Table A3.

Supplemental quotes.

Themes (Subthemes)	Quotes
Perceptions of the Pharmacy Profession
Expectations of Pharmacist’s Role (CP perception of patient and provider)	“…I believe we can play a critical role in lowering the overall healthcare costs of patients, but it must be recognized by other healthcare providers to get buy-in and it must be known to the public so that they can take advantage of it. We can do it one at a time when the patient comes up to the counter or when we look for opportunities, but if the patient doesn’t know then they won’t know to ask for it.” [Pharmacist 11] “…the public perception of pharmacy. You have major players in the retail field pushing for the “mcdonaldization” of pharmacy, so that is the kind of service people expect. In order to convince patients to sit down and take the time to meet with pharmacists, it would definitely be helpful if other members of the healthcare team referred patients to us, like doctors and nurses. I’ve spoken to other providers about this and they think it’s an okay idea but they don’t see so much value that they push their patients to do that.” [Pharmacist 3]
Need for Marketing pharmacy care services	“First thing is to find a person who can relay our story to patient, payer, and PBM, even though PBM is not listening. Historically, pharmacists are not comfortable about all their accomplishments and what they can do. We do things to help people and do not tell the whole story. If we do not tell people about what we do, it does not matter. If I had unlimited resources, I would hire a consultant to relay the pharmacies’ story to everyone – ACOs, law makers. I want someone to market their services to help move the needle forward” [Pharmacist 3] “The public is undereducated on the pharmacist’s role, what they can provide.” [Pharmacist 7]
Advocating for the Pharmacy Profession	“Getting involved in the profession and advocacy also leads to changes in legislation which can improve our practice of pharmacy.” [Pharmacist 10] “While healthcare dollars and spending continues to increase, it’s not the pharmacy making the money but the PBMs that are profiting. Until pharmacy is able to get provider status and be given a little bit more liberty legislatively to show what we can do with POC testing and other things, there really isn’t a desire for product reimbursement.” [Pharmacist 6]
Prioritizing Patient Care	“I think the personal service, taking time out and speaking to them [patients], answering all their questions and having them get a good grasp of what is going on with their medication regimen. Again the educational component is probably the thing they value the most. Also being able to know them on a personal level, it makes them feel comfortable with us. I think that goes a long way as opposed to the far other extreme of something like a mail order pharmacy where they [patients] don’t know any of the pharmacists, they probably get a different person every time they call—if they can even get through to a pharmacist in a timely fashion. I think just being available to them, being a familiar face, that type of this is what they [patients] would value the most.” [Pharmacist 8] “…[allows] us to provide these services and provide that quality of care that I strive for. Improving patient care has always been a priority.” [Pharmacist 1]
Reimbursement Models
Unsustainable Current Reimbursement Model	“...it costs money to do these programs. We’re trying to do that to maximize our clinical effectiveness and hopefully get reimbursed for our services, not through PBMs but through other avenues. It might be a last-ditch effort to do as much as we can to make us more valuable.” [Pharmacist 4] “Reimbursement, there’s only so much you can do for free. Pharmacists aren’t cheap, and our time is very scarce. So, it’s disappointing when they don’t get paid for their time.” [Pharmacist 7]
Current Progressive Models	“I’ve heard of pharmacies receiving grants, which would be a huge benefit. We were in a blood pressure one which provided a fair amount of money for pharmacist’s assistance. Any government-funded programs or initiative where there is proper reimbursement for a pharmacist’s time would be some resources that we would be interested in.” [Pharmacist 8] “Even though you can’t classify our business as nonprofit, our goal is to help patients in our neighborhood and I should explore this avenue to see if organizations are willing to help pharmacies like mine through grant money to improve patient outcomes and services.” [Pharmacist 1]
Future Progressive Models	“Another thing is to get more contracts through CPESN and push those enhanced services and build a medical side of the healthcare pie for the services that pharmacists provide.” [Pharmacist 1] “Resources such as CPESN have been fantastic. I’ve learned so much about enhanced services and engaging payers and understanding how payers look at things such as services and how they pay for things such as extra services. Since CPESN, we’ve had a great education into the other side of what we do as pharmacists - the payment world that the PBMs and insurance folks are in.” [Pharmacist 2]
Provision of Patient Care Services
Barriers	“Definitely cost. Reimbursements keep on bringing down our abilities to bring on new services.” [Pharmacist 2] “I’m trying to get more involved through organizations and programs like CPESN, prescribe wellness. They have platforms for integrating data through our pharmacy software systems to help increase star ratings. The problem is that they have tools to help, but everything’s an additional cost.” [Pharmacist 4]
Operational Concerns	“Probably number one would be staffing and time. That would probably be the biggest issue. A lot of these things take time, and time is money when it comes to staffing.” [Pharmacist 8] “Home delivery you encounter barriers every day because if we don’t establish policies around if a patient doesn’t answer the phone and we don’t have a safe place to leave medication, like we may have 30 or 40 deliveries per day that go to tenant buildings. So patients need to be home and that’s a challenge. Delivery business is always a challenge because you want to make sure you get the patient what they need when they need it but if they make it difficult for you, that’s a barrier. You can’t afford to send a driver to a place more than once in a day because it’s just not economically feasible. [PBMs are] not paying for delivery.” [Pharmacist 11]
