How to Ask Patients for Remuneration

Taking the first step

Presenter biography

Brandon Tenebaum

bull Graduated from the University of Toronto with pharmacy

degree in 1995

bull OPA board member for past three years

bull OPA pharmacy practice chair for past two years

bull Pharmacy manager at both independent and corporate

community pharmacies for over 17 years

Conflicts

bull No conflicts to declare

Learning objectives

bull Understand the changing economic climate within pharmacy and how this necessitates a different way of thinking surrounding charging patients for services

bull Become familiar with the OPA fee guide and how it can be incorporated into practice

bull Become familiar with the tools available to support billable services and how can they be optimally used

bull Understand communication strategies that can be used with staff and patients to lay the ground work for billable services

Hello to the competition bureau

bull The bureau can investigate and penalize anti-competitive activity such as price fixing

bull Competitors cannot agree on the prices they will charge their customers (1)

bull This presentation is not meant to come to any agreement on what should be charged to clients

bull Each pharmacy must determine what they will charge for professional services based on their individual circumstances

The economic climate

bull Constrained provincial budgets have governments

seeking savings with public expenditures

bull Health expenditures including medications represent a

large and growing portion of government expenditures

bull As a result governments have been seeking to slow the

growth of health expenditures

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Presenter biography

Brandon Tenebaum

bull Graduated from the University of Toronto with pharmacy

degree in 1995

bull OPA board member for past three years

bull OPA pharmacy practice chair for past two years

bull Pharmacy manager at both independent and corporate

community pharmacies for over 17 years

Conflicts

bull No conflicts to declare

Learning objectives

bull Understand the changing economic climate within pharmacy and how this necessitates a different way of thinking surrounding charging patients for services

bull Become familiar with the OPA fee guide and how it can be incorporated into practice

bull Become familiar with the tools available to support billable services and how can they be optimally used

bull Understand communication strategies that can be used with staff and patients to lay the ground work for billable services

Hello to the competition bureau

bull The bureau can investigate and penalize anti-competitive activity such as price fixing

bull Competitors cannot agree on the prices they will charge their customers (1)

bull This presentation is not meant to come to any agreement on what should be charged to clients

bull Each pharmacy must determine what they will charge for professional services based on their individual circumstances

The economic climate

bull Constrained provincial budgets have governments

seeking savings with public expenditures

bull Health expenditures including medications represent a

large and growing portion of government expenditures

bull As a result governments have been seeking to slow the

growth of health expenditures

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Conflicts

bull No conflicts to declare

Learning objectives

bull Understand the changing economic climate within pharmacy and how this necessitates a different way of thinking surrounding charging patients for services

bull Become familiar with the OPA fee guide and how it can be incorporated into practice

bull Become familiar with the tools available to support billable services and how can they be optimally used

bull Understand communication strategies that can be used with staff and patients to lay the ground work for billable services

Hello to the competition bureau

bull The bureau can investigate and penalize anti-competitive activity such as price fixing

bull Competitors cannot agree on the prices they will charge their customers (1)

bull This presentation is not meant to come to any agreement on what should be charged to clients

bull Each pharmacy must determine what they will charge for professional services based on their individual circumstances

The economic climate

bull Constrained provincial budgets have governments

seeking savings with public expenditures

bull Health expenditures including medications represent a

large and growing portion of government expenditures

bull As a result governments have been seeking to slow the

growth of health expenditures

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Learning objectives

bull Understand the changing economic climate within pharmacy and how this necessitates a different way of thinking surrounding charging patients for services

bull Become familiar with the OPA fee guide and how it can be incorporated into practice

bull Become familiar with the tools available to support billable services and how can they be optimally used

bull Understand communication strategies that can be used with staff and patients to lay the ground work for billable services

Hello to the competition bureau

bull The bureau can investigate and penalize anti-competitive activity such as price fixing

bull Competitors cannot agree on the prices they will charge their customers (1)

bull This presentation is not meant to come to any agreement on what should be charged to clients

bull Each pharmacy must determine what they will charge for professional services based on their individual circumstances

