Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our Health and Wellness System

Transcription

1 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our Health and Wellness System Working with Government to Maximize the Benefits of Newfoundland and Labrador s Pharmacy Sector Prepared by The Pharmacists Association of Newfoundland and Labrador September 2011

2 Table of Contents Introduction... 3 The Current Policy Environment... 3 The Role of Pharmacists... 4 Expanding the Role of Pharmacists in NL Health Care... 6 The Pharmacy Business Model... 8 Dr. Wade Locke Study.9 Dispensing Fees... 9 Trade Allowances... 9 Front of House Sales The Mark-Up on Prescription Drugs The Current Challenge Policy Recommendations Conclusions Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

3 Introduction As important partners in health care delivery, pharmacists maintain an extensive network of facilities that are conveniently located and operate extended hours. Pharmacists are accessible, knowledgeable and committed to client service. Every day, pharmacists provide advice and counseling on new prescriptions, choosing the right over-the-counter treatment and the safe use of these products. They work with physicians and specialists to ensure the correct use of drug-based therapies. The adoption of specialized information management technology allows pharmacists to monitor prescriptions and provide point-of-sale coverage from benefit providers. Looking forward, pharmacists will play a key role in improving health care outcomes for patients as the system moves away from institution-based models of health care. Further, pharmacists will provide expertise and assistance as the system is streamlined to provide better care while restraining escalating costs. To sustain this forward progress, we hope to use this document to assist decision-makers in understanding the progress we have made, the environment that supports this progress, and the opportunities that lay before us. This document also outlines a number of areas of mutual concern, where government and pharmacists need to work together to resolve outstanding issues or to prevent the implementation of policies which, as in Ontario, results in doubtful benefits to the system while undermining patient access to pharmacy services. When used properly, prescription medications are an important enhancement to our lives. Pharmacists know the most about medications and how we should best utilize them. Pharmacists are part of the solution to health care reform. We look forward to discussing the contents of this document with you and how we can work together to ensure a healthy future for the citizens of Newfoundland and Labrador. The Current Policy Environment As all of us are aware, we are confronted with ongoing and escalating pressure on our healthcare system. On one side, the people of Newfoundland and Labrador are asking for better and more convenient access to services. On the other, they are concerned about the rising cost of health care and the increasing amount of tax dollars it requires. Many stakeholders are working to mitigate this pressure, and to ensure that excellent patient care and treatment are delivered consistently and effectively. Pharmacists are part of the solution to providing better care at a reasonable cost. Our healthcare system faces increasing challenges. Healthcare costs continue to escalate as a percentage of government expenditures. Our aging population requires more (and more costly) treatments. At the same time, expenditure on prescription medications is one of the fastest 3 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

4 growing components of overall healthcare costs, four times greater than the rate of inflation or the growth of government revenues. All of this is occurring at a time when Canadians are demanding that all governments rationalize their expenditures and return to balanced budgets. We are doing more, with less, under incredible scrutiny, for rising numbers of people with healthcare needs. In Newfoundland and Labrador, roughly 640 pharmacists fill more than eight million prescriptions every year. For the pharmacists who work outside the hospitals, they fill these prescriptions in pharmacies throughout our province. Aside from pharmacies that serve neighborhoods in our cities, many communities rely on a single community pharmacy to provide dispensing and advisory services. In June 2010, changes to the Pharmacy Regulations, as approved by the Hon. Jerome Kennedy, Minister of Health and Community Services, allowed pharmacists the ability to expand their scope of practice through Medication Management. This expansion will ultimately advance individual patient and client care, along with enabling improvements to the overall health care system. Medication Management is an umbrella term that encompasses a variety of professional activities, undertaken by the registered pharmacist, as the medication expert, to optimize safe and effective drug therapy outcomes for patients. Currently, Medication Management includes the following: Providing an Interim Supply Extending a Prescription (Continuation of Care) Adapting a Prescription o Change Dosage Form o Change Dosage Regimen o Change Quantity o Complete Missing Information o Make a Non-Formulary Generic Substitution Authorizing a Non-Prescription Product This advancement in scope has been made possible in large part through the ongoing, positive partnership between the Government of Newfoundland and Labrador and the Pharmacists Association of Newfoundland and Labrador. The Role of Pharmacists People may have multiple doctors but, more often than not, frequent only one pharmacy. This puts pharmacists in a unique position to have a positive impact on their clients and on the broader healthcare system. But pharmacists do more than dispense pills. They provide counseling on the proper use of new prescriptions. They work with home care workers and with elderly patients to simplify the medications used by our seniors. They communicate daily with doctors and nurse practitioners, as 4 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

