The current system of payment for dispensing in Spanish community pharmacies is aimed at the product through setting a margin that depends entirely on a percentage of the price of the medication that is dispensed. This generates a great conflict of interest with regard to the pharmaceutical intervention that is given for this service, acting as a disincentive and constituting a barrier for introducing services based on knowledge management about medications. In addition, the progressive drop in the real benefit margin obtained by the community pharmacist for carrying out the dispensing service, as a result of the multiple measures that the health administrations have adopted over the last 12 years, is jeopardising the economic feasibility of many chemists.
Both these reasons have a direct impact on the pharmaceutical service given to patients, which is why SEFAC (the Spanish Society of Community Pharmacy) decided to get a committee to study whether it is feasible to change the payment system of community pharmacists to a system not based on margins on the price of the medication dispensed, in order to avoid this conflict of interests with professional activity and which, at the same time, does not involve an additional eco-nomic impact on the National Health System (SNS), the patient or the community pharmacist.
To do this, in the first place, a benchmarking analysis was carried out, with the aim of analysing the international situation of the community pharmacist, in which the methodologies that exist in the 10 most relevant countries in pharmacies in Europe (Germany, Belgium, France, Great Britain, Holland, Ireland and Switzerland), Australia (Australia) and America (Canada and the United States) were
observed. It was concluded that developed countries show an evolution on the payment system based on margins (percentage of the price of the medication), such as any commercial mercantile activity, towards a system focused on payment for pharmaceutical services offered, more typical of professional activities, through a professional timetable and, based on this, it was suggested that Spain should evolve in the same way.
In the second place, a pioneering study was carried out to estimate and analyse the cost of Spanish community pharmacy dispensing with the data compiled from 3,482,524 dispensing procedures in 2010, corresponding to 80 pharmacists distributed all over Spain. The result was that this is closely related to the number of dispenses made, with an average estimated cost of each dispensing procedure in a pharmacy in Spain (50,001-75,000 yearly dispenses) of 3.35 euros (IC95%: 2.12 to 5.47). The cost is found to be below the average margin of contribution to benefit (3.56 euros that correspond to a margin of 27.9%) in a third of the pharmacies that corresponds to those that dispense a reduced number of prescriptions (RNP), set at less than 25,000 dispensing procedures a year. The disaggregated components of this cost are the cost of the basic dispensing procedure: 74.18% (labour costs associated to dispensing: 66.19% plus other costs related to dispensing: 7.99%) and the logistics cost: 25.82% (costs related to the premises: 24.18% plus costs for interests derived from the delayed payment of the medications: 1.64%).
Based on the results of the two abovementioned studies and the analysis of the dispensing process (the basic sub processes of which it is made up and the additional sub processes derived from additional pharmaceutical interventions), a proposal for a payment system for dispensing in Spanish community pharmacies was drawn up, taking into account the following premises. That it should encourage the participation of the community pharmacist in improving the morbidity associated to the medications; that it should prevent the conflict of interests for pharmacists encouraging justified non-dispenses and actions aimed at rationalising the use and expense of medications; that it should maintain the current network of community pharmacies; that it should keep payment for the professional activity of dispensing obtained by the community pharmacist independent from the price of the medication that is dispensed; that it should allow the assessment of complementary pharmaceutical interventions; that it should not increase the budget assigned by the National Health Service (in 2010) to basic pharmaceutical service; that it should maintain the system of setting the retail price of the medications; that it should enable the economic feasibility of community pharmacists and that it should not affect the part to be paid by the patient.
SEFAC proposes a change in the current payment system for dispensing in community pharmacists to a mixed payment system, fundamentally based on a professional fee complemented by a variable logistics charge and —additionally and exceptionally—a feasibility charge applicable to pharmacies with a reduced number of prescriptions (RNP).
The professional fee is the result of the sum between a basic professional dispensing fee at a set amount that pays for the basic sub processes of the professional activity of dispensing and other additional fee(s) that pay for other additional sub processes that can be required as a result of other activities or verifications during the dispensing procedure. Both would be annually reviewable against the consumer prices index. The logistics charge is variable with the annual number of dispenses made in the pharmacy and with the acquisition price of the medication dispensed, in order to cover the costs of acquiring, taking care of and storing the medications and health products that the community pharmacists have.
The objective of the feasibility charge applicable to RNP pharmacists is to ensure that the patient can obtain the medication, guaranteeing the economic sustainability of these pharmacies and it is in line with the regulatory measures established by the health administrations since 2011.
Finally, and with the aim of determining the amounts corresponding to the basic dispensing fee and to the logistics and feasibility charges proposed, a budget impact analysis on the National Health Service derived from this proposal was carried out. The result showed these potential values: 3.37 euros for the basic professional fee; 3.97% above the retail price-VAT for the first 25,000 dispenses a year; 4.05% for yearly dispenses between 25,001 and 65,000; 3.78% for yearly dispenses of more than 65,000 and 0.4 euros to compensate for the low levels of yearly dispenses in RNP pharmacies.
The sum of the additional fees was not included in this analysis, nor was it determined because of the complex nature of calculating it, due to the high casuistry and number of factors that intervene in its assessment.
In view of these results, SEFAC proposes a change in the current payment system to the new system proposed, taking into account that the impact on the national health system is practically neutral (0.00595% of the total cost: 15,126.05 million euros) at the same time as not creating an economic detriment to the community pharmacists.
SEFAC believes that the new model proposed is a model for the future that encourages a more professional pharmaceutical dispensing service, focused on the patient, that permits the feasibility of the network of community pharmacists and opens the door to carrying out other pharmaceutical interventions and activities with the aim of improving the health service offered to the patient, through the rational use of medications and the decrease in the morbidity associated to them.
SEFAC hopes and trusts that the health administrations as well as the community pharmacists and the associations, corporations and organisations that represent them get to know, analyse and reflect on the content of this report, with the aim of modifying the current system for paying for community pharmacist dispensing procedures.