Recently, the Journal of the American Pharmacists Association published a secret shopper study describing counseling provided during the dispensing of naloxone at chain pharmacies in Texas. Although it may seem crazy that the average counseling time was only 89 seconds, what was more striking was that any formulation of naloxone was unavailable at almost one-third of the randomly selected chain pharmacies. Keep in mind, this is naloxone, a drug with no major side effects, is responsible for reducing opioid related overdoses by almost 14%, and does not require a prescription in numerous states. Unfortunately, problems with accessing or utilizing pharmacist services are not unique to naloxone dispensing. So why aren’t pharmacies and pharmacists adopting policies designed for accessibility? The long answer involves a lengthy discussion of stigma, discrimination, and logistical constraints. A reasonable discussion requires highlighting the importance of ensuring the decisions made during the policy process allow for efficient and effective policy implementation.
Why is Policy Implementation so Important?
Nurse Practitioners (NPs) interested in expanding their scope of practice use a major talking point that they need independent practice ability so NPs can practice in medically underserved and rural areas and thus increase access to care. However, the American Medical Association recently made a statement arguing that ineffective policy implementation in underserved areas, the main argument many professional groups have utilized to advance scopes of practice, is why these scopes should remain limited and dependent on physicians. You may think this argument is invalid but persistent and equitable implementation issues already exist in states with advanced pharmacy practice, such as those seen with pharmacist-prescribed and OTC hormonal contraception in Los Angeles County.
Successful policy implementation not only has a significant effect on policy outcomes but also agenda setting and issue framing for subsequent issues that follow. Given pharmacists are the most accessible healthcare provider (with most people living within 5 miles of a pharmacy), it is essential pharmacists effectively and efficiently implement expanded scope policies such that these arguments are discredited. If pharmacists fail to do this, policy agendas concerning expanded practice will be much harder to push in the future. Of course, more important than expanding pharmacist scope of practice is the responsibility of pharmacists as healthcare providers to ensure all patients (regardless of their geographic location) are receiving affordable and accessible healthcare. Likewise, if pharmacists truly wish to continue to expand the scope of practice to help provide accessible healthcare to patients in need and serve as better members of interprofessional collaborative healthcare teams, then pharmacists must focus on successful implementation of the initial policies at hand.
What Impacts Policy Implementation?
There are numerous factors which contribute to a policy’s implementation and success. However, when discussing pharmacy practice policy there are three main areas pharmacists are missing in their implementation: comprehensive implementation style, policy feasibility, and policy salience.
There are two main forms of policy implementation styles, top-down and bottom-up. Top down policy implementation follows a more traditional path of governance. Healthcare organizations see this with CMS performance measures. CMS incentives encourage management to require healthcare providers to change their practice behaviors or implement a desired policy/action. Bottom-up policy implementation emphasizes policy decisions that are influenced by the target groups or service deliverers. This is usually seen in patient safety where systems allow individuals to make mistakes and in turn force management to implement new policies. If the failures that result in mistakes go unaddressed and occur frequently, larger policy change may occur through actions by accreditation organizations (e.g. the Joint Commission) or the regulatory system (e.g. CMS or FDA).
Pharmacy organizations utilizing the narrative of patient need for medical access intuitively emphasize a bottom-up policy implementation style. However, pharmacists are utilizing a top-down implementation style at the federal level by focusing on large centralized statutory changes to be further diluted as it gets implemented downstream. This approach often leads to disconnected, uneven, and sometimes ineffective policy implementation, especially regarding issues regulated at the state-wide level like pharmacy practice. Likewise, if a bottom-up argument is going to be made, suggested policies will have to be significantly more responsive to lower level needs. Currently, surveys repeatedly show that needs of pharmacists to implement these services not only revolve around reimbursement but also time constraints, lack of healthcare communication, and much more.
Unless other issues barring the implementation of expanded pharmacy services at community pharmacies are addressed, it is unlikely these services will be implemented in areas with the most need. This brings us to the second missing factor in pharmacy policy implementation: ensuring feasibility. Without appropriate resources, pharmacists will be unable to implement these services across the board. Although provider status will address the issues of payment, if other underlying barriers are not addressed it is unlikely that underserved areas will implement these services due to a constraint in resources. Instead, implementation will mostly be seen in areas with the means to do so. Likewise, pharmacists need to advocate for innovative solutions which allow pharmacies to shift current resources to better fit the policy agenda at hand such as increasing technician responsibilities to focus on administrative functions so the pharmacist can focus on providing care.
Assuming pharmacists address the underlying barriers within pharmacies, it comes down to policy salience to ensure successful usage of these services. Saliency refers to the visibility of a policy to those it impacts. For instance, if prescription prices change for a pharmacy or insurance company due to regulation changes but the co-pay for the patient stays the same, then it is not a salient policy for the patient. In this scenario, the patient is largely unaware this change has occurred since there is minimal interruption to their life. However, if the patient’s prescription co-pay drops then it would become a more salient policy to the patient. A good example of this is how co-pays for birth control dropped after the passage of the Affordable Care Act and subsequently resulted in an increase of birth control usage. In a similar fashion, pharmacists need to ensure expanded services are salient and widely known to the patient to ensure reasonable usage.
Let’s go back to the secret shopper study discussed earlier and apply these concepts of policy implementation. To start, pharmacists dispensing naloxone is already a bottom up policy change stemming from the opioid epidemic. So what could encourage a more equitable implementation? Well the average counseling time was 89 seconds, indicating a possible underlying issue of time constraint. This means future policy should focus on feasibility, which may be addressed by encouraging legislation allowing technicians to practice in more advanced roles so pharmacists have more time to discuss naloxone with patients. The second issue of naloxone being unavailable at one-third of stores could be addressed by increasing policy salience. Pharmacy organizations and pharmacists utilizing ads targeted directly to consumers in locations where pharmacies are not dispensing naloxone, advising them to obtain naloxone from a pharmacy near them, would likely increase the saliency of this policy. This could result in increased demand and force implementation of services at more locations, much like what happened with immunization policies.
Although regulatory and legislative changes can help pharmacists increase the accessibility of care through expanded practice, if pharmacy organizations fail to successfully implement policy, then future agenda setting could be at risk. To avoid this, pharmacists need to advocate for changes at the state level that will make practice expansion more feasible and responsive to the needs of the individual pharmacists and organizations responsible for implementing expanded practice services. Additionally, pharmacy organizations need to make these policy changes more widely known when they occur. If pharmacists truly want to expand patient access to medical services, then they must focus on ensuring successful policy implementation.
Guest Writers Profile
Matthew Westling is a PGY1 Pharmacy Resident at the Ralph H Johnson VA Medical Center. Matthew received his Doctor of Pharmacy and Master of Public Administration from the University of Kentucky. During his time at the University of Kentucky, Matthew was involved with SNPhA, the Kentucky Pharmacist Association, SCCP, Kappa Psi Fraternity inc., Phi Lambda Sigma, and the Student Philanthropy Board. He has a strong interest in policy implementation and research. Specifically, Matthew is interested in how pharmacy practice policy can be best utilized to help correct health inequity/disparities. He believes pharmacists are uniquely positioned to help directly break down barriers to health equity and wants to ensure policy implementation does not leave under-served patients behind.