5 well as insurance companies. They maintain a secure and comprehensive inventory of medicines to ensure that, when a patient comes in with a prescription, it can be filled promptly. Newfoundland and Labrador pharmacists provide advice and counseling on over-the-counter medications and are often the go to person when it comes to treating family ailments. They assist in the management of chronic health conditions, like high blood pressure or diabetes, and are on the front line of addiction prevention and treatment. Pharmacists undertake the following roles as part of their professional activities: Preventing Adverse Drug Interactions: Pharmacists are the healthcare system s medication experts. As pharmacologists, they are highly trained in the characteristics, nature of and contra-indications of drugs. As such, they are uniquely positioned to prevent drug interactions that may reduce the efficacy of a drug, or cause unexpected side-effects. There is significant evidence that patients taking multiple medications are often confused by their medication usage and that, as a result, their health outcomes are compromised. As many as 28% of emergency visits have been estimated to be drug related, with 70% of them being preventable. Each visit to the ER costs our provincial healthcare system approximately $1500. Currently, adverse drug reactions are the number one cause for hospitalization among seniors. Appropriate Prescribing: Pharmacists are often the one healthcare professional with a global view of a patient s drug regime and, as such, they are well positioned to help ensure the appropriateness and appropriate use of medications. Tapping that capacity to its full extent can reap benefits both in terms of health and savings. Pharmacists work with other health care professionals to ensure that prescribed drugs are appropriate and effective. Proper Dosage: Patients often see their pharmacist more often than their physician. Pharmacists, therefore, are best able to consistently work with these patients to ensure that they are taking the proper amount of medication. This is especially important when adjusting medications to minimize side effects and to maximize effectiveness. Altering and Refilling Prescriptions: Pharmacists are also now able to refill most prescriptions. This is essential to providing continuity of care to people whose condition has already been diagnosed or who are following an existing treatment and find themselves either unable to get to their physician for a renewal, lose their medication or need a temporary renewal. Patient Education: As the front line service provider, pharmacists play a key role in educating patients on the appropriate use and ongoing adherence to their medication as prescribed by their physician. In addition to counseling on new prescriptions, pharmacists are often called on to provide training on medical devices, such as blood sugar monitoring devices, used by patients. As well, patients often ask pharmacists for advice on the appropriate over-the-counter medications and the use of non-pharmaceutical products, such as meal replacements, dietary supplements and smoking cessation products. In a pandemic, pharmacists need to fulfill their primary obligation, which is maintaining the continuity of access to prescription drugs. However, pharmacists could play a role in the delivery of seasonal flu shots or other immunization programs that the Department of Health and Community 5 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

