EDMONTON, Alberta — Pharmacists in Alberta are now able to provide their patients with a wider range of remunerated cognitive services than those in any other Canadian, or indeed North American, jurisdiction. In a recent interview, Fred Horne — Alberta’s Minister of Health and Wellness when the fees for the recently approved services were negotiated — provides insight into how the current arrangements came into being.

Fred Horne

Horne was first elected to Alberta’s Legislative Assembly in 2008. Up to that point he had worked as a health policy consultant for 25 years, advising various government bodies and regional health authorities in the public, private and nonprofit sectors. With that background it was not surprising that he was appointed to be, first in 2010, parliamentary assistant to the Minister of Health and Wellness and then in 2011 minister in that portfolio, a position he held until September this year. Horne continues to represent the Edmonton-Rutherford constituency in the ­legislature.

Horne describes the background to the situation in 2007 when pharmacists were authorized to deliver some of the patient services that had previously been entrusted only to ­physicians.

In Alberta, as in all other Canadian jurisdictions where health care is publicly funded, health care costs were consuming a progressively larger share of the provincial budget. Elderly patients with two or more chronic diseases, representing no more than 5% of the population, were accounting for some 65% of the government’s health care expenditures. Health care costs were crowding out other priority claimants on provincial revenues, such as education.

At the inception of publicly funded health care systems across Canada, in the early 1960s, health care was predominately delivered by a combination of physician- and hospital-provided care. In a population where the average age was substantially lower than it is today, and where chronic disease states constituted a much lower share of the case load, there was no compelling pressure at that time to change the system or the roles of the professionals within it.

But by the first decade of this century costs were by no means the only driver for change. It was inconvenient for patients to have to attend physicians’ offices or hospital emergency departments for services that could be delivered more conveniently closer to where patients lived and worked. “After all, there are some 1,000 pharmacies located in communities across the province,” notes Horne. “Utilizing them for patient services and interactions that pharmacists are equipped to provide makes sense for patients as well as reducing the pressure on physicians’ time.”

It was apparent to many health care professionals, Horne says, that the traditional pattern of delivering at least some health services deserved to be adjusted. It was timely to give a greater role to pharmacists, nurses and other health professionals whose education and training equipped them to perform some of the functions that at the time only physicians were entitled to deliver.

The Alberta College of Pharmacy and the Alberta Pharmacists’ Association (APA) proposed legislative changes that would significantly extend pharmacists’ scope of practice. Though initially there were some reservations expressed by physicians regarding the new role that pharmacists might play, physicians’ professional organizations swung their support behind the initiative and the first tranche of enabling legislation was passed in 2007.

That legislation gave pharmacists the power to prescribe in emergency situations; adjust prescriptions by altering dose, formulation or regimen; order a therapeutic substitution or renew a prescription to provide continuity of care. With additional training, pharmacists were able to initiate a prescription and monitor ongoing therapy. Two years later pharmacists who took prescribed training were authorized to administer injections. Further powers have since been added.

When Horne was appointed Minister in 2011, discussions on how pharmacists might be recompensed for delivering the new services had been the subject of discussions for almost a decade among Alberta Health and Wellness, the APA and the Alberta Blue Cross (the organization that operates the Coverage for Seniors plan, sponsored by Alberta Health).

A pharmacy practice model initiative, administered by APA with funding provided by Alberta Health, ran from March 2009 to June 2010. The initiative explored what fee levels would be fair for community pharmacy in delivering the newly authorized services. No final decision on fee levels had been made by the time Horne was appointed minister, but the results of the 16-month experiment were available to the interested ­parties.

Holding up a decision had been the question of how government, the major payer, could fund the services. Horne says that the issue became easier to solve after the government’s expenditures on drugs under its plans for seniors and other eligible categories were reduced as a result of the progressively lower ceilings it applied on pharmacists’ charges for generic drugs. An initial ceiling of 75% of the cost of the branded equivalent was established in July 2010. The ceiling was eventually set at 18% in May 2013.

