John A. Gans is executive vice president and CEO of the American Pharmaceutical Association (APhA), the national professional society of pharmacists. APhA's more than 50,000 members include practicing pharmacists, pharmaceutical scientists, pharmacy students, and pharmacy technicians.
Gans began his career in 1966 as a community pharmacist in Pennsylvania. Since 1970, he has been professionally affiliated with the Philadelphia College of Pharmacy and Science, where he earned his pharmacy degree in 1966 and his doctorate in pharmacy in 1969. He served on the faculty from 1980 to 1988; and from 1988 until his appointment to APhA a year later, he served as the dean of the school of pharmacy.
Gans has been actively involved in international pharmacy for many years. He served as the secretary general for the Pan-American Federation of Pharmacy (19911994) and has been its vice president for North America since 1994. He has served as a council member for the International Pharmaceutical Federation since 1989. In late August, he spoke with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: What's your opinion of the Bush Administration's Medicare prescription drug proposal?
JOHN GANS: We support what the president is trying to do but we think that the mechanism that he has chosen to do it won't work. The president's proposed discount card does nothing but potentially reduce slightly, if at all, the cost of drugs. The public needs to say that it's time to stop using prescription drugs as a political football to stimulate Medicare reform. Let's cover prescription drugs and pharmacists' services. Even if we can cover them only for people who are very poor and in need, that's a start. All this proposal does is offer a slight price reduction for everybody in this program. We don't think it will be significant because we have experienced discount cards before and they haven't been helpful.
MC: Why won't the program work?
GANS: Remember that senior citizens are pharmacy's best customers. They use the most drugs. Pharmacists deal with their customers people-to-people, so if customers can't pay for their meds — and I've been in that situation — pharmacists will do everything they can to help them, including informal discounts. They know how critical those medications are. The president of the United States says, "you're going to get a 20-percent to 40-percent reduction in price," when the average prescription gross margin is around 22 percent. When you introduce a new discount on top of those informal discounts, the numbers just don't add up. There isn't room for an additional 20- to 40-percent discount. Then it's left to the front-line pharmacists who are APhA members to explain why the president's program doesn't work, and that stretches the pharmacist's credibility with patients.
MC: Why do you advocate Medicare prescription drug coverage?
GANS: When Medicare started in 1965, drugs were not nearly as effective or expensive as they are today. Let me give an example. There are all kinds of sequelae to diabetes, including significant vascular disease and potential kidney degeneration. Medicare will pay for a kidney transplant, but won't pay for the drug therapy that can prevent the need for the kidney to be transplanted. I don't understand how that makes any sense. If you add an ACE inhibitor when someone starts to have some renal failure (as indicated by protein in the urine by a simple test that can be done by the patient), you double the time it takes to develop significant renal disease, to need dialysis, or to need a kidney transplant. Yet seniors have to pay for that ACE inhibitor themselves. I keep wondering how long can we continue this situation. Given a list of what Medicare pays for, seniors may well say they'd rather have drug coverage than something else. I don't know what that something else is. We at the association believe it's time that we pay for this primary type of treatment and medication services by the pharmacist to guarantee results.
MC: How well do our legislators understand the bottom-line value of drug therapy?
GANS: A few people understand it, but the vast majority of people in Congress don't. Everybody has their areas of expertise, and you can only really deal with two or three major issues at any one time as a legislator. All of the discussion has been about the high cost of prescription medicines. Outpatient prescription drugs cost around $67 billion annually. But we spend about as much on crisis care because asthmatics, diabetics, and others never learned how to use their drug therapy. We're getting to the point where we're giving very expensive treatments to people who are not prepared to utilize them correctly, and that is a failure of the health care system — not the patient. Merck has data showing about a 40-percent adherence rate among patients who have been prescribed lipid-lowering drugs. If you stop taking that kind of drug after six months or a year, it's a total waste. We set up a program where you could go into the pharmacy and for $25 get a total lipid profile and some education and counseling from the pharmacist. Over two years with 400 patients, we had 94 percent compliance. We are dispensing medications to people with chronic illnesses in the same way that we did 150 years ago, but the drugs have changed and we're not seeing the quality outcome. Although pharmaceuticals are enormously valuable and you can show that in controlled studies, with patients in the real world you need to have constant motivation in coaching. We as a profession see that as our responsibility.
MC: To what degree are managed care plans or employers putting that kind of continuing pharmacy care in place so that all the money they're spending on drugs isn't wasted?
GANS: That's not in place yet. It's not managed care's fault and it's not pharmacy's fault. We know we can do it because we've demonstrated it with three of the big ones: diabetes, cardiovascular disease, and asthma. The question is how to construct a business model so that the managed care company knows that this education, training, and oversight is happening and we can document that the patient is complying. For people taking cholesterol-lowering drugs, there's a lot of time between doctor appointments when they don't have any checks on their lipid levels. Our profession's focus is trying to educate folks to become their own primary caregivers. The technology exists to do that monitoring in pharmacies. You can go in and quickly get a lipid level or hemoglobin A1c level to see where you are. The machine that measures lipid levels will do liver-function tests as well. The pharmacist sends that information back to the primary care physician. Physicians love it, the patient knows that they're OK, and they are motivated by this objective evidence of how well they're doing. Successful drug therapy doesn't occur in one visit, it occurs over a period of time. We've got to figure out a business model that supports that. Clearly it's easy enough to pay for a lab test, but paying the pharmacist for that education and monitoring is the challenge. We need to develop a method with managed care to document this.