6 Services may have under review. One of the benefits of this potential service is that pharmacists can clearly document and maintain records for patients who have received an injection under their care. This also applies to management of inventory. A pharmacist s first priority is still the management and distribution of the eight million prescriptions per year that are dispensed here in Newfoundland and Labrador. Part of a collaborative primary care team: Pharmacists are playing an increasing role as a member of a collaborative primary health care team. As a result, they are well positioned to alert team members of the misuse of a prescription, unreported changes in the condition of a patient, the failure to take all of their medications, and adverse drug reactions. The accessibility and approachability of pharmacists also means that patients more readily confide health conditions that may be symptomatic of a more serious problem. Pharmacists can then direct the patient to take appropriate action to ward off a health crisis. Many of the services provided by pharmacists are provided at no charge to the patients and with no compensation for the pharmacist. Expanding the Role of Pharmacists in Newfoundland and Labrador Health Care A growing body of research supports the benefits of an expanded scope of practice for pharmacists. Programs and services already in place in some jurisdictions are helping ensure increased access, reduced time-related stresses on over-taxed healthcare providers, improved continuity of care and the more appropriate use of medications, treatments for minor ailments, immunizations, and other services that reduce pressures on the broader healthcare system. In Newfoundland and Labrador, the expanded prescribing authority of pharmacists means that, when a person runs out of a medication, they receive consistent care until they can see their physician. Additionally, if a person loses their medication, or a visitor forgets to bring a sufficient supply, a Newfoundland and Labrador pharmacist can provide them with an emergency supply. If a physician has prescribed a format or dosage which may not be ideal for the patient (a tablet when a patient would benefit from a liquid, for example, or prescribing a 100mg pill that needs to be broken rather than the same medication in the 50mg format), a pharmacist can now adjust the prescription without going back to the physician before doing so. Documentation of the modification is recorded and reported to the physician when clinically significant. In a recent pilot project in Alberta, physicians and pharmacists partnered to explore how patients on blood-thinning therapies could benefit from having their care and ongoing treatment managed by their pharmacist. Integrating specialized pharmacist services and follow-up with the laboratory, home care nursing, retail pharmacy and physicians was shown to ensure optimal outcomes for patients receiving this therapy. Improved patient education and outpatient planning enabled patients to better manage their care and ensured better patient outcomes and more effective use of health system resources. 6 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

7 As the author of the Alberta study concludes, With specialized training and clinical experience, pharmacists can apply this model of care to managing other chronic diseases such as hypertension, cholesterol and diabetes, and also aspects of women's health. This represents a workable combination of the elements of integration, including patient-centered care, workforce optimization, and organized care continuum, reduced clinical variance, and improved process management. Newfoundland and Labrador should be looking at the progress made by other jurisdictions who are integrating pharmacists into health care delivery. Examples that could be readily adopted include: Call-back Programs Follow-up with patients regarding adherence to appropriate use of the medications and their impact offers a proactive approach that can prevent adverse reactions leading to physician and ER visits and/or hospitalizations. A 2006 study conducted with elderly patients reported that the callback program improved adherence and reduced all-cause mortality by 41 percent. Chronic Disease Management A growing body of evidence points to both the healthcare and dollar savings as a result of interventions with patients suffering from such chronic conditions as diabetes, asthma and hypertension. In terms of healthcare dollar savings alone, providing patient education, monitoring, offering feedback and behaviour modification, and communicating frequently with physicians on behalf of patients can save conservatively from $ per patient per month to $ per patient per month. Health Promotion and Disease Prevention Here again, the body of evidence supporting this role in areas such as weight management, cholesterol risk management, smoking cessation and heart disease risk behaviours continues to grow. Medication Reviews and Medication Adherence Programs These programs, which review medications and ensures better compliance, should be made more available to seniors across Newfoundland and Labrador. It may also be beneficial to provide similar counseling opportunities for non-seniors with chronic health conditions. Collaborative primary care health team member Pilot programs in other provinces have integrated pharmacists into a collaborative primary care team where pharmacists were involved in conducting medication histories, identifying drug related problems, monitoring care, providing consultation to the family physician and other team members, and communicating with hospital and community pharmacists ensuring a smooth transition from hospital to community-based care. Continuity of Care When patients progress through the healthcare system, gaps can occur in documentation and communications regarding medication use, thus resulting in adverse effects that can impact health 7 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

