ommunity pharmacies are the most visible representation of the healthcare system at work. Drugstore chains, including those found in grocery stores, are easily recognizable, although independent pharmacies also have locations inside other health-related facilities like clinics or hospitals. Pharmacists regularly interact with customers who are picking up prescriptions, and they respond to inquiries about over-the-counter medicines and symptoms. In Alaska, pharmacists are recognized as a highly trained medical profession, though this is not the case nationwide. This lack of recognition can create difficulties providing medical services to those who need it most.

In the past 100 years, pharmacy practice has evolved dramatically. Once responsible for compounding most of the prescriptions they received, they gradually moved toward dispensing premanufactured medications. However, the pharmacist’s role was limited in the ‘50s, as they were discouraged from discussing the contents of the prescription with patients to avoid potentially violating the physician/patient relationship. By the ‘80s, this began to change as pharmacists saw themselves as clinical professionals and advocated taking a more active role in prescription counseling and as immunizers. Educational standards reflected this increased role as healthcare providers. Pharmacists once only needed a Bachelor of Science degree to practice. They now must also complete a post-graduate PharmD degree, continuing training, and regular recertification.

“Pharmacists do more than count pills and put them in a bottle,” says the director of Denali Pharmacy in Fairbanks, Karen Miller. “We screen patient profiles to ensure they receive the right dose at the right quantities for their age.”

Miller says pharmacists conduct Drug Utilization Reviews (DURs) to identify potential and adverse effects, duplications, drug allergies, medication appropriateness, and more. This review ensures that medications are used appropriately, safely, and effectively.

“There are times when a provider may overlook something or prescribe a medication with a similar name to the medication they meant,” says Jackie May, pharmacist in charge at Bernie’s Pharmacy in Anchorage. “Pharmacists provide the necessary checks and balances that improve our healthcare system.”

However, community pharmacists aren’t the only ones providing this oversight. Clinical pharmacists work directly with healthcare providers to ensure patients receive the best combination of medications that lead to the best possible outcomes. Clinical pharmacists don’t dispense medication like community pharmacists. Instead, clinical pharmacists are part of a collaborative healthcare team that supports efforts to improve the patient’s health. In this role, they often interact directly with patients to identify potential medication options that meet the patient’s needs and goals.

“The role of a clinical pharmacist is essentially the same as a community pharmacist,” says Jane LeBlond, clinical pharmacist for Foundation Health Partners. “We work further upstream at the provider level where we can head off any complications at the pharmacy window.”

Ask pharmacists about the number one challenge in the industry right now, and most will point to PBMs, or pharmacy benefits managers. PBMs first appeared in the ‘60s as third-party administrators of prescription drug programs for commercial health insurance plans, self-insured employer plans, the Federal Employees Health Benefits Program, and state government employee plans.

PBMs’ main goal is to curb the cost of medication therapy; however, pharmacists have issues with the methods used to achieve that goal. According to the Alaska Pharmacists Association (AKPhA), PBMs limit patient choice of pharmacy by funneling patients to PBM-approved pharmacies often owned by or affiliated with the PBM.

Furthermore, AKPhA says PBMs engage in “white bagging” and “brown bagging” practices that impose barriers between patients and their healthcare providers. In the case of “white bagging,” PBMs bar hospitals and clinical pharmacies from filling prescriptions onsite to treat patients (e.g., infusion cancer drugs) and require prescriptions sent to an external, PBM-selected pharmacy that will ship the drug to the patient’s providers for storage until the patient arrives for treatment. In “brown bagging” situations, PBMs require the drug to be shipped to the patient’s home. The patient then becomes responsible for storing and carrying the drug to the clinic for treatment. In these scenarios, the clinical pharmacies can no longer guarantee the drug’s source, dosage, handling in transit, or even if they will have the medication when needed for treatment.

AKPhA says PBMs also influence the reimbursement rates for community pharmacies. PMBs currently reimburse affiliated pharmacies at a higher rate than non-affiliated pharmacies. They also impose unequal copayments, fees, or conditions for the same benefit category and penalize patients for using a non-affiliated pharmacy. At times, PBMs will mandate that patients use mail-order or PBM-affiliated pharmacies, prohibit a network pharmacy from shipping drugs to patients, and require undue credentialing and fees from pharmacies seeking to join a PBM network. Likewise, AKPhA says PBMs also engage in “spread pricing,” where they collect more for a drug from an insurer than the PBM reimburses to the pharmacy, allowing the PBM to pocket the difference.

