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Addresses Pharmacy Education in an Era of Health Care Reform1 Leslie Z. Benet School of Pharmacy, University of California, San Francisco CA 94143-0446

One of the responsibilities of the AACP President is to represent our Association at the meetings of our sister professional organizations. This was an especially challenging task considering the changing scenario in health care as driven by the reform initiatives of the Administration. During this past year, I was privileged to represent AACP at six professional and/or trade meetings as I have described in my last presidential message (1). Here, I will briefly review the Association’s position and then move to some of the more controversial issues facing us in this era of health care reform. The two main issues/objectives which AACP hopes to see in any health care reform measure are (i) support for education and training of health professionals, and (ii) the inclusion of pharmaceutical care as a benefit in any health care reform measure. The specific points which AACP has emphasized relative to our concern for support for health professions education and training are: all payers should contribute; inter-disciplinary/multi-site experiences in primary care and acute care should be available; unique roles in teaching, research and service of health professions schools should be recognized and supported; utilization of all disciplines to the full capacity of their skills should be enhanced; and planning for future needs (e.g., enhanced support for pharmacy residency/fellowships as appropriate) should be assured. 1

Address of the President: presented to the Opening Session of the House of Delegates, 95th AACP Annual Meeting. Albuquerque. New Mexico, July 17, 1994.

Our emphasis on pharmaceutical care comes from previous AACP policy positions; its extension to primary care is emphasized in Policy Statement 1 of the 1993-94 AACP Professional Affairs Committee: “AACP supports the position that pharmaceutical care is pharmacy’s most essential and integral contribution to the provision of primary care.” Our emphasis on these two AACP objectives in health care reform serve as the basis for our participation in the Coalition for Consumer Access to Pharmaceutical Care (CCAPC) together with seven other association partners. The issues in health care reform of primary importance to CCAPC are: prescription drugs as a core benefit; pharmacists’ services as a core benefit; proper medication management by pharmacists generates savings; integrated information systems improve quality and control costs; and enhanced support for health professions education. Our Association’s leadership and professional staff have emphasized the importance of the education/practice partnership in achieving reform objectives. We acknowledge this relationship in the theme for this 95th Annual Meeting. “Partners for Success.” A major obligation which AACP has undertaken in this partnership is the formation and implementation of CAPE, the Center for the Advancement of Pharmaceutical Education. With broad professional representation on our advisory panels, we are presently focusing on defining outcomes of pharmaceutical education, as well as emphasizing nontraditional education. I want to underscore here, however, an additional responsibility which academia must meet in this education/practice partnership.

American Journal of Pharmaceutical Education Vol. 58, Winter 1994

399

That is, our responsibility to be honest with our practice partners and with ourselves. I have always believed that one of academia’ s roles is to verbalize our view of the future, even when that view may be unpopular. In fact, our societal responsibility to put into words what we believe to be the truth is the basis for the tenure system, manifested in the willingness of society to grant us the privilege to let our views be known unfettered by the need to please our bosses, our students and, in this case, our practice partners. Last year, in my address as President-Elect(2), I attempted to forecast changes which I expected to occur in our profession and in academia. The leadership of some of our sister associations were not pleased by my remarks. I was publicly, verbally scourged during the October 1993 NARD meeting for the predictions which I made concerning the increasing role of technicians and mail-order operations in the drug distribution system, together with my prediction of the future demise of State Board regulations requiring the physical presence of a pharmacist supervising a technician. Yet, as the year progressed, and as health care reform changed the perception of the public, the government and the health-insurers toward the needs for pharmaceutical services, it was amazing to see the shift in the public positions taken by the associations representing the various aspects of our profession. Let me review two extremes of pharmaceutical services that became apparent during this past year. Our profession was almost dumb-struck by the MerckMedco merger in the Fall of 1993, and the resulting implications of the Medco model with respect to the practice of pharmacy. Mail-order Medco dispensing under the supervision of 40 pharmacists can facilitate the mechanical distribution of 58,000 prescriptions per week. If one considers that the Clinton Health Care Plan predicts 2.2 billion prescriptions per year, and if we further assume that the Medco model were utilized for all prescription dispensing in the United States, then the math indicates that only 29,200 pharmacists would be required, as shown in Table I. This is a 6-fold decrease from the approximate 170,000 pharmacists presently in practice. This “reality of the new marketplace” served as the basis of a “wake-up call” meeting of deans and department chairs held at this 95th Annul Meeting. In contrast to the Medco Model, consider the recent publication by Borgsdorf and co-workers (3) entitled, “Pharmacist-medication Review in a Managed Care System.” Here the authors reported a 23-month experience with 836 patients undergoing pharmacist-managed medication review. The authors document annual savings in utilization costs for a managed care facility, Kaiser Permanente of Bakersfield, CA, that exceed $280,000 per year, while total cost per year of this service was $89,000. That is a benefit-tocost ratio of 3.2. Using this pharmacist-managed medication model throughout the U.S. would suggest that 550,000 pharmacists are needed (calculated as the U.S. population divided by the number of patients managed per year per pharmacist, see Table I). That is a 3-fold increase in our present professional population. Such an example of pharmaceutical care implementation serves as the impetus for a recommendation from the 1993-94 AACP Argus Commission, which “recommends that schools and colleges of pharmacy develop residency training programs in community-based primary pharmaceutical care settings.” The figures in Table I, correspond well with the comments of the Argus Commission with respect to future demands for practitioners: “While the 400