8 outcomes. Pharmacists are best placed to ensure the continuity of documentation and consistency in communications. Flexibility and Accessibility Pharmacists are able to provide on-demand services as they are accessible throughout the week, in the evenings and during the weekend. The potential to realize even more savings as a result of pharmacists playing a larger role in the continuum of care is well researched and already in effect in a number of industrialized western nations, as well as some US states. Despite the challenges of integrating private partners in a public system, more Canadian provinces are looking to generate savings by leveraging the skill and capacities of pharmacists to provide a number of new services. Newfoundland and Labrador should build on its leadership position by learning from the experience of other jurisdictions. Below is a link showing a schedule of Pharmacy abilities across our country. This helps to highlight additional opportunities for expanded Pharmacy activities and corresponding improvements and efficiencies within the Health Care System by showing provinces where this is currently operational. The Pharmacy Business Model In order to maintain their operations, pharmacists need to earn revenue to cover costs and to maintain the comprehensive network of facilities across Newfoundland and Labrador. In Newfoundland and Labrador, as in the rest of Canada, pharmacists are not paid by the public health system or by clients for the majority of the services provided to patients. Pharmacies are entirely responsible for all of the costs associated with running their businesses. This includes all salaries (including associated taxes and benefits), infrastructure (including rent, equipment, stock and utilities), insurance, prescription documentation, verification, maintenance of all records, training and professional development. Unlike other private sector entities, the pharmacy sector is highly regulated. Opportunities for revenue tend to focus on three main areas the dispensing fee, front of store revenues and trade allowances. The following section outlines these various sources of revenue and the policy issues associated with each source. Dr. Wade Locke Study Even with the inclusion of professional allowance, it is clear that NL pharmacies are not making excessive profits that would allow them to easily absorb the loss of this important revenue source. 8 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

9 Dispensing Fees The dispensing fee is the single fee per prescription that pharmacists are allowed to charge when they dispense medications. The Province has established a fee schedule regulation in the Prescription Drug Payment Act. Most prescriptions are reimbursed at $7.15. While patients appreciate the low dispensing fee, the reality is that the dispensing fee only covers a portion of the cost of dispensing medications. When the various cost elements of dispensing prescription drugs are considered, the cost of providing a prescription is between $13 and $15 in today s dollars, depending on the volume of prescriptions filled by a pharmacy. If we assume an average dispensing cost of $14, this means that there is a shortfall to the pharmacy of almost $7.00 every time a prescription is filled. Given the amount of prescriptions filled each year (approximately 8 million), this results in a minimum annual shortfall of $56 million in the government funded pharmacy sector to reach the break-even point. Currently, this minimum shortfall in dispensing fee revenue must be made up by other revenue sources to maintain the viability of pharmacy services. Trade Allowances One of the most significant costs for pharmacists is maintaining a comprehensive inventory of medications to fill the wide range of prescriptions that clients expect to be filled promptly. They must not only have the stock, but also ensure secure storage facilities, monitor expiry dates, document prescriptions, participate in recalls and quality assurance trials. Patent pharmaceutical companies have 20 years to build brand awareness and secure space on pharmacy shelves. They actively work to ensure that pharmacists understand the benefits of their product and are able to manage their stock appropriately. When a generic equivalent enters the market, they must compete with the established patent drugs for inclusion in the pharmacist s inventory. Considering the wide range of drugs that pharmacies must stock and limits to secure shelf space, there is little incentive for pharmacists to stock multiple versions of any one drug. To ensure access to the limited inventory space of pharmacies (and, therefore, patient access to lower cost generic equivalents), generic drug companies provide trade allowances to pharmacies to defray some of the costs associated with stocking their medication. Unlike retail businesses like supermarkets or department stores, who also receive manufacturer payments, trade allowances for pharmacists do not provide for prominent placing on shelves, are not based on the volume of prescriptions filled or confer exclusivity on their product to the detriment to their competitors. Although these allowances were established to ensure access to inventory space, they provide a vital source of revenue for pharmacies. Ironically, these trade allowances enable pharmacists to cover the dispensing fee shortfall and maintain patient access to all prescription pharmaceuticals generic and patent alike. 9 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