“PBMs are a middleman that negotiates pricing on behalf of insurance and pharmacies while at the same time owning pharmacies that fulfill prescriptions via mail order and control how much we get reimbursed,” says May. “I don’t know what you would call an industry with that kind of oversight, but it doesn’t encourage fair competition. And it’s putting the independent pharmacy out of business.”

Miller says poor reimbursement practices hit especially hard during the COVID-19 pandemic, when pharmacies regularly tested and vaccinated people, often without reimbursement.

“We proved our worth when the State of Alaska issued an emergency order that allowed us to fill the gaps in patient care,” says Miller. “With the passing of HB145 last fall, pharmacists were recognized on a state level as a highly trained Doctor of Pharmacy that, with the training and licensure, can work in collaborative practice to manage chronic disease. Now we need that same recognition on a national level.”

Currently, the Federal Trade Commission is conducting an extensive inquiry into PBMs’ practices, lack of transparency, and their impact on the accessibility and affordability of prescription drugs. Miller encourages small businesses to consult a pharmacist when considering a health insurance package for their employees. She says a pharmacist can explain the prescription coverage, present alternative therapies, and help keep employees healthy without breaking the bank.

The general procedure for processing prescriptions starts with the provider giving the patient a hardcopy request for a specific medication or the provider faxing, phoning, or electronically prescribing the prescription directly to the patient’s chosen pharmacy. The pharmacist, a pharmacy technician, or a pharmacy intern enters the prescription into the patient’s profile in the pharmacy computer system along with the billing information to determine insurance coverage, discount savings, or cash price designated by the product manufacturer. The pharmacist conducts an initial prescription check to make sure the request is appropriate for the patient before approving the pharmacy technician to fill the order. This is followed by a second prescription check from the pharmacist to make sure the label has the correct medication name, strength, and quantity. Only then is the prescription available for the patient to pick up.

Technicians are vital to a pharmacy’s operation, Miller says. Though their positions do not require degrees, they are licensed with the Alaska Board of Pharmacy and are responsible for many day-to-day tasks that allow pharmacists to provide healthcare to customers.

“We like our technicians to be fully certified, but they are hard to find,” says Miller. “Technicians are the bread and butter of a community pharmacy. They cannot perform drug utilization review checks, but they do a lot in terms of data entry, billing, drug ordering, and insurance.”

Technical skills are important in determining the appropriateness of a customer’s medication; however, interpersonal skills are also needed. Pharmacists serve customers with diverse backgrounds (age, socio-economic status, education) and emotional states (happy, stoic, sad, anxious). Interacting with customers who are picking up regular prescriptions is often different from serving customers who are picking up prescriptions for a sudden illness.

“The most important thing in a stressful situation is not to add to that stress,” says May. “It’s important to give the customer all the information they feel equipped to handle.”

In cases where prescription costs are the stressor, May says a pharmacist can check if a less expensive generic brand exists, help locate possible manufacturer coupons, or, in extreme cases, find samples until the provider can identify an affordable option.

“At the end of the day, pharmacists just want to help people,” she says.

As a clinical pharmacist, LeBlond sees additional barriers to medical compliance, like if the medication has an unexpected side effect, the patient is unable to get to the pharmacy to pick up prescriptions, or difficulty reading the label because the print is too small or English is not the patient’s primary language.

“No one wants to be sick,” says LeBlond. “If they aren’t taking their medications, it’s usually for a specific reason.”

As much as the pharmacy industry has changed in the last ten years, LeBlond expects it to evolve further. She foresees pharmacists playing a more significant role in healthcare teams working directly with patients and influencing drug therapy choices at the time of prescribing. Already she says pharmacists are increasingly becoming more specialized, with advanced accreditation and board certifications needed for specified fields within the industry.

“I see pharmacists moving into roles more closely aligned with mid-level practitioners like PAs [physician assistants] and nurse practitioners,” says LeBlond.

Miller feels there will always be the need for a medication expert, whether a community pharmacist, a clinical pharmacist, a consulting pharmacist, or a specialist in a related field. Though clinical pharmacists are higher up the chain than community pharmacists, Miller says the important thing is that everyone works together as a healthcare team on behalf of the patient’s best interest.

In May’s case, recent supply chain issues created a need for expertise that had been idle in the era of premanufactured medications. As one of the remaining compounding labs in the state, Bernie’s is finding a frequent need to mix prescriptions onsite when the premanufactured option is on backorder, May says.

“As a nation, we’re going to have to figure out how to be nimble,” says May. “Large corporations can’t pivot fast enough. A small pharmacy like ours can decide here the best way to use our specialized services to help the community.”