Opportunities	“Having access to EMRs. We have one office that does that with us. It’s limited so that we can access labs in their EMR. I think partnering with technology companies to allow us to see some of that information and having provider’s offices see the value in that. It would cut down on some of the phone calls and questions we ask the office. It would allow us to run more thorough MTMs, CMR, identify gap therapy. There would be better communication between the primary care provider and the pharmacy, we both would benefit.” [Pharmacist 6] “We are perfectly positioned to be that go between in transitions of care, which is becoming a standard of care from a CMS standpoint. There is a significant revenue stream for primary care if they see patient within 7 days of discharge and 55% of hospital readmission are drug related which puts pharmacists in a perfect position to help with this role and hopefully get reimbursed.” [Pharmacist 10]
Quantifiable Outcomes	“The third service would be our asthma therapy and helping patients with this. This is a huge financial opportunity especially because we created a partnership with The American Lung Association. We provide peak flow and spacers for asthma patients so we can monitor their results and ensure they are using their inhalers properly. This can also help predict their exacerbations and help keep our patients healthier and track statistics to see how we are improving patient health.” [Pharmacist 10] “When we put patients on med sync and furthermore the adherence packaging, their PDC almost immediately goes to 100% with some outliers like discontinuation of meds, increase or decrease in dose, and it gets hard to compute the PDC at that point because you get some blurred lines around therapies like changes in therapies from one statin to another or one oral hypoglycemic to another and things such as that.” [Pharmacist 11]
Perceived value of Patient Care Services	“We had a patient on blister packaging who went down from mid-8 to mid-6 HgA1c score. The patient was on a ton of medications and was taking the medications all wrong prior to the blister packaging. With counseling and education on how to use the blister packaging, the patient was able to see the 2-point drop in HgA1c.” [Pharmacist 5] “Then with medication synchronization, some barriers are that you have patients that understand it or say they understand it then you implement it and before you know it 4 months goes by and you find out that they’re stock piling medication because they’re not taking it properly. Months into this they realize they have all this extra medication and they tell us to stop sending it to them. That was a barrier that pushed that patient into medication adherence packaging because we realized that even though we were filling the medication and PDC scores were going up, the patient wasn’t necessarily adherent or compliant to their medication schedule. That was a barrier at first, and pushes folks into the adherence packaging which forces them to become more compliant with their schedules.” [Pharmacist 11]
Social Determinants of Health
Personalized Approach	“The fact that we really incorporate them into their own care, with our med sync program they get multiple phone calls from pharmacy. I think they really feel that we are really looking out for them as far as their overall health and wellbeing. They get at least 3 phone calls a month from us, a consultation with the pharmacist to reinforce how important each medication is. They just really feel empowered themselves.” [Pharmacist 6] “Some patients are proud and don’t want help or anything that might be perceived as charity. You need to develop a relationship with a patient before you ask them if they want to try a program. I assume that my patient is going to need to utilize the services that I offer, but if I think they are that type of person I dial it back.” [Pharmacist 1]
Patient Barriers to Care	“We offer charge accounts for patients living check to check can pick up their prescriptions at any time during the month then pay at the end of the month. This doesn’t seem like an enhanced service because we have been doing it for so long, but it is.” [Pharmacist 1] “We tried pushing for compliance packaging but a big barrier to healthcare among underserved populations is low health literacy. A lot of patients don’t understand that they need to be constantly treating their chronic disease states, they can’t just take a few things and be done with it. It’s just really difficult to shake those misconceptions. It needs a coordinated effort from all members of the healthcare team.” [Pharmacist 2]
Pharmacy PCS Solutions	“The compliance (adherence) packaging definitely helps many of my patients. I had a patient who went from completely non-compliant and unreliable to compliant enough where their liver specialists decided to put them on treatment for Hep C and now they’re cured of Hep C.” [Pharmacist 2] “Our diet program has done more than anything. We had a patient who was a type 2 diabetic on an insulin pump. She’s been on our wellness program for about 4 months and they just turned off her insulin. She’s needs no insulin, not on any diabetic meds right now, and is just controlling it with diet. We had patients with sugars around 300 that we got controlled. Our goal with the wellness program is not so much the weight loss but to cut back on patient’s meds.” [Pharmacist 5]

Abb. ACO, Accountable Care Organization; CP, Community Pharmacist; CMR, Comprehensive medication review; CMS, Centers for Medicaid and Medicare services; CPESN, Community Pharmacy Enhanced Service Network; EMR, Electronic Medical Record; Hep C, Hepatitis-C; HgA1c, hemoglobin A1c; Med sync, Medication Synchronization; MTM, Medication therapy management; PBM, Pharmacy Benefit Manager; PDC, Proportion of Days Covered; PCS, Patient Care Services.