinges on structural and incentive transformations. Without such changes, pharmacies risk continuing as mere dispensaries, perpetuating the current status quo and our society’s dependence on prescription medications.

No matter how optimistic I may be, the truth is that the community pharmacy will always have a bottomless pit of demand. The unhealthier an individual is, the more a pharmacy stands to profit off their suffering and poor health. However, if we are to fulfill our role as stewards of medicine, it’s time we trade short-term profits for a long-term perspective. Let’s reimagine our efforts to improve the health of our communities, aligning our practice with the ideals we aspire to as true, healthcare professionals.

Thanks for reading. Much love.

P.S. If you or anyone you know is interested in coming off their meds or learning more about deprescribing, click on “Work with Shawn” at the top of the site, or you can fill out the form below to contact me directly.

May you be happy and healthy.

SG