The savings that resulted from the limits placed on generic prices prompted a series of questions, Horne says. “How do we use these funds for the benefit of patients? How can we improve the patient experience, minimize pain and suffering? What can we do to cut down on hospital admissions? How can we better utilize the skills and competencies that exist in the health care professions that supplement the care that physicians provide?”

Horne presented these challenges to the negotiators from APA and Alberta Blue Cross. “These parties consulted or brought to the table everyone who had an interest, even if not directly involved. I give huge credit to the negotiators for coming to a defensible, sustainable agreement.”

Horne says his colleagues in the cabinet supported his recommendation that 50% of the savings from the generic drug ceilings should be reinvested in non-physician-provided health care professional services. It was accepted that pharmacists, in delivering the new services, would account for a substantial share of those funds. In fact, Horne says, last year Alberta pharmacists earned some $45 million in fees for their nonprescription services.

“Pharmacists welcomed the new arrangements,” says Horne. “They were excited that their skills in providing these new services would be appropriately rewarded. There was some concern that the business impact on pharmacies might be different, depending on the size of the business involved, but whatever these tensions might be, the overall pharmacy reaction was supportive.”

“The public reaction was also strongly positive,” says Horne. “A meaningful indicator of how the public feels about the expanded role of pharmacists is the fact that last year pharmacists accounted for one-third of the flu shots administered in Alberta, and this year I expect that proportion to be considerably higher. People in Alberta are increasingly aware of the range of services pharmacists can provide. And they appreciate the convenience of being able to access a pharmacy in their neighborhood ­community.”

“My belief is that physicians are increasingly supportive of the concept that we should, as a society, rely more on the patient support that can be provided by other health professions, not just pharmacists but nurse practitioners, paramedics and optometrists,” comments Horne. “An increased role for these professions meshes with the current emphasis of providing care outside the hospital system, wherever that is possible. That movement not only reduces the high costs of hospital treatment but is much more comfortable and convenient for the patient.”

The benefits of the type of care that pharmacists can provide is particularly evident in the case of newly diagnosed type 2 diabetes patients, says Horne. “A new type 2 diabetes patient not only needs the monitoring of his or her medication regimen but also, particularly in the early stages, needs coaching in management of blood sugar levels. That type of advice and care can most conveniently be provided in a ­pharmacy.”

Hugely important in the operation of the new regimen is communication among the parties involved — pharmacists, physicians, patients and any other health care professionals that may be involved in a patient’s treatment. Horne observes that expected cost savings would obviously not be realized if, for instance, two or three professionals each ordered the same tests to be carried out on a ­patient.

Protocols for communication have to be clear. Health professionals recognize this and, even at this early stage, inter-professional communication appears to be carried out effectively. Horne mentions that when electronic health records are in place, communication among all patients and every health care professional involved will be simplified. Such a system also makes for more informed patients and ones who can be more fully involved in their own health management, he notes.

“We recognized that it was important that the results of the new arrangements should be evaluated, and I believe that discussions are under way between Alberta Health and APA on how that evaluation should be carried out,” says Horne.

The Alberta initiatives of empowering and remunerating pharmacists have not gone unnoticed in other health care jurisdictions. Last year it was Horne’s turn to chair a committee of Canada’s federal, provincial and territorial health ministers that meets periodically. All Canadian jurisdictions have been widening the scope of pharmacists’ powers and have introduced or are working on remuneration schemes. Alberta has gone further and, recently, faster in implementing its plans. As a result, the representatives of other Canadian jurisdictions were keenly interested in the positive experience Alberta was able to report.

The Alberta experience is also being observed internationally. Horne reports that at the Global Forum on Primary Health Care, held last year in Belgium, participants were anxious to hear how all those affected were reacting to the extended role Alberta pharmacists were playing in health care.

Similar interest was displayed by participants in a recent meeting of the U.S.-based Commonwealth Fund, a nonpartisan foundation that supports independent research on health and social issues.