10 Front of House Sales Given the shortfall in dispensing fees, there is increasing pressure on pharmacies to increase revenues from Front-of-House sales in order to maintain the viability of their operations. While pharmacies that operate within a larger operation, a supermarket or department store for example, are best positioned to benefit from revenues earned in their respective facilities, smaller pharmacies have limited opportunities to earn revenues from over-the-counter medicines, greeting cards or other activities that are more suited to a local convenience store than a pharmacy. Even in the larger chain pharmacies, one-half of overall revenues come from front of house sales. This includes groceries, toiletries, personal care, beauty products, snacks and a host of other kinds of items. Although these margins allow pharmacies to continue to operate, there are growing concerns among pharmacists that the continuing subsidization of dispensing activities by front-of-house sales, while necessary, could undermine perceptions of the profession. Further, this pulls focus away from the practice of pharmacy in order to maintain sufficient revenues that maintain hours of operation and the province-wide network of pharmacies. The Mark-Up on Prescription Drugs There is a persistent myth that pharmacies obtain significant revenues from a large mark-up on prescription drugs. As provincial officials know, there is little and often no mark up on prescription drugs. As in many other fields of endeavor, the pharmacy business model has evolved over generations. While some would argue that the model itself could be reformed, there is no question that the current system provides an extensive network of community-based facilities that are conveniently located, operate extended hours and provide good client service on a no wait basis. Unilateral changes to revenue sources without any thought given to revenue replacement or the impact on the smaller pharmacies serving rural areas, minority language communities or urban neighborhoods is an approach that should be rejected by policy-makers in Newfoundland and Labrador. The Current Challenge While several provinces continue to work in partnership with pharmacists to improve health outcomes and maximize the effectiveness of healthcare dollars, The Government of Ontario, in their attempt to reduce the cost of generic drugs, has passed aggressive legislation that has had and continues to have a significant and negative impact on the pharmacy sector, particularly those that are community-based or rural locations served by only one pharmacy. The Government of Ontario is inviting the other Provinces to follow their lead, a prospect that pharmacists fear may be considered in Newfoundland and Labrador. The difference in the situation between Ontario and Newfoundland and Labrador provides compelling reasons why the Government of Newfoundland and Labrador should stay focused on its agenda rather than to adopt the approach taken elsewhere. In Newfoundland and Labrador, we are focused on improving patient access to care, better health outcomes and holding the line on costs. 10 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

11 Although there are concerns about the increasing cost of prescription medications as part of the overall health care budget, it should be noted that the increasing use of drug-based therapies has reduced the need for institutional care. It is better for the patient and less costly to the system to have treatments that can be conducted on an outpatient basis. While the cost of new and innovative drug-based treatments may be increasing, there is a net saving to the system as patients are diverted from hospitals, which are already struggling to free up hospital beds for acute care patients, and are treated in the comfort and convenience of their homes. This said, decision-makers need to be vigilant on the cost of prescription medicines and even more vigilant on costs associated with adverse drug reactions, the misuse of prescription drugs, and poor patient care. These are areas where Newfoundland and Labrador pharmacists are working with patients and the Government to improve patient care, obtain better health outcomes and constrain costs through the roll out of the provincial Health Care Network. Generic drugs provide a cost effective alternative to patent medicines. Of course, generic equivalents can only be produced once the 20 year patent period expires and then only if there is sufficient demand for these products. Although there is considerable misinformation about generic drugs, these products are regulated by Health Canada and must meet the same standards for quality and effectiveness as their brand name counterparts. Further, companies seeking to introduce generic equivalents must comply with the high standards for production, quality control, quality assurance and clinical testing as every other prescription drug allowed in the Canadian market. The primary difference in the cost of patent drugs and generic drugs is the need for cost recovery on the research and development process sponsored by the patent drug companies. Given the cost differences in the production of any form of prescription drug, patent or generic, setting an arbitrary reduction on the cost of the generic equivalent could make the production of the generic equivalent uneconomic. For example, Ontario is imposing a regime that will see generic equivalents cost no more than 25% of the patent version. If this makes the production of the generic equivalent uneconomic, then common sense dictates that the companies producing these products will stop providing them. Ironically, the result will be decreased access to lower cost generic equivalents and increased cost to both the patient and the Government. Predictably, this will create shortages and frequent changes in pill shapes, colors and familiarity to consumers. Further, by basing this arbitrary ceiling on the price of the patent drug, the brand name pharmaceutical company can choose to adjust the price of their drug so that the 25% price ceiling pushes the price for the equivalent generic drug below the cost of production. By making production uneconomic, competition from the lower cost generic equivalent can be eliminated. While this was not the intention of the Ontario policy, it will have the unfortunate effect of decreasing patient access to generic equivalents, increasing the market dominance of higher cost patent drugs and making it easier for these companies to buy out the generic manufacturers. Any limitations on trade allowances will have to be offset by revenues drawn from other areas, such as professional fees for service. Since the Competition Bureau prevents pharmacists from effectively negotiating with third party payers, the Government of Ontario and those without 11 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

