Well I don’t know why I came here tonight
I got the feeling that something ain’t right
I’m so scared in case I fall off my chair
And I’m wondering how I’ll get down the stairs
Clowns to the left of me
Jokers to the right, here I am
Stuck in the middle with you.

—Stealers Wheel, “Stuck in the middle with you”

“Stuck in the middle” is where community pharmacy is right now. Whether you’re a staff pharmacist or management, we’re stuck with each other, so we have to find ways to make it work. The “it” is the challenge we have to meet the public’s growing demand for medications delivered to patients together with information and services to help patients use those medications effectively and safely. Margins on products have dwindled as austerity measures by states are implemented, managed care payers have leveraged purchasing power into lower cost reimbursements, and reference pricing (average wholesale price/average manufacturer price/actual acquisition cost) continues to change. At the same time, we’ve seen training, systems, and demand grow for the provision of pharmacists’ services (medication therapy management, immunizations, and various chronic disease management programs, for example). But demand for services is growing faster than compensation for those services. As a result, pharmacists and their employers are feeling the pinch.

Pharmacists feel it when they’re asked to fill hundreds of prescriptions per shift, provide immunizations on demand, make outbound calls to promote adherence with patients and to do so with less technician help because management just saw another big contract pricing level get cut. And pharmacists are feeling less respected as the supply of pharmacists has increased and employers find positions are easier to fill.

As you know, APhA has members from every corner of the profession, so we hear from all sides about the above challenges. We’re the association of pharmacists—for pharmacists. As your association, we are doing everything we know to advance medication use and improve patient care by creating and promoting new opportunities for pharmacists, from new roles and access as primary care providers to electronic health records (EHR). Access to EHR will improve care and facilitate documentation that will lead to additional reimbursement for our services. We’ve proven that if pharmacists get involved in medication use, quality goes up and costs go down.

We don’t mind being “stuck in the middle with you,” but we’re eager to find solutions that keep our profession growing and relevant to patient care. I’ve talked with enough pharmacists to know the frustration level is rising for those who go home exhausted and unfulfilled. And the urgency is rising as well for those investing in and building the capacity to provide pharmacy services. We all are working to ensure sufficient revenues begin to flow for the services being provided.

One thing we learned in our work in the APhA Foundation with HealthMapRx and the Diabetes Ten City Challenge was that it takes large groups of patients enrolled in programs in a pharmacy to make the services financially viable. Without that critical mass, the cost per service is prohibitive and disruptive to workflow. I believe we’re currently in that middle state. We are growing the numbers to a point where compensation for a specific service can fully support that service, but the process is painfully slow. During this growth period, there will be a lot of grinding it out for both pharmacists and management. We must work together to address workflow and patient safety issues until compensation allows sufficient support staff and pharmacists dedicated to those services. Right now, pharmacists are split four different ways as we build demand for services and promote improved adherence.

I would ask pharmacists to hang in there and to be as constructive and creative as possible to address workflow issues. Management: Please do your best to stay aware of and attendant to the challenges you are asking your pharmacist to meet. Pharmacists only have patients’ best interests in mind.

If readers will send best practices to us, we’ll spread the word so your fellow pharmacists can benefit. As technology continues to facilitate product delivery, our profession must succeed as a provider of services. We will only succeed if we work together.