Pharmacy U

Opportunity knocks. Private payers are paying attention to pharmacy services


For pharmacists, when opportunity knocks, private payers are often on the other side of the door.


By donalee Moulton


To take advantage of the opportunities to have pharmacy services covered, pharmacists need to establish relationships, demonstrate value, and advocate for change.

“Frontline pharmacists are in the best position to do all of this. No one will tell the pharmacy story better than you will,” says Leanne MacFarlane, Senior Director of Business Development at MHCSI (Managed Health Care Services, Inc.) in Dartmouth, NS.

When opportunities with private payers are realized, the result is improved health for your patients and their employees. At MHCSI, for example, medication reviews have been covered in the last several years, and more recently additional pharmacy prescribing services are being covered. The reviews started as a pilot program that was so successful they became an inherent part of plans. Now comprehensive programs to help with smoking cessation and living with diabetes, among others, are also included as well as care plans to help patients reach their health care goals.

“Employers understand the connection between healthy employees and a healthy organization,” says MacFarlane. “They are not necessarily looking to cut costs; they are looking to enhance the value of their investment with better health for their employees. We need to show them how coverage of pharmacy services can do just that.”

Approximately two years ago, Green Shield Canada, located in Windsor, and the Ontario Pharmacists Association launched a pilot program called “Impact of Community Pharmacist Interventions in Hypertension Management on Patient Outcomes”. The initiative, which involved a randomized controlled trial with more than 150 patients and 38 community pharmacies across the province, examined the impact of a six-month, pharmacist-led hypertension management program on patient health outcomes.

“The pilot provided clear evidence that people who took part had better heart health, lower body mass index, increased compliance, and decreased drug costs at the end of the study,” says Sherry Peister, a pharmacist and Board Chair of Green Shield Canada.

Now the program is building on its success. As part of GSC’s Change4Life initiative, the Pharmacist Health Coaching – Cardiovascular Program is a new counselling service provided by Ontario and BC pharmacists that focuses on cardiovascular health and offers blood pressure and cholesterol management to patients. Pharmacists will be reimbursed for an initial assessment, which includes taking the patient’s history, identifying blood pressure and cholesterol goals and lifestyle changes, and up to three follow-up sessions.

“Green Shield has built this product into their plan. It’s the first of its kind,” says Peister.

Wellness and prevention are key targets for plan sponsors, she adds. “It’s about keeping employees healthier as opposed to simply paying for a medication.”

Pharmacists are key partners, but they need to work with plan sponsors to demonstrate the benefits of including pharmacy services in their plans. That requires advocacy and evidence. “Pharmacists need to understand the type of dialogue that resonates with private payers. They want to spend wisely and drive value,” stresses MacFarlane.

The conversation is an important one for pharmacists to initiate. The focus for the profession has often been on the public programs, but the reality is that 60 per cent of medications are paid by private payer plans. Pharmacists have a significant opportunity here to demonstrate benefits. But they need to be visible and they need to be heard.

“Pharmacists have been building relationships with private payer companies and employers for decades. It’s been a way to build business, but the opportunities today are greater than ever before,” says Peister.

So are expectations. Private payers are looking for proof that programs are producing positive outcomes. “You need to document results. This translates into something meaningful that you can discuss with the plan sponsor,” says MacFarlane.

As Canada’s most accessible healthcare professionals, pharmacists need to become more comfortable with their role as advocates. That role requires them to talk about payment for services, a conversation that is uncomfortable for many professionals. “Pharmacists need to recognize the importance of the services they provide and advocate with confidence,” says Peister.

Leaders in Pharmacy, including this independently written article, is supported by GenMed, a division of Pfizer Canada.