The question of quotas: As pharmacists wait for answers, Ontario's Health Ministry responds with the status quo

As pharmacists hope for change in the wake of recent media reports exposing the practice of imposing quotas on medication reviews and clinical services, one province’s Health Ministry issued a statement that merely reiterated the status quo.“One of the requirements under the MedsCheck program is that the MedsCheck Personal Medication Record be shared with the patient’s primary care provider to support collaboration between and among providers,” stated the email from the Ontario Ministry of Health’s communication branch. “Pharmacists who are providing MedsCheck services to eligible patients must also receive their written consent on an annual basis. This must be done before the pharmacist conducts the MedsCheck service.”The email to Pharmacy Practice + Business, which also explained the mandate of the Ontario College of Pharmacists and provided a link for filing a complaint, did not address a question about a commitment made at the end of February by Health Minister Sylvia Jones to “absolutely do our due diligence” to ensure the province’s MedsCheck program is being used appropriately.Jones had told a CBC News reporter on Feb. 28 that the Health Ministry will be looking into the issue of MedsCheck quotas. She was also reported to have stated that Shoppers Drug Mart had launched an internal investigation into allegations that some of its locations were imposing quotas on MedsChecks.Shoppers did not respond to an inquiry from Pharmacy Practice + Business about the status of this internal review.Meanwhile, many pharmacists continue to wait for answers—and solutions. The big question for some of them is: Who should be responsible for fixing this problem of quotas on pharmacy services?“I think the college is the one to deal with this,” said Randy Luckham, a pharmacist and pharmacy owner in Dresden, Ont. “Yes, we can have it done externally by the (Health) Ministry to regulate professional autonomy, but really we're a self-regulated profession. So it needs to be internally done, and the college is internal.”Why the Ontario College of Pharmacists—or, for that matter, regulators in other jurisdictions—hasn’t taken action to date is confounding, he added.“It almost seems like an excuse—are they waiting for somebody to report this in a certain way?” he asked. “Pharmacists in our community have been aware of these pressures for a long time. We’ve all got employees who used to work in other places and they tell us stories about quotas. So since the college is also composed of pharmacists, I can’t imagine they weren’t already aware.”Read: Between a 'quota' and a hard place: Many pharmacists tell us they increasingly face mandatory targets on clinical servicesAn OCP survey that closed recently—which the college said was not about MedsChecks specifically but rather about “whether pharmacy professionals are experiencing business pressures that may impede their ability to provide quality patient care and to meet their professional and ethical obligations”—is a step in the right direction, said Luckham.Proactive monitoring of claims sent to the public health insurer could also act as a deterrent against abusive billing for taxpayer-paid pharmacy services.“For example, the Ontario Drug Benefit program pays for MedsChecks and they should be doing audits on various services, not just MedsChecks,” said Luckham. “That would certainly pick up on trends such as excess billing.”A big challenge, said Ontario Pharmacists Association president Justin Bates, is that while pharmacists are expected to act according to the profession’s code of ethics, a lower level of accountability seems to apply to the pharmacies that employ them. This leads to a “disconnect” between who’s making the decisions in the pharmacy and who’s held responsible by the college.“When we get to the heart of the issue, pharmacists are expressing their distress that they individually could be liable to findings or discipline by their college but they don’t feel they have the protections to make decisions that would align better with their code of practice but that might contradict what their employer wants,” said Bates. “In these instances where there is a power dynamic, what do they do?”While regulators have, in general, been effective enforcers of professional standard and code of ethics among pharmacy professionals, they appear to be less rigorous in the application of standards among pharmacy owners, whether independent or corporate.Looking at pharmacy discipline cases in Ontario, for example, Bates could recall only one instance where directors of a pharmacy corporation were found liable by a regulator for the actions of the pharmacy practice.“The levers that are at the disposal of colleges in going after registrants doesn’t necessarily address the pharmacy owners who may be imposing some of these practices around quotas,” he said. “I think what needs to be addressed by the college is how to enforce what's already there in terms of the code of ethics and ensure that there aren’t quotas that would supersede the professional autonomy of the pharmacist practice in any setting.”The OPA would support a ban on quotas, said Bates.Read: Speak up: Ontario regulator wants to hear about pharmacists' experiences with clinical services targetsBeverley Zwicker, registrar and CEO at the Nova Scotia College of Pharmacists, disagreed with the idea of explicitly forbidding pharmacy owners from setting quotas on services.“If we set out a very rigourous policy that said ‘thou shalt not lay quotas, and if you do there’s be a fine of this or that’—I don’t know if that rule necessarily gets us there,” she said. “Rules are only helpful if there are people to report and then we are able to action.”Besides, added Zwicker, “we already have the strength of the code of ethics.”A possible solution, at least when it comes to medication reviews, would be to eliminate the additional fee for this service and instead integrate it into a pharmacist’s dispensing fee.“So amend the professional fee—the dispensing fee—to reflect that service . . . incorporate that into the care that's provided,” she said. Kristen Watt, a community pharmacist and pharmacy owner in Southampton, Ont., said it’s a good idea to do a scan of what other jurisdictions—in Canada and in other countries—are doing around quotas and billing of pharmacy services. Such a scan would, ideally, look at how pharmacists in other parts of the world are compensated.“I think it's also prudent to remind pharmacy professionals and pharmacy owners that we all have taken an oath,” she said. “We have a code of ethics that we need to adhere to. And we need to get back to basics and focus on providing patient care and less about shareholder returns.”Read: Your pushback on pharmacists’ shortage solutions is not helping your patients: Watt

The question of quotas: As pharmacists wait for answers, Ontario's Health Ministry responds with the status quo

Register for free access or login.

Related Topics