Table I. Numbers of pharmacists required in the United States under the extremes of pharmaceutical services Pharmacists at Pharmacists-managed Medco model present medication 29,200

170,000

Å 6-FOLD Æ increase

550,000 Å 3-FOLD Æ increase

Commission believes a demand for pharmaceutical care will continue to increase over time, there may be a lag phase when demand for dispensing-oriented pharmacists slacken and demand for large numbers of pharmaceutical careoriented pharmacists develop.” As I emphasized in my address as President-Elect(2), academia foresaw this transformation from mechanical and distributive to cognitive services. More than 30 years ago, academia began to realize that if pharmacy practice were justified only on the basis of laws and regulations, it would not survive. The emergence of clinical pharmacy and its transformation into pharmaceutical care resulted from academia’s vision of necessary pharmacy services which would transcend legal requirements. I have tried to bring to our sister professional associations this view of the dramatic changes which are occurring in our profession. I emphasized that the rapid changes occurring today were expected by many in academia a long time ago. The pharmacist-managed medication paradigm described so well in the Borgsdorf and co-workers paper (3) requires a practitioner who can deliver pharmaceutical care and patient counseling. In fact, many in academia feel that there is an inadequate number of pharmacy professionals trained to provide such service at this critical juncture, and that the potential for our pharmaceutical care contribution may be diminished by the present lack of trained professionals. Our practice partners should realize that this concern underlies academia’s reluctance to support “degree equivalence.” The boundary figures in Table I raise serious questions concerning our role and duties in training pharmacists. Do we have too many colleges of pharmacy? Perhaps a better question today for us witnessing this revolutionary change in the expectations of a pharmacist’s expertise would be: do we have too many schools that are not giving adequate training in primary pharmaceutical care? My answer to these two questions is that we will probably need as many colleges of pharmacy as we have today, but they must rapidly change their emphasis to training in pharmaceutical care. Up until now, I have concentrated on pharmacy education and its interaction with our practice partners. I would now like to address a number of internal Academy issues— issues which can lead to sources of tension. Let me first discuss proposed Policy Statement 2, from the 1993-94 AACP Research and Graduate Affairs Committee. That Policy Statement has the potential to create a division among our members. The statement reads, “AACP affirms the importance of research (i.e., ‘scholarship of discovery’) as a vital component of scholarship that is expected of every full-time faculty member to the extent that is consistent with the mission of his/her college or school of pharmacy.” This 1993-94 proposed Policy Statement appears to contradict that of the 1992-93 Research and Graduate Affairs Committee, encouraging key leaders and administrators of colleges


