Minor ailments a conflict of interest for pharmacists? Pu-leeze!

Two weeks ago, I finally made it to an overdue dentist appointment that had been twice postponed—once due to my coming down with COVID-19 and then a second time when my appointment conflicted with a work commitment.

During those several months since my last check up, as expected,  the decline of a childhood filling had continued to the point where the dentist decided I required a crown to save the now-compromised tooth. The work should be done sooner rather than later, at an estimated cost of $1,300. My insurance will cover half of that, and my savings account will have to cover the balance.

That’s the equivalent of a plane ticket to Europe, I noted, as the office administrator contacted my insurer and scheduled the appointment. I wouldn’t buy a plane ticket—or almost anything, really—without doing a significant amount of research into ways to bring down the cost. Are there cheaper times to fly? Any upcoming promotions? Should I use my points?

But did I question my dentist about the absolute necessity of this costly procedure? Did I ask if there were less expensive ways to get similar results? I did not. Did I question the ethical appropriateness of  the person who decided I required a $1,300 procedure also being the person who would perform said procedure? Bill for it? And as the owner of his clinic, receive the payment for it? I did not.

Rightly or wrongly, I assumed that the professional whose job it is (and who is in fact well-educated and strictly licensed) to treat dental issues had done a fair and ethical job of assessing and treating mine.

It was the same when I took my cat to the veterinarian and learned she had liver disease. I paid (more than the cost of a dental crown!) the veterinarian who owned the clinic for the assessment and also for an overnight stay, medications and special food.  And when I saw a dermatologist for a skin check and she determined that I should have a few moles removed, I paid her a fee for removing said moles.

It’s what professionals do, is it not? So why, then, do so many “experts” continue to express outrage about pharmacists’ prescribing as a conflict of interest?  

The latest incident of this comes via a recent article on the Television Ontario website and newsletter, TVO Today. In an opinion piece about 'The risks and benefits of pharmacist prescribing, journalist Matt Gurney outlines two key concerns about the province’s initiation of pharmacist minor ailment assessment and prescribing, as expressed by an unnamed doctor friend:

“The first is that some pharmacists run their own pharmacies, so there’s a financial conflict of interest in issuing a prescription that you’ll then bill the patient to have filled. That’s . . . a real concern. I don’t think it’s an insurmountable one or worth scrapping the approach over (for reasons we’ll get into in a minute), but it’s real and should be given consideration.”

The second concern is about the lack of patient/pharmacist privacy in most pharmacies and—the un-tallied third concern—the fear that pharmacists will miss potentially serious issues when they diagnose. (Some other day I’ll go into more detail about that time when an emergency room physician diagnosed our five-year-old daughter with a sprained finger and broken blood vessel and then proceeded to cover up her entire arm with a plaster cast, when in fact she had a staph infection, which festered and spread under said cast until she was life-threateningly ill. Pharmacists do not have a monopoly on potential errors!)

There’s way too much here to even begin to tackle, but for now let’s just focus on the issue of conflict of interest. Obviously there is a huge mis-information problem here, when so few Canadians, including other healthcare professionals, understand how pharmacists are paid. Once more for the record: In the majority of Canadian provinces (and especially in Ontario which  this article refers to) pharmacists do not have provincial billing numbers. Any payments made for prescriptions or pharmacy services by public or private drug plans are paid to the pharmacy. Unless they are the pharmacy owner, pharmacists are paid a salary by their employers. They do not receive any direct payment for the scripts they prescribe or authorize, nor do they even receive the small fee that is tied to their minor ailment assessment.

Unlike the psychologist who performs, bills and is paid for each consulting session they believe their patient requires, or the physiotherapist who determines that a IT band issue will need four treatment sessions that they themselves will provide and be paid for, the vast majority of pharmacists have no personal connection to the remuneration tied to the services they provide.

Whether this system is right or wrong is a subject for a whole other blog, but for now, let’s finally set the record straight.