Between a 'quota' and a hard place: Many pharmacists tell us they increasingly face mandatory targets on clinical services

Whether you think it’s terrific pharmacists are lending a helping hand with clinical services, or that they should stop encroaching on doctors’ territory (or you hold any of the other opinions somewhere in between)—physicians may be interested to know that, lately, many pharmacists don’t really have a choice about whether take on these activities. Between dispensing and providing clinical services, there are few opportunities for breaks in a pharmacist’s day. Some even talk about not having time to go to the bathroom.That’s tough enough. But in recent years, even as the urgency of the pandemic has abated, many pharmacists have found themselves facing a different kind of pressure. Not from a new strain of COVID or from expansions to their scopes of practice but rather from demands from their employer that they deliver a specified number of services within a given period.Or else.“I’m looking at the last email I received from the pharmacy where I recently worked and it’s basically saying either I do 100 (clinical services) a week or they will reduce my hours,” an Ontario pharmacist, who asked not to be identified, told the Medical Post's sister publication for pharmacists, Pharmacy Practice + Business. “So in other words, that target of 100 is not a suggestion—it’s a quota I needed to meet or I will be penalized.”The pharmacist said the company eventually structured workloads so that certain pharmacists focused only on clinical services. But even then, the pharmacists who were assigned to the dispensary were required to do four medication checks per shift.“So how do you ensure you get four MedsChecks done per shift?” asked the pharmacist, referring to the official name of Ontario’s medication review program (which according to the province are meant to take approximately 20 to 30 minutes per patient). “You have to get your patient to agree to do a MedsCheck and in many cases it’s unnecessary because there hasn’t been any changes to the patient’s health or medications and the patient’s profile is not complex.”These "quotas" on services are putting pharmacists in an uncomfortable position, this pharmacist added.“The concept of MedsChecks was to provide it to the patient who has a complex medication profile or if there has been dose change or major change, or if they’ve been discharged from a hospital and we want to ensure continuity of care,” he said. “But now it has turned into something pharmacists must do because they’ve been given a quota and we get stuck in this dilemma of doing something that is not 100% ethical or choosing to feed our families.“When I got my licence as a pharmacist, I took this oath that I will work for the best benefit of the patient—that does not align with this practice of essentially incentivizing pharmacists to prioritize meeting their quotas over what’s best for their patients.”This pharmacist’s experience does not appear to be an isolated incident. In January, Pharmacy Practice + Business asked its readers if their employers are imposing quotas on clinical services. Close to 60% of the 555 pharmacists who responded said yes. A social media invitation to share their stories anonymously generated numerous emails from pharmacists in different parts of the country.In recent weeks, a number of pharmacists have also discussed the subject on social media, prompting a response from the Ontario Pharmacists Association.“We expect pharmacy professionals and organizations that employ pharmacy professionals to adhere to the Ontario College of Pharmacists Code of Ethics in their provision of patient care,” wrote Ontario Pharmacists Association CEO Justin Bates. “Simply put, pharmacy professionals must be able to practice in patient care settings where they have the autonomy to practice in a way that puts the patient's interests before all else.”Yet by several pharmacists’ account, this professional autonomy is increasingly being threatened by the pursuit of profit.Another pharmacist, who works in Nova Scotia for a national chain pharmacy that’s participating in the province’s primary care clinics pilot program, told a similar story about quotas on services. In this pharmacist’s case, the quota was not based on a total number of services but rather on total dollars billed.“We each have to hit $1,000 a day every day in services—that’s the benchmark,” said the pharmacist. “It’s daunting, that’s for sure and it’s not about healthcare anymore. It’s about the owner being able to achieve a certain level of billing.”For the pharmacists at this site, the thresholds have led to gruelling workdays. Some days are just one appointment after another, with no breaks in between.“I mean, some shifts you’re seeing 32 patients in eight hours, every 15 minutes and there’s no break,” said the pharmacist. “It’s just an impossible shift—so intense, so very intense.”Most of the pharmacists working under this system struggle to meet their targets. So when one pharmacist started to bill double what everyone else was billing, the team started to speculate.“They were like, ‘there’s no way you could have done all that in a 15-minute appointment,’” said the pharmacist.” But instead of questioning the quality and the validity of the work, (this pharmacist) gets praise from the associate because while most of us can barely make $1,000 in fees from our shift, this person is pumping out $2,000.”A big barrier to meeting the service quotas, said the pharmacist, is that some patients need more time.“You want to stay on schedule but you never really know what’s going to walk through your door. Maybe today it’s a patient with seven prescriptions and you’ve got 15 minutes to do an assessment for seven prescriptions and do all the documentation,” said the pharmacist. “And if blood work is needed . . . your day can get out of control in a hurry and it's hard to maintain the quality. As most pharmacists, you try to be as mindful as possible to ensure that your patient is getting the level of care that they deserve. But there’s a lot of pressure to stay on schedule.”An additional source of pressure for this pharmacist was the lack of adequate training provided to the pharmacy team.