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What we can learn from pharmacy remuneration models around the world

For community pharmacies to be an effective part of a health service, they need to be paid for the value they provide patients, not just medicine they dispense, says Sónia Queirós.

The core of community pharmacy’s activity and the main component of pharmacy remuneration is, and will always be, dispensing medicine. But pharmacy remuneration models need to evolve to reflect the changing role of community pharmacy and to address challenges faced by healthcare systems across the globe.

In many countries, community pharmacies are operating within the context of scarce healthcare budgets and measures to decrease medicine prices and pharmacy margins to control health expenditure. All the while, this is happening in an environment of increasing competition from new players entering the healthcare market.

Community pharmacies need to adapt to these challenges, innovating service provisions, delivering new and pioneering solutions to meet demand for convenience.

Remuneration models are key to transforming professional practice. Through sustainable remuneration models that prioritise value to patients and the healthcare service over just dispensing medicine, community pharmacies can continue to support the wider healthcare systems they are part of.

The view from Europe

In Portugal, this transformation has been driven by a new relationship with the government, based on agreements that include a new vision and approach to the pharmacy profession.

The agreements with the government – although no longer in force – enabled community pharmacies to establish a new framework for the remuneration of services based on the added value for patients and the Portuguese health system as a whole.

This was key to change the way that community pharmacies are perceived by the national health service, by the other healthcare professionals, and patients.

Through these agreements, important milestones were achieved, such as generic incentives, the evolution of pharmacy services regulation and remuneration of a needle exchange programme. It was also the starting point for the dispensing of hospital medicines through community pharmacies. The legislative evolution clarified and introduced new services, namely nutrition consultation, treatment of wounds, as well as care for ostomy patients and those suffering from diabetic foot.

The source of funding for community pharmacy in Portugal is also being diversified to include partnerships with stakeholders in the health industry beyond central government. Pharmacies are working with the pharmaceutical industry to implement remunerated services to promote the correct use of medicines and medical devices. Partnerships with health insurance companies are being established, enabling the integration of pharmacies in the healthcare provider network in similar ways to GPs and dentists.

Furthermore, alternatives to central funding from the national health service are being sought, including from regional and local authorities.

Community pharmacies can easily identify and address local health needs, collaborating with other local health professionals and authorities and target the populations most in need of personalised health services. As such, local and regional authorities are implementing remunerated services within community pharmacy such as individualised dosing preparation, flu vaccination and COVID-19 rapid testing.

The evolution of Portugal’s remuneration model to one based on value means that the contribution of community pharmacies must be measured using new metrics - namely access, sustainability and health outcomes.

Cost-effective, beneficial pharmacy services

Community pharmacies have proven their contribution to increase access to several services.

In Portugal and Spain, the dispensing of hospital medicines through community pharmacies during the COVID-19 pandemic was designed to have positive results on access, reduced costs and reduced worker absenteeism.

Pharmacy involvement in immunisation services, from counselling and education to the administration of vaccines, has shown to increase immunisation uptake.

Point-of-care testing and screening services in community pharmacies are other areas of intervention that can bring healthcare services closer to the communities with better health outcomes in the long term. Community pharmacies are the arm of the healthcare services that are closest to patients, with long opening hours and guaranteed access to qualified professionals every day of the year. Colon cancer screening in Swiss pharmacies, for instance, have encouraged more people to get screened, contributing to the early identification of colon cancer.

Healthcare systems have limited financial resources, but remunerated pharmacy services can have social and economic benefits. The savings to the healthcare system that result from pharmacy’s interventions can be used to cover – either totally or partially – the public funding for community pharmacies, according to a Pharmaceutical Services Negotiating Committee study.

Evidence-based policies lead to the remuneration of cost-effective interventions, with better health outcomes. A needle exchange programme in Portuguese pharmacies decreases inequality of access and reduces new cases of HIV and HCV, with savings to the health system. In England, the new medicines service is effective at improving adherence, with better patient outcomes at reduced costs to the NHS.

COVID-19

The COVID-19 pandemic is reshaping healthcare systems all over the world. There is an urgent need to optimise health systems’ capacity.

Most countries still face barriers to accessing healthcare. There are reports of access problems to GPs, surgeries, cancer screening, and many other areas that will have a long-term impact on the health of the population.

In many countries, community pharmacies were given expanded powers during the pandemic to ensure continuity of care. Renewal of prescriptions, home deliveries, referral of patients and testing, are among just a few examples of areas where pharmacy stepped up.

Pharmacy-based vaccination services were expanded – not only for COVID-19, but also to deliver the flu vaccination. In some countries, this was done by changes in the legal framework and remuneration for the provision of pharmacy services.

The contribution of pharmacies is being recognised by international organisations, such as the OECD, highlighting the opportunity to change the traditional roles of different healthcare providers.

In light of the pandemic, remuneration of community pharmacy needs to adapt and be prepared for a new health ecosystem driven by the acceleration of digitalisation.

In the future, pharmacy will be a healthcare hub for the community, virtually and physically, supported by digital technologies. A central and focal point for helping people find care, prevent or manage illness, at home or in the pharmacy, with integration and collaboration with other healthcare providers.

To adapt to the evolution of the profession and health systems, remuneration models are evolving from pure margins systems to fee-for-services, to pay-for-performance – such as in the United States.

“Remuneration models must reflect the contribution of community pharmacy”

In many countries, community pharmacies' remuneration is evolving from dispensing to the provision of services to value-based remuneration models, promoting the integration of pharmacies in multidisciplinary health teams.

Sustainable and fair remuneration models must reflect the contribution of community pharmacy to people-centred healthcare systems, promoting universal health coverage, decreasing health and social inequalities, and meeting patients and health system needs.

Sónia Queirós is the head of institutional affairs at the Associação Nacional das Farmácias of Portugal

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Superintendent Pharmacist
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