The economic climate

bull Constrained provincial budgets have governments

seeking savings with public expenditures

bull Health expenditures including medications represent a

large and growing portion of government expenditures

bull As a result governments have been seeking to slow the

growth of health expenditures

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Hello to the competition bureau

bull The bureau can investigate and penalize anti-competitive activity such as price fixing

bull Competitors cannot agree on the prices they will charge their customers (1)

bull This presentation is not meant to come to any agreement on what should be charged to clients

bull Each pharmacy must determine what they will charge for professional services based on their individual circumstances

The economic climate

bull Constrained provincial budgets have governments

seeking savings with public expenditures

bull Health expenditures including medications represent a

large and growing portion of government expenditures

bull As a result governments have been seeking to slow the

growth of health expenditures

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

The economic climate

bull Constrained provincial budgets have governments

seeking savings with public expenditures

bull Health expenditures including medications represent a

large and growing portion of government expenditures

bull As a result governments have been seeking to slow the

growth of health expenditures

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Canadian health spending

bull The three largest parts of health care spending in

Canada are physicians drugs and hospitals comprising

more than 60 per cent of health expenditures

bull The second largest category drugs is forecast to have

grown by 08 per cent from 2013 to 2014 reaching $339

billion

bull Of the three categories of health spending mentioned

drugs represent the slowest growing category (3)

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

The economic climate

bull Across Canada governments have targeted generic drug

costs to achieve some savings which has contributed to the

slowing of growth in spending in this area

bull Unfortunately the reality is that pharmacies have relied on

funding from generic manufacturers to fund operations

bull Expanded scope has provided opportunities for community

care but has not fully replaced lost revenue derived from the

actual drugs

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

We are not alone

bull While pharmacy has experienced a dramatic shift in the

economic climate with drug reform other areas of health

spending have not been left untouched

bull Recently the Ontario government unilaterally cut all the

fees it pays to doctors by 265 per cent

bull In order to balance the budget and eliminate an

estimated $125 billion deficit Ontario will need to show

further fiscal restraint

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

What does this mean

bull In the near term it is unlikely that payers such as the

government will step in to make large investments in

health care including pharmacy

bull Any government funding of pharmacist services is likely

to be targeted and modest in relation to the decrease in

revenue from the actual drugs

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Charging for professional services The

current landscape bull In 2014 25 per cent of pharmacies in Canada report

charging for services not reimbursed by provincial

governments

bull Only 11 per cent charge enough to make a reasonable

profit

bull 63 per cent do not charge but believe that we should be

charging for professional services (this figure is high for

all types of pharmacies) The question is why do they not

charge

bull Only 13 per cent do not charge and believe we should

not be charging (4)

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

What are we waiting for

bull While OPA will continue to advocate for expanded

pharmacist scope and funding for pharmacist services

we have the ability to charge for pharmacist services

bull For services such as prescription renewal assessments

the government has explicitly stated that pharmacists

can charge the public for these services

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Why charge for professional services bull These services have a value sometimes as significant as the drugs

we dispense (Smoking cessation counselling)

bull Funding a viable practice will increasingly rely on funding from a

source other than the actual drugs

bull Charging for professional services can reduce the reliance on

funding from sources unrelated to pharmacy or those potentially

harmful to the public (eg cigarette sales in some jurisdictions)

bull Establish a market value for these services to encourage future

payer funding (why would a payer fund a service given at no

charge)

bull To fund the staffing necessary to properly deliver the service and

meet standards of practice

bull If we do not believe enough in the value of our services why should

anyone else

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

The ethics of charging

bull Are there ethical issues surrounding charging for

professional services The answer is potentially yes

bull How do we navigate these potential ethical issues By

providing options for the patient and using professional

judgment

bull Is giving away services at no charge any different from

giving the drugs at no charge They both have value and

can impact upon a patientrsquos health

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Client or patient bull Should we refer to people we serve as clients or

patients

bull Each term carries its own assumptions and beliefs and

may help us understand some of the difficulties in

charging for professional services

bull In general for a patient there is an expectation that

medically necessary services are covered

bull With clients there is a service expectation and

understanding that payment may be required for

services or products

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Client or patient The patient perspective

bull Some have emphasized the obligations and

responsibilities due to ldquopatientsrdquo but not to ldquoclientsrdquo (a

hospital in Canada would not refuse life saving treatment

for inability to pay)

bull A survey of 101 people at a back pain clinic showed 74

(almost three quarters) preferred ldquopatientrdquo 19 chose

ldquoclientrdquo and 8 stated no preference

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Client or patient The patient perspective