and schools of pharmacy to accept the broader definition of scholarship for pharmaceutical education. In fact, it was the expressed intent of this year’s committee to take a contradictory stand. The issues are of internal import to our Academy and require reasoned discussion. I recommend the recent editorial of the Chairman of the Council of Faculties, Lee Evans, on this topic(4). I personally find myself in agreement with the statement as proposed by this year’s Research and Graduate Affairs Committee, recognizing the inclusion of the proviso “to the extent that is consistent with the mission of his/her college or school of pharmacy.” My personal position affirming the importance of research relates to another issue of internal tension, that was identified by the 1993-94 AACP Academic Affairs Committee, under a discussion of leadership within academe “The most critical aspect of a leader’s ability is to provide the organization with a vision or goal for the future and motivate other individuals to share, either partially, or fully, in achieving this goal.” Considering my call for our responsibility to be honest with ourselves, can a basic scientist with no clinical training provide a college of pharmacy with a vision or goal for the future and motivate other individuals to share in achieving this goal? My answer is, “sometimes yes, but often no.” I say this since previous experience suggests that the vision or goals of basic scientists will be related to basic science, and to building an outstanding program in that area. At this point in our history, this is not the appropriate primary vision or goal for most schools of pharmacy. Yet. prestige and clout within the local university environment as well as the national and international arena, still come from success in receiving peer reviewed federal funding. There is no doubt that strong basic scientists exert the most influence in what are considered our best schools and colleges of pharmacy. However, we must also remember that in most cases, basic scientists have been very supportive of the strengthening of the clinical and patient care aspects of our curricula. Is there a solution to our problem in identifying leadership at the dean level, as eloquently posed by the Academic Affairs Committee? I believe that there is a solution, and that future leadership will come from clinicians who have had post-PharmD (and most often post-residency) science training. In some cases, this may come from PharmD/PhD programs, but in most cases, I believe it will come from postPharmD research fellowships. This solution is the rationale behind the first six recommendations of the 1993-94 Research and Graduate Affairs Committee. I raised this as an important issue in my President-Elect address, as a need for our Academy, and a need for all of our schools and colleges of pharmacy. I expect that our newly recruited Director of Graduate Education, Research and Scholarship will focus on this issue and the recommendations of the 1993-94 Research and Graduate Affairs Committee. The final internal issue which I wish to raise relates to who assumes responsibility for teaching in our colleges and

schools of pharmacy. Again, I addressed this issue in one of my presidential messages: “Beware the Hired Guns—They Could Shoot us in the Foot”(5). My concern is that we not be so short-sighted as to hire individuals to do our teaching while we carry out research or clinical practice or service. Our Association has recognized the importance of identifying good teaching and we have received notoriety from the academic community for our planned implementation of the Master Teacher Program. I personally am not willing to give up any of the definitions of scholarship, believing that faculty members should be required to fulfill all aspects of the academic paradigm: teaching, research, and service. I am very proud to have been chosen to be your President during this past year. I am enthusiastic about our profession and can tell you as your elected leader during this past year, that from my perspective, the Association and academic pharmacy are in excellent shape. Let me just briefly mention a few of the many good things that I can identify in our Association. We are blessed with outstanding Association leadership, and I am pleased to announce that we have reached agreement on an extended five-year contract for our exceptional Executive Director, Carl Trinca. I am greatly impressed with the senior staff leadership at our Association, and commend Dick Penna, Ed Webb, Susan Meyer. Mary Bassler and Jack Cole, for their unswerving dedication to our Association and academic pharmacy. We should be proud of the fact that we were far-sighted in anticipating the changes in our profession and that we have reached a consensus on our academic goals and requirements. I believe that health care reform, in fact, fits into our agenda. Pharmaceutical care and health care reform are synonymous. We continue to be proactive as an association and within our individual colleges in advancing the scholarship of teaching and we have received recognition for this from our academic colleagues outside of the profession. Finally, our faculties are enthusiastic and innovative. Thank you for letting me serve you during this past, most interesting year, as our nation and our profession struggle to implement health care reform. Am. J. Pharm. Educ., 58, 399-401(1994); received 7/20/94. References (1) Benet. L.Z., “AACP and our sister professional societies during a year of health care reform implementation.” Am. J. Pharm. Educ. 58. 236-237(1994). (2) Benet. L.Z., “Where to now? or ‘Sure, it’s safe out there’,” Ibid., 57, 402-405(1993). (3) Borgsdorf, L.R., Miano, J.S., Knapp. K.K., “Pharmacist-managed medication review in a managed care system.” Am. J. Hosp. Pharm., 51, 772-777(1994). (4) Evans. L., “Redefining scholarship: It is a faculty responsibility.” Am. Pharm. Educ., 58, 238-241(1994). (5) Benet. L Z., “Beware the hired guns—they could shoot us in the foot,” ibid., 58, 117-118(1994).


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