12 coverage will need to pay more. In this situation, the winners in Ontario will be the brand drug manufacturers and third party payers. By volume in Newfoundland and Labrador, generic drugs are estimated to represent approximately 50% of all drugs dispensed. However, they represent only approximately 25% of the overall costs of all drugs prescribed, both in and out of hospital. Patent drugs, which comprise the other remainder of drugs dispensed in Newfoundland and Labrador, account for 75% of the total money spent on prescription drugs. If we are worried about the cost of prescription drugs, why would we be more concerned about the lower cost generic equivalents that total only 25% of the budget for prescription medicines? Prior policies to encourage the use of cheaper generic drugs helped to develop the system that currently exists. Another emerging factor indicates that the use of generic drugs creates greater affordability in our health care system. Over the next five years, patent medicines that account for more than $125 billion in global sales (Plavix TM and Crestor TM, among them) will see their patent expire. The introduction of generic equivalents for these products has and will yield significant cost reductions to patients and to taxpayers. Therefore, sound policy would focus on the significant savings that could be obtained through this transition to new generic products and ensuring patient access to these lower cost medicines through the pharmacy network. Given that this transition will not happen overnight, pharmacists will play a key role in managing this process, ensuring adequacy of supply and providing patient information. In order to provide relief for generic drug companies, Ontario would forbid the use of trade allowances paid by these companies to ensure access to pharmacist inventories. As discussed earlier, there is a cost to pharmacies to maintain and manage a comprehensive, secure inventory of prescription medicines. These trade allowances provide a necessary incentive for pharmacists to stock the generic equivalents alongside the patent products. These allowances also cover the shortfall in the dispensing fee. Eliminating trade allowances will reduce patient access to lower cost generic drugs as well as threaten the viability of pharmacies that cannot compensate for this significant loss of revenue. While the smaller pharmacies serving rural communities or urban neighborhoods are the most vulnerable, every pharmacy would face decreased revenues and would have less incentive to include lower cost generic drugs in their inventories. Given the approach taken in Ontario, there is every reason why pharmacists and the patients they serve should be concerned that a similar approach might be adopted in our Province. It may be that the adversarial, harshly negative relationship between the Government of Ontario and their pharmacists has resulted in this unilateral and ill-considered policy change. Given the growing chasm between the Government and these key players in health care delivery, perhaps officials in Ontario figure that there is nothing to lose by adopting such an abusive policy stance. 12 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

