Since the 19th century, the distinction between the physician as therapist and the pharmacist as compounder of medications has been generally accepted.
However, a small but growing number of physicians are starting to dispense drugs from their offices as a convenience to patients, aided in the effort by drug repackagers who provide turnkey software and hardware.
While no one collects statistics on how many physicians are now filling prescriptions in their offices, it appears that less than 10% have contracts with any of the companies providing the turnkey systems or packaged drugs. That perception is borne out by an association of drugstores, which says its members have not raised concerns about the physicians.
Most observers agree that the profit from dispensing prescription drugs is a small part of a physician's overall income. In this era of competition for patients and consumer satisfaction surveys mandated by managed care, the primary motivation appears to be developing an ongoing relationship with patients.
"We don't make a whole lot of money from it, but it covers our costs," says Victor Plavner, M.D., in family practice with Maryland Primary Care Physicians in Arnold, Md. "We do it because it's good for the patients." Plavner's group has used a system from Libertyville, Ill.-based Allscripts Healthcare Solutions since the practice opened in June 1999.
Companies that serve physicians interested in filling prescriptions in their offices range from those that simply provide prepackaged medications that can be sold for cash payments to those that provide a full system including claims processing for patients who have prescription drug insurance coverage. They also either serve a particular specialty, such as dermatology, or try to meet needs of primary care doctors who regularly prescribe a number of different medications.
DRx, a Skokie, Ill., company that has been providing prepackaged prescription medications to medical offices for 15 years, now offers physicians a labeling and integrated logging system that their office staff can use to easily dispense prescription medications to patients as part of their office visit. The company says office staff can dispense and record a prescription in about 20 seconds.
DRx says dispensing usually works best in offices that prescribe acute care medications to treat conditions that are usually cured with a single course of therapy. Practices that frequently dispense medications directly to their patients include urgent care, minor emergency, walk-in medical centers, family practice, occupational medicine/workers' compensation, oral and maxillofacial surgery, pediatrics and dermatology, the company says.
Allscripts has expanded its services and is now an e-healthcare solutions company. One of its products, FirstFill, is a medication management and electronic prescribing system that it provides to physician offices.
"In many ways, prescribing today is like banking used to be," says Allscripts' vice president of marketing, Dan Michelson. "It isn't always convenient for the customer. Banking changed with the ATM machine enabling you to access your account anytime and anywhere. We're offering another option in the way drugs are provided to make it more convenient for the patient while providing significant benefits to the physician."
Allscripts says its FirstFill system allows physicians to fill a patient's first prescription for the most commonly prescribed medications at the point of care.
"Instead of handing out a sample, physicians can provide patients with a complete prescription and save them a trip to the pharmacy," says chief medical officer Peter Geerlofs, M.D.
The company's literature says outcomes may be improved through increased compliance when patients take their first dose at their doctor's office. Studies indicate that 20% of prescriptions written are never filled at a pharmacy.
In-office dispensing also provides an opportunity for the physician to give additional instructions directly to patients.
Internal Allscripts studies have shown that 93% of patients prefer to receive their medication at the doctor's office; there does not appear to be objective research to support this contention, but physicians who use such systems report strong patient acceptance.
Maryland Primary Care Physicians' Plavner ticks off such patient benefits as convenience, since it takes just seconds to fill a prescription; excellent safety, because the drugs are prepackaged and don't have to be counted; and an "almost foolproof" double barcode system to guard against errors.
"Many of our patients are moms with sick kids or elderly people, and they don't want to have to drive somewhere else and wait for their prescription to be filled. The patients love it."
Plavner also says that because Allscripts adjudicates the claims, patients pay their co-pay at the doctor's office just like at the pharmacy.
"It's seamless for the patients. They're confident that they're getting the correct medicine and it builds good relationships with our office."
Approximately 30% of Plavner's patients take advantage of the dispensing. It would be higher, he says, but Allscripts does not have contracts with all of the patients' PBMs and insurers.
Plavner's practice does not keep or dispense narcotics, stocking only those medications they prescribe most often. "There's no problem getting everything we want and they will special order for us if necessary."
DRx says its system makes it as easy for physicians to dispense a controlled substance as a noncontrolled prescription. The company provides DEA dispensing guidelines and works with practices to comply with DEA regulations.
Allscripts' client physicians pay a monthly subscription fee to the company.
Michelson says that by providing patients the option of receiving medications in the office, the physician can end up breaking even or perhaps earning a small profit.
Phil Schneider, spokesperson for the National Association of Chain Drugstores, says physicians may stay away from dispensing because they don't have a patient's complete drug profile, as a pharmacist might have, and don't have as easy an access to prescription records.
Michelson counters that the Allscripts system is not a traditional dispensing program because it combines e-prescribing with the ability to provide prepackaged medications at the point of care through an automated process.
While more primary care physicians are getting into dispensing now, dermatologists have been doing it for some time, helped by companies such as Genesis Pharmaceutical. Company vice president and general manager Elliott Milstein says physician dispensing was always part of the business of C & M Pharmaco (now part of Genesis).
"I think physician dispensing is here to stay," Milstein says. "Even if every product that a doctor dispenses were commercially available--and that won't happen--the physicians can usually dispense them less expensively. The advantages will never disappear."
John G. Hope is based in Harrisburg, Pa., and is a frequent contributor toModern Physician.