Unsolicited comments included

bull I am here for help not to use you [ldquopatientrdquo preference] I

am not doing business with you nor do I want to be

paying directly for this service

bull You are a service I think Canada is admired for and I am

at your mercy [ldquopatientrdquo preference]

bull It doesnrsquot really matter A patient receives treatment A

client receives a bill [no preference] (5)

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Client or patient

bull With a client there is an expectation of consumer choice

bull A patient treated in hospital will have most services and medications covered

bull Once that same patient leaves the hospital services and medications may not be covered

bull Patient alludes to health while client associated with business

bull It appears the people we serve display elements of both (health and business) (6)

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Themes related to effective change

techniques

bull Answer the question of how to change in practical terms

bull A system to support change is needed such as

mentoring

bull Positive reinforcements and incentives aligned with the

change desired support the process of change Work

conditions discussed more often than money

bull Feedback is necessary to support change initiatives (7)

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Laying the ground work for change

bull Small steps can represent significant progress

bull Start the process with individuals who have disproportionate

influence in organization (influential assistant technician or

pharmacist)

bull Once these individuals committed to change highlight their

accomplishments to send message to others

bull Tipping point approach recognizes not realistic to convert everyone

at once

bull Help foster understanding of harsh realities that make change

necessary (drug reform etc)

bull Try to redistribute resources toward activities that require few

resources but result in large change (8)

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Challenges in charging with corporate versus

independent

bull Independent has smaller patient and staff base to

educate about charging

bull Able to customize charging to specific patient base

bull Owner in better position to know specific clientele

bull Corporate pharmacy has larger patient and staff base to

educate about charging

bull Challenges with consistent policy across all stores as

patient base can differ from store to store

bull Potential to make larger impact by virtue of size and

marketing expertise

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Real life example Charging for prescription

renewal assessments

bull Why start with prescription renewal assessments

bull Easier to quantify value to patients

bull Consider travel costs to prescriber and waiting time (the

convenience factor)

bull There are also clinical aspects of the assessment

(review current health status possible side effects)

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

What to charge for the service

bull This is an individual decision that will be guided by your

individual circumstances such as competitors market

demographics etc

bull The OPA fee guide can also provide a starting point

bull You can always start small to allow patients and staff to

grow accustomed to the idea of payment for services

bull Changing the culture will be more important than actual

price when starting

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Overcoming fear

bull Charging for services requires a leap of faith to

overcome the fear of patient rejection

bull There is a need to overcome the fear that patients will go

to a competitor if you charge for services

bull This is why the messaging is so important

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Provide the patient with options

bull Empower the patient to make decisions regarding their

care

bull For prescription renewal assessment we offer the patient

options and let them decide

bull For renewals there is the option of waiting for prescriber

authorization walk-in clinic or a prescription renewal

assessment which is paid by the patient

bull A posted sign should clearly explain the policy to assist

staff with communication and provide full disclosure

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

PRESCRIPTION RENEWAL

ASSESSMENTS $CHARGE

AFTER AN ASSESSMENT A PHARMACIST MAY

RENEW A PRESCRIPTION FOR A CHRONIC AND

LONG TERM CONDITION WHERE THE PATIENT

HAS TOLERATED THE MEDICATION WITHOUT

SERIOUS SIDE EFFECTS (THIS SERVICE DOES

NOT APPLY FOR NARCOTICS OR CONTROLLED

DRUGS)

