Background
In 2011, the World Health Organization (WHO) and the International Pharmaceutical Federation (FIP) officially adopted changes in the practices of community pharmacists from the delivery of medicines to a collaborative, person-centred care process [
1,
2]. In practice, a variety of professional pharmacy services are now available in pharmacies, ranging from screening services to prescription renewals, medication reviews, and adherence-enhancing services. From a healthcare system perspective, some of these services are effective [
3‐
7] and cost-effective in experimental contexts [
8] and can increasingly be charged as fees-for-services [
9,
10].
Medication nonadherence is endemic and decreases the cost-effectiveness of chronic treatments [
11‐
13]. In 2004, the Community Pharmacy Center of the Department of Ambulatory Care and Community Medicine (Policlinique Médicale Universitaire, PMU), University of Lausanne (Switzerland) developed and implemented an interprofessional medication adherence program (IMAP) for chronic patients. It consists of a multifactorial, semi-structured intervention combining individualised, short but repeated motivational interviews, medication adherence electronic monitors (EMs) (MEMS, Aardex MWV, Switzerland) and feedback to the patient. A secure web platform allows the pharmacist to record the patients’ data, provide adherence feedback to the patient during the interview, report to the physician and other professionals, and use the electronic records to guide the intervention from one interview to the next one. The program has been described in detail elsewhere [
14,
15]. For example, in 2014, 268 patients were followed up by the Community Pharmacy Center: 187 HIV patients, 28 multiple sclerosis patients, 9 oncology patients and 44 patients with various chronic diseases (e.g., hypertension, type 2 diabetes and chronic dialysis) [
15]. Currently, the program is being implemented in some voluntary community pharmacies in the French-speaking part of Switzerland for HIV patients [
16], multiple sclerosis patients [
17] and patients with type 2 diabetes [
18]. Published literature on the program in HIV patients showed an increased medication adherence and persistence among participants compared to a control group at 6 months (quasi-experimental study,
n = 32) [
19]. Moreover, the number of undetectable HIV patients increased during the 11-month program (retrospective analysis,
n = 104) [
14]. Finally, the program significantly improved retention in care at 6 and 12 months (retrospective analysis,
n = 762) [
20]. Other findings in the literature assessing the effectiveness and cost-effectiveness of interventions to improve adherence in HIV and chronic patients corroborate these positive results [
21‐
23].
Despite these encouraging developments, the implementation of professional pharmacy services in routine care faces certain challenges [
24‐
26]. Among other factors investigated in the literature, cost is a potential barrier to widespread implementation [
27‐
29]. Implementation costs is defined as the cost impact of an implementation effort [
28]. They can be significant and may hamper the provider’s decision to invest [
30,
31]. They occur during three different phases of the implementation process [
32‐
34]: installation phase (i.e., the preparation of the pharmacy and service provider to deliver the service), initial implementation phase (aimed to experiment the service provision to a small number of patients) and full operation phase (i.e., the full implementation and the provision of the service in routine care) [
32]. Within these phases, two components of implementation costs can be distinguished [
31]: direct service delivery costs and service support costs. First, direct service delivery costs vary with each additional patient (i.e., variable costs) and include all costs associated with the delivery of the service, primarily labour costs. Second, service support costs occur both in the installation phase, as start-up costs (e.g., initial staff training, equipment), and in the implementation and full operation phases (e.g., continuous training, supervision meetings). These costs are independent of the number of patients (i.e., fixed costs). Finally, the true implementation cost of a professional pharmacy service notably depends upon the complexity of the service, the complexity of the used implementation strategies, and the setting of service delivery (complexity and overheads) [
28].
The literature often focuses on the direct service delivery costs, and rarely includes service support costs, or it values at best the initial staff training. However, the implementation of a sustainable, innovative service requires substantial resources to organise, engage and integrate the pharmacy in a novel philosophy of practices and business strategy. To be financially feasible and viable, the total revenue generated by the implementation of the service must at least cover the total cost of its implementation. Hence, traditional financial planning tools can help to analyse and support the business decision to implement a service by assessing the net impact of a new service on the provider’s budget [
35]. The break-even analysis (BEA) can identify the price of a service and/or determine the volume of service needed to break even financially [
36]. In a context of a fee-for-services fixed price, BEA is interesting to identify the required number of patients to follow up with (“the break-even point”) to ensure that the generated revenue will exceed the total cost.
This pragmatic study aimed to estimate implementation costs and the break-even point (in terms of the number of patients to follow up with) based on a real-world activity of the interprofessional medication adherence program for chronic patients.
Discussion
These estimates provide a better understanding of the real cost of implementing an interprofessional medication adherence program for chronic patients in Swiss community pharmacies. Due to the heterogeneity in interventions, data collections, item costs, or national professional costs, it is difficult to directly compare with other similar studies [
32,
39]. However, all these studies consistently indicated that service support costs in the installation phase are substantial and that professional costs are the primary drivers of direct service delivery costs.