13 However, in Newfoundland and Labrador, a positive working relationship between Government and pharmacists benefits the patients we serve. Working together, we are proving better patient care, reducing costs and looking to further progress in the short- and medium-term. Research has identified the benefits of maximizing the skills and training of pharmacists in the interests of better healthcare and savings. Any changes to the intricate business model that sustains pharmacies will, as one columnist recently wrote, take years to get right. Policy Recommendations There are a number of policy recommendations that we are offering that will sustain the forward progress that Newfoundland and Labrador is making on patient care, access to medicine and support for better outcomes. The PANL welcomes the opportunity to provide you with additional detail on the benefits that would flow from these recommendations and how pharmacists would work with Government to achieve these policy objectives. Build Better Policy-Capacity within Government on Pharmacy Issues While there is a strong and positive relationship between PANL and the Department of Health and Community Services, there is still room and opportunity for enhanced policy capacity. This effort would result in better regulation and would identify areas where further progress could be achieved. Continue to Involve Pharmacists in the Implementation of the Health Care Network Pharmacies are significantly advanced in terms of electronic records for their clients and can also provide evidence to other partners in the health care system of how useful and effective new information management solutions can be. Expansion of the Prescription Drug Program Pharmacists are also key partners in the frontline efforts to monitor abuse and misuse of prescription drugs. As their records become largely integrated electronically, pharmacists can identify unusual or inappropriate use of drugs. Resolving the Shortfall in Dispensing Fees Working together, the PANL and the Department of Health and Community Services should negotiate an agreement that sets a new fee schedule for dispensing services, as well as for nontraditional services such as patient assessment. These services could come from budgets outside the traditional drug program. Compensation Schedule for Health Promotion Activities Pharmacists provide advice and counsel on a number of health promotion activities, such as smoking cessation, and, most importantly, helping patients manage chronic health conditions. Currently, pharmacists receive no compensation for activities that promote better health a decrease reliance on doctors or institutions to provide care. The Department of Health and Community Services and the PANL should implement a working committee to establish a schedule 13 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our

14 of specific services that could be provided through pharmacists and paid by the public health system. Retaining Trade Allowances As stated above, trade allowances are a vital source of revenue for pharmacies. These allowances defray the cost of maintaining and managing inventories and ensure patient access to lower-cost generic drugs. The PANL needs a clear commitment that the Government of Newfoundland and Labrador will retain the use of trade allowances as part of the pharmacy business model. Expanding the Scope of Practice The PANL suggests that the Government of Newfoundland and Labrador establish an interdisciplinary working committee, including pharmacists, which can examine opportunities for further expanding the scope of practice of pharmacists. Evidence from other jurisdictions, as well as pilot projects sponsored by the Government, could be used to determine how increasing this scope of practice will provide better patient care, better access to treatment and reduced costs. Conclusions The primary focus of every stakeholder in Newfoundland and Labrador s healthcare system is patient care and better outcomes not simply the bottom line. Pharmacists know that, while the ongoing sustainability of our system will depend on our ability to manage costs, the solution to the challenges we face in our health care system cannot be found through arbitrary cost-cutting or by imposing unilateral and ill-considered policies. Pharmacists in Newfoundland and Labrador can be an even greater part of the solution to the challenge of improving patient outcomes and reducing demands on an overburdened and resourcestretched system. The collegial and collaborative relationship enjoyed between pharmacists, physicians, and other health care providers as well as with the Government of Newfoundland and Labrador will help make that happen. Substantive research in Europe, the United States and across Canada points to the long term benefits of patient-focused collaborative care provided by a multidisciplinary team that includes the pharmacist. Pharmacists are increasingly reaching out to patients in a more proactive manner, understanding the positive impact that increased interaction with customers is already having in Newfoundland and Labrador. In this document, we have set out the opportunities and challenges that face the pharmacy sector in Newfoundland and Labrador. We believe that there are gains to be achieved, just as we know that there are problems to be avoided. On behalf of all our colleagues in the pharmacy sector, we look forward to a positive, constructive relationship with you in pursuit of our common goal a healthier, happier Newfoundland and Labrador. 14 Newfoundland and Labrador Pharmacy s Role and Ability in Protecting the Future of Pharmaceutical Care and our