REGULAR APPOINTMENTS WITH THE USUAL

PRESCRIBER SHOULD BE KEPT AS THIS SERVICE

IS NOT MEANT TO BYPASS THE CARE THAT IS

GIVEN BY THE OTHER HEALTH PROVIDER

OTHER OPTIONS AVAILABLE INCLUDE WAITING

FOR AUTHORIZATION FROM THE ORIGINAL

PRESCRIBER OR GOING TO A WALK-IN CLINIC

FOR PRESCRIPTION RENEWALS

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Elements of the sign

bull Sign assists staff with patient communication

bull Discloses charge and amount

bull Relies on OCP expanded scope manual to set out

guidelines

bull Sets out restrictions (for chronic long term condition

where medication tolerated without serious side effects

and no narcotics controlled drugs or targeted

substances)

bull Reminds patient service not meant to bypass care given

by other health provider

bull Sets out options for patient (walk-in clinic etc)

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Menu board sign

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Provision of expanded scope services The

basics from OCP

bull Assess patient and need for activity related to expanded

scope

bull Communicate with patient to obtain support and consent

bull Document actions in patient record including rationale

and notify prescriber as necessary (9)

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

OPArsquos prescription renewal assessment form

bull Found on the OPA website under resources for

pharmacists tools and forms

bull OPA prescription renewal assessment form provides

documentation in line with OCP requirements and

provides supporting documentation for billing

bull Pharmacy software can be used to support billing by

populating drug card with service and fill as you would a

prescription with the pharmacist as prescriber (affix copy

of assessment form to prescription hardcopy)

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

OPArsquos Rx renewal assessment form PHARMACIST AUTHORIZED PRESCRIPTION RENEWAL DOCUMENTATION AND NOTIFICATION FORM Note to Prescriber Please update your records No response required

Patient Information

Name Date of Birth (YYYYMMDD)

Address Phone

Original Prescriber Information

Name Phone Fax Pharmacy Information

Name Fax

Original Rx Rx Renewal Details (Drug name strength quantity directions)

Rationale for Prescribing

Affix Original Rx Label Here

Medication is for a chronic and long-

term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication

without serious side-effects

_____________________________

Affix Original Rx Label Here

Medication is for a chronic and long-term condition

Patientrsquos condition is well-controlled

Patient is tolerating the medication without serious side-effects

_____________________________

Date Pharmacist Name Pharmacist Signature OCP

Additional details (incl patient assessment)

Monitoring and Follow-up Plan

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Patient was advised to follow-up with their primary care provider for their next Rx renewal (if applicable)

Original PrescriberPrimary Care Provider Notification

Date of Notification

Primary Care Provider Name and Contact Information (if different than Original Prescriber)

Method of Notification Fax Phone Other

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Overcoming obstacles

bull Staff I am using my professional discretion when not charging for this service as I feel the patient may experience harm if they do not receive this service (There is no immediate harm that the patient would experience and they have options to choose from Professional discretion should be used in the provision of the service but charging is an ownermanager decision)

bull Patient The pharmacist used to throw some pills in my bottle to tide me over (Under expanded scope legislation pharmacists have the authority to extend prescriptions under certain conditions An assessment and documentation are required to support the pharmacists decision to extend the prescription and this is a service that is not currently covered)

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Positive reinforcement works

bull Important to get support from key people in organization

(owner manager key employees)

bull Meet with staff before implementation to explain policy

answer questions and adjust policy if necessary

bull Praise those who support policy (congratulatory e-mail to

all employees highlighting individuals who have

promoted policy)

bull Reinforce policy through follow-up meetings and one-on-

one coaching

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

OPA Fee Guide

bull Currently being updated

bull Found on OPAsrsquo website

bull Current fee guide reviewed by OCP

bull To help determine fair value for services provided

without compensation

bull Current guide has suggested flat or hourly rates

bull Fees are suggestions only

bull May provide ideas on what to charge for

bull In the future guide may serve as reference point for

insurers looking to reimburse pharmacy services

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

OPA Fee Guide bull The Ontario College of Pharmacists reviewed the draft fee guide and

provided the following comments in a letter dated June 20 2010

ldquoIn our opinion the draft fee guide

does not contravene any regulations or policies respecting fees for

services provided by a pharmacist to the public As you are

aware while the College does not have the authority to determine or establish

fee levels we do have the responsibility to investigate allegations respecting

fees charged to determine whether such fees are excessive

or unreasonable It is our view that your service fee guide does not fall

within such definition The College will through its Professional Practice

Committee be developing policy to guide pharmacists in the implementation

of services that the College considers would fall

outside of the lsquousual and customaryrsquo dispensing activities

In the meantime we suggest that pharmacists be reminded in your

guide of the rules of disclosure posting and filing of dispensing fees and the

need for the patient to understand why a different fee is being charged

and to agree to itrdquo (10)