“Our training was really non-existent—we were told to watch videos. So when you get into some of the more complex appointments like chronic disease management, we’re not adequately trained for it.”But the pharmacy owner insists on providing these services because “the billing is big, about $150 to $200,” said the pharmacist. “When the bloodwork comes back abnormal and the patient is elderly and hasn’t had a family doctor in years, we’re just guessing because we haven’t been trained properly to manage complicated patients. And there’s no doctor or nurse practitioner that we can call up to say ‘how do I manage this?’ We haven’t even been offered that as a support system.”Other pharmacists who spoke with Pharmacy Practice + Business shared similar concerns. With the exception of one who worked for a cooperative, all the pharmacists who spoke to us worked for either Shoppers Drug Mart pharmacies or Rexall pharmacies. A Shoppers spokesperson stated in an email that the company does not have quotas on pharmacy services.“Given the challenges currently facing our patients, including getting timely access to care from a doctor, one important way that pharmacists can make sure their customers have better health outcomes is through Med Checks (sic)–a process where the pharmacist reviews current medication, dosages, potential counter side effects, and any necessary adjustments, particularly for those who are on multiple medications,” the spokesperson wrote. “Med Checks are offered consistently at the majority of Canadian pharmacies and is part of a continuity of care that enables the pharmacy teams to mark progress, catch and address emerging issues and develop a deeper understanding of the patients’ healthcare needs. And it works."The email went on to say that “Pharmacists across the country support their patients with this service. We take exception to any suggestion that pharmacists are inappropriately billing for the service, or that they are at any point doing something that is not allowed by their training and/or college requirements.”Rexall did not directly address the question about whether or not it sets quotas on services but sent the following statement by email:“At Rexall we uphold the highest standards of conduct and ethical guidelines as set out by the Colleges of Pharmacy in each province. As the role of pharmacists continues to expand in Canada, our priority is ensuring that our pharmacists have the tools and support they need to continue playing a pivotal role in providing quality healthcare using their expertise and professional judgement to determine appropriate care for each patient while improving access to care.”Regardless of where they’re working, what are pharmacists to do when faced with an employer’s demands to meet service targets?Beverley Zwicker, registrar and CEO at the Nova Scotia College of Pharmacists, said pharmacists should always keep in mind that they’re bound to the code of ethics set in the standard for pharmacists.Those who are concerned about potential or actual breaches in ethics caused by mandated targets should contact the college.“I would encourage pharmacists to report specific events to us so that we could follow up directly,” said Zwicker.“I would say to any business owner: You are setting yourself up for unethical behavior by your staff when you set numeric target,” she said. ”As the regulator, if we find out that a pharmacist is billing for services that weren't actually provided or were provided in a sub-par way that didn't meet the standards, we would certainly take that pharmacist to task but we're also going to be looking at the policies of the pharmacy and holding the owner responsible for any role that they had.”Instead of setting quotas as a means to motivate their pharmacy team to provide more pharmacy services, “I think a much much more strategic approach would be to encourage a focus on how staff can bring more value to the care that they’re providing? How do they increase the quality of the care that they’re providing?”Given that many pharmacy services are covered by public health dollars, Pharmacy Practice + Business also reached out to the health ministries in Alberta, Ontario and Nova Scotia—where the pharmacists we interviewed practice.In its emailed response, the Nova Scotia’s Department of Health and Wellness stated that it does not “support the use of quotas” and that it has established clear criteria for each publicly funded service and that includes audits.“In the case of medication reviews, patients must provide consent and agree that they would benefit from a medication review, and the pharmacist must be able to visually confirm all prescription and non-prescription products used during the patient encounter,” stated the email, which also noted that the department hasn’t received any complaints from the public or from pharmacy professionals about quotas or billing for services that were not provided.For the pharmacists who have reported working under quotas, the overwhelming sentiment is that such conditions are untenable—and in the end it’s the patient who suffers. One Alberta pharmacist said the pressure of quotas has made some colleagues make conscious decisions to stay away from medication reviews with patients with needs that are genuinely complex or are on multiple medications.“They might just choose a more simple patient and they just do the review, sign off on it and then there you go,” said the pharmacist. “So then it's not getting done for the patient who really needs it.”Some colleagues grew so frustrated with the quotas that they quit the pharmacy and went somewhere else. If more pharmacists decide to protest with their feet, patients will feel the impact as continuity of care gets disrupted.“I’m hearing that more and more pharmacies are imposing (quotas) just because they’re seeing other companies doing it,” said the pharmacist. “For the pharmacist, it’s starting to feel like everybody’s doing this and there’s no way to get out of it. But at this point, I think it’s time to take back our profession and just do what we’re trained to do.”

Between a 'quota' and a hard place: Many pharmacists tell us they increasingly face mandatory targets on clinical services

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