Our study is the one of the first to estimate the service support costs, distinguished during the implementation phases. Their significance supports the development of their valuation in cost analysis and economic evaluation. Service support costs, as described in this analysis, are required to guarantee the delivery of a high and standardised quality level service, but could also hamper the decision to invest from the provider perspective. In Switzerland, pharmacists’ training in advanced patient-oriented services is part of their postgraduate or continuous education. Today, the costs of such trainings are therefore borne by the pharmacy owners. However, this could change over time in accordance with the current curricula reform in Switzerland. One of the objectives of this reform is to strengthen in the pre-graduated cycle the clinical skills of pharmacists to deliver advanced patient-oriented services in the pre-graduated cycle. The curricula content influences the dissemination of professional pharmacy services and must accompany the evolution of the profession, according to national needs. Moreover, the specific education required to deliver the program can generate indirect revenues in other fields of business, allowing the pharmacist to invest time and skills in communicating with patients at risk for nonadherence.
Variable costs were primarily driven by workforce time (68%). We assume that this time will decrease and stabilise in the medium term with routine program delivery [
32], providing a better profitability. Space cost was not very high. However, this valuation considers the opportunity cost associated with the use of a private area for the delivery of the program. Assuming that this area already existed, the growing number of patients followed could disrupt its previous use. Business diversification, including new professional services, affects the spatial organisation at the community pharmacy, notably associated with the offer of activities with and without appointments.
With our assumptions and the current national reimbursement system model, a minimum of 16 patients must be follow up with to ensure a profit for the pharmacy, with a range from 10 to 27 according to scenarios assessed in sensitivity analyses. In real life, some patients may stop the follow-up before one year, and the frequency of interviews will depend on the patient’s needs. Is this number realistic in terms of inclusion and follow-up rates? The patient inclusion process into the medication adherence program depends on several factors, which are specifically linked to the setting: the needs of the targeted population of patients, the state of the interprofessional collaboration, and the pharmacists’ ability to include patients. First, about 50% of chronic patients do not take their medications as prescribed [
40]. Each professional has a role to play to support such patients in the management of their medications, notably the community pharmacist, as the first port of call in primary health care and the specialist of medicines. Due to the endemic nature of medication nonadherence, a large proportion of chronic patients could reasonably benefit from this service in a pharmacy. Second, the existence of local interprofessional networks has been identified as one of the major factors for successfully implementing a medication adherence program in community pharmacies [
41,
42]. We observed at the PMU that the inclusion in the program by the physician plays a key factor. In fact, it is determinant that this program is part of the medical care plan, as many patients rely on this traditional way of therapeutic decision-making process. The other barriers that may affect program success are poor patient-pharmacist communication (resulting in an insufficient promotion of the program), difficulty in integrating the program into the pharmacy organisation, and insufficient pharmacist motivation [
42].
In our model, only one full-time equivalent (FTE) pharmacist and one FTE technician followed up with the entire cohort of patients. However, the management of 16 patients only represents a 7% FTE for pharmacists and a 4% FTE for technicians (9 and 5% respectively for 27 patients). In the context of a pharmacy, this implies a solid management and planning of staff resources for each basic and advanced activity. Strategically, we recommend training at least two pharmacists and technicians to ensure a turnover in case of absence. Assuming an amortisation over 5 years, the doubling of trained professionals had a minimal impact on the break-even point (see Table
2).
Regarding the generalisability of this cost analysis to other contexts, the BEA depends on the national reimbursement system model. In our context, the “price” of the service corresponds to a fee-for-service plus the sale of pill boxes. The Swiss pharmacist can charge them only if the patient is simultaneously prescribed at least three chronic medications (resulting in three EMs). With a fourth chronic medication or more, the pharmacist can charge an additional polymedication check fee (48.60 CHF every 6 months). Although the number of tablets can affect adherence [
40], these restrictions are debatable as chronic patients with only one drug (e.g., HIV, multiple sclerosis or cancer patients) also need the program. According to the PMU data, patients had an average of 2 EMs over their entire follow-up period [IQR: 1–3] [
12]. Moreover, it is impossible to estimate the potential hidden incomes generated by the delivery of the program from the building of patient loyalty or the increasing of the medication adherence, both of which could add to the revenue.
The estimates or our analysis is not generalizable per se as it is context-dependent. However, the BEA equation (see Fig.
2) can be applied to other healthcare contexts to either calculate the price of the service or the number of patients to include in order to reach the local break-even point. For instance, Noain et al. 2017 estimated a potential medication review with follow-up service price ranged from €237 to €628 per patient a year in Spain, according to different scenarios including professional level of the service provider (pharmacist in charge/pharmacy owner), potential number of patients receiving the service (60/120/180) and mark-up applied (10/20/30/40%) [
39].
Some methodological considerations should be noted when interpreting these findings. BEA is a simplistic representation of reality. Although the estimated parameters are based on the experience of the PMU and expert opinions, BEA assumed a similar variable cost for all patients. However, the pharmacy faces a variety of patients, leading to a range of variable costs in the type and extent of nonadherence issues, frequency of visits, number of EMs, duration of interview and duration of follow-up. For instance, at the PMU, patient retention in the program is longer in patients with more serious nonadherence issues than in patients with less serious issues. This repartition is nevertheless unknown in the community and different in each pharmacy setting. Prospective studies should assess this variability in real life. The major unpredicted event that occurs in the IMAP program is when patients do not show up and the visit is rescheduled. We have not taken this uncertainty into account in our model as extra-cost because the pharmacist is directed to another clinical activity when this situation happens.