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

OPA Fee Guide

Service categories

bull The services described in this document fall under the

following categories ndash Category 1 Professional

Dispensing Services ndash Category 2 Additional

Dispensing Related Services ndash Category 3

Pharmaceutical Care Services ndash Category 4

Specialized Pharmacy Services ndash Category 5

Pharmacist ConsultantAdvisory Services ndash Category 6

Preparation of Customized Pharmaceuticals ndash

Category 7 Services for Long Term Care

FacilitiesInstitutions ndash Category 8 Miscellaneous

Services (10)

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

OPA Fee Guide

bull Suggested rates were determined 1 by ndash Estimating

amount of time required for each service ndash Considering

the associated hourly rate (including overhead costs) to

staff delivering the services ndash Factoring additional

elements such as complexity travel costs added risk

where needed bull Time estimates presented in this guide

are averages of service delivery duration ndash It is

recognized that these time estimates may vary between

pharmacies bull Rates include allowance for overhead

return on investment and general and administrative

expenses bull Suggested rates provided in this document

are meant to provide indicative guidelines to

pharmacies ndash Pharmacies may adapt these rates to

reflect their cost structure and market environment (10)

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Looking ahead

bull Further expanded scope will give patients more choice in the

health provider they access

bull While optimal patient care is the goal of further expanded

scope the changing economics of pharmacy will force us to

seriously consider charging patients for these services absent

insurance coverage

bull A Lawtons drug store in Saint John New Brunswick charges

$2250 for minor ailment assessments

bull This same store charges $25 to immunize lower risk patients

for the flu (only high-risk populations covered for pharmacist

administered flu shot)

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

Take home messages

bull With expanded scope there is no better time to charge

than now

bull Be patient change will not happen overnight

bull Do not be discouraged by resistance as persistence

will pay off

bull Create a work environment that supports change in

terms of training and ongoing positive feedback

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

References

1 Government of Canada Competition

bureauhttpwwwcompetitionbureaugccaeicsitecb-

bcnsfengh_00125html (accessed March 12 2015)

2 Canadian federal and provincial fiscal tables Accessed Mar 1515

httpwwwrbccomeconomicseconomic-reportspdfprovincial-

forecastsprov_fiscalpdf

3 National health expenditures Canadian Institute for health

information Accessed Mar 515 httpwwwcihicacihi-ext-

portalinternetendocumentspending+and+health+workforcespen

dingnhex_2014_chapterinfochap3

References

4 Rogers media market research 2014 Trends and insights survey of community pharmacists Pharmacy practice +

5 Peter C Wing MB ChB Patient or client If in doubt ask httpwwwcmajcacontent1573287fullpdf (accessed March 15 2015)

6 Savithiri Ratnapalan MBBS Med Shades of grey patient versus client CMAJ httpwwwncbinlmnihgovpmcarticlesPMC2638036 (Accessed March 15 2015)

7 Paul Am Gregory MLS and Zubin Austin PhDManaging Change in Community Pharmacy Practice Perspectives of Pharmacists Ontario Pharmacist Volume 79Issue 1March-April 2015

8 How to Change Your Organizationrsquos Culture The Wall Street Journal httpguideswsjcommanagementinnovationhow-to-change-your-organizations-culture

References

9 Ontario College of Pharmacists Expanded scope of practice

orientation manual httpwwwocpinfocomlibrarypractice-

relateddownloadExpanded20Scope20Orientation20Manual

pdf (accessed Mar 1815)

10 Prepared by nD insight for the Ontario Pharmacists Association

Suggested fee guide for uninsured clinical and professional

pharmacy services

httpswwwopatodaycomMediaDefaultSuggested20Fee20G

uide2012-10-

0920OPA20Uninsured20Clinical20and20Professional2

0Services20Fee20Guidepdf (accessed March 24 2015)