MC: Why is that such a hurdle? Where's the hole in the business model?
GANS: There are two holes in the business model. One, pharmacy has always been practiced in retail establishments, and most people don't think of a pharmacy as health care facility, but it is. When you go into a Wal-Mart or an Albertson's or a Safeway, there's a pharmacy there. The model of pharmacy has always been a convenient, easy-to-access place to get drugs, but not a place where you pay for advice. You ask somebody about a product and you buy it. This must change. The second hole is in the mindset of pharmacists. Pharmacists are inundated by a growing number of prescriptions, medicines, and payers. We don't have a single-payer system; we have as many as 1,500 different payer systems. It's not like a physician's office or a hospital where they can give the care and then come back to get the payment, as long as they know the patient has coverage. In our case, a drug may not be covered, so the pharmacist has to take time to communicate with the third-party plan and get approval while the patient stands in front of them.
MC: What are some ways to free up pharmacists' time?
GANS: One simple thing we've asked for is a standardized prescription drug card. That may seem like a little thing, but often the patient doesn't have the information a pharmacist needs to process a claim. We've asked the major vendors to adopt a common format and they've said it would cost too much money. So we've pushed for states to require a standard card, which is not something we wanted to have to do. We would have preferred a voluntary industrywide initiative. Somewhere between 15 and 20 states that have now passed such laws. The problem with passing laws is that it's difficult when you want to change them.
MC: Would a single-payer approach be worthwhile in your view?
GANS: A single-adjudication system may work without moving to a single-payer system. We've standardized how we do our job at the pharmacy end, yet we spend a lot of time with insurance companies dealing with formulary and coverage issues. Patients come get hostile because their pharmacist tells them their copayment went up. That pharmacist had nothing to do with that change. But we end up delivering the bad news.
MC: How can the Internet improve communications among patients, pharmacists, and doctors?
GANS: Say, for example, a drug is taken off the market. Communicating that to physicians by calling them on the phone is impossible. But sending out a mass e-mail is easy. I'll give another example. There's an antipsychotic drug called Clozaril. Patients who take it need to have their white blood cell count checked every two months after they've been on the drug a while. In the past, we faxed the information from lab to pharmacy and physician. Now, we can do it over the Internet in a confidential way.
MC: Essentially we're talking about expanding and redefining what pharmacists do. Are the large chain pharmacies and other retailers that employ pharmacists behind that evolution, or do they still see their pharmacists as dispensers?
GANS: They all have experimental models that they're working with to try to do this. For example, Ukrops, a small high-end grocery-store chain in Richmond, Va., is 100 percent behind this redefinition of pharmacy. They see how it increases traffic in the larger retail environment. They see it as being good for patient care in all of the activity with Congress and other decision makers, pharmacy is united in obtaining recognition for pharmacists' services. The profession has moved to a new model. Yes, we want to get the correct drug to the patient at the correct time in the least expensive way. We don't have any choice given the cost-containment pressures. On the professional side, we believe that we're trying to help patients help themselves. Our association is celebrating its 150th anniversary. When we started, our mission centered around eliminating contaminated drug products. We set standards and formed organizations and developed lab tests to determine their contents. Today, we believe that people take the quality of drug products for granted — and they should. As an association, we've gone from making drugs safe to making drugs work. The key to making them work is not the physician, not the pharmacist, but the patient. The patient has to take the product, has to exercise and eat right. As the Institute of Medicine has pointed out, the health care system needs to be redesigned around the patient, not around hospitals and physicians, as it is now. The most accessible health care practitioner in America is the pharmacist. We need to figure out how we can charge for the information and advice that we communicate. Up to this point, we've been doing that by making it up when they purchase something else.
MC: Since so much responsibility lies with the patient, how do you deal with patients who don't adhere to their treatment?
GANS: If the consumer doesn't want to use the product correctly and won't follow the directions, I think there's a serious concern about whether they should continue getting the medicine. People have responsibility. Yes, we need to empower patients with information. Pharmacists can measure a patient's cholesterol level and if it's going down, that person needs incentives and motivation to become a star patient. If another patient has the same cholesterol level but doesn't lose weight, doesn't exercise, doesn't take the drug, and doesn't lower his cholesterol, there should be some consequence for that. They are wasting health resources.
MC: If pharmacists spend their time educating patients, how are they going to fill prescriptions, particularly given the shortage of pharmacists?
GANS: We believe that with electronic prescribing and other automation tools that are here now and that we know work, we can do both. One thing that would be a tremendous help would be machine-readable coding on the finished product. Another thing that might be helpful is moving to unit-of-use packaging, which is used in Europe. Drug manufacturers already ship some of their products in such packages for export. The small cost of going in that direction would be more than offset by a significant reduction in errors and in the time and involvement of the pharmacist in fulfilling orders. Those kinds of things will allow us to utilize pharmacists in ways in which we could make these drugs work and help consumers understand them.
MC: Thank you.