Objective: To provide descriptions of existing remuneration models for pharmacist clinical care services and to summarize the existing evaluations of economic, clinical, and humanistic outcome studies of the remuneration models. Methods: We searched MEDLINE, EMBASE, International Pharmaceutical Abstracts, EconLit, Scopus, Web of Science, Google Scholar, and PubMed from date of inception to June 2006. We also searched the World Wide Web, hand-searched pertinent journals and reference lists, and contacted experts in pharmacy practice research. One reviewer assessed titles and, with a second independent reviewer, assessed abstracts and full-text articles for inclusion and abstracted data. Disagreements were resolved by discussion or by a third independent reviewer. We included English language articles that described or evaluated current remuneration systems for pharmacist clinical care services and that involved a substantial number of pharmacists and that were paid by a third party other than the patient. Due to heterogeneity between systems, data were compiled qualitatively. Then, based on these results, an expert panel developed recommendations for implementing a remuneration model into current pharmacy practice in Alberta. Results: We identified 28 remuneration systems. Most commonly, payers were government agencies, and services were directed at the management of chronic diseases or complex medication regimens. While capitation models were evident, most systems provided payment according to each intervention carried out. Program evaluations were available from 14 models, and in many systems, initial uptake by pharmacists was high, but participation dropped after initial enrolment. Conclusion: To ensure that the provision of clinical care services will provide a sustainable avenue of income for pharmacists and costeffective quality care for patients, a viable business model with additional training and support for pharmacists and ongoing program evaluation is needed.

Background: Several practice models have been developed to support pharmacists in providing chronic disease management. However, most of these models have not been readily accepted by pharmacists, which has led to low uptake and short-term change. Methods: Pharmacists were recruited to participate in focus groups held in Alberta and British Columbia. Qualitative methodologies involving a phenomenological approach with content analysis were used to gather and analyze information. Results: In total, 36 pharmacists participated in 8 focus groups. Analysis of their discussions revealed 4 main themes: the current practice environment and the need for education about, remuneration for and a plan for the implementation of chronic disease management services. Participants cited several challenges to the provision of this type of care, as experienced in the current practice environment: time constraints; relationships with physicians, patients and employers; limited access to clinical information; and absence of a model for chronic disease management in pharmacy practice. However, these perceptions were not universal, and pharmacists with experience in this area described some of these commonly cited “challenges” (e.g., relationships with physicians) as enablers in their own practices. In addition, staff pharmacists, regional managers and owners often had differing opinions about the key challenges and the role of remuneration. Conclusion: Some of the perceived challenges to providing chronic disease management described by staff pharmacists were not consistently supported by employers or those with experience in this practice area. This observation suggests that the greatest challenge to developing a successful model of chronic disease management for pharmacists lies in pharmacists' own perceptions about their relationships with other health care providers and their own role as health care professionals. These issues must be addressed if the practice of pharmacy is to move forward.

Background: The need for alternative methods of providing primary care and chronic disease management (CDM) is becoming more urgent. To understand pharmacists' role in this changing health care system, we must better understand their desire and capacity to provide these services. Methods: Key stakeholders from all facets of pharmacy practice were recruited to participate in focus groups held in Alberta and British Columbia. Qualitative methodologies involving a phenomenological approach with content analysis were used to gather and analyze information. Results: In total, 36 pharmacists participated in 8 focus groups to identify enablers and challenges to the provision of CDM (reported in Part I). The topic of how such services could be implemented in the community developed naturally from these discussions. Participants expressed a need for changes to both the physical layout of pharmacies (to incorporate private counselling spaces) and the documentation and information systems used (to improve communication and continuity of care). Furthermore, the intentions of both pharmacists and employers must be communicated effectively to all parties, including patients. Participants also identified an alternative remuneration model as being essential, to allow adequate time for provision of CDM services and to ensure that current high-quality dispensing practices can be continued. Conclusion: Pharmacists have a tremendous opportunity to change practice and to contribute more to patient care. To guide and implement such change will require that pharmacists restructure their physical and information environments, strengthen their relationships with key stakeholders and develop a sustainable model of practice that includes the needs of the business, the client (patient) and the pharmacist.

Public drug programs in Canada are increasingly implementing cost management strategies. A multidisciplinary review of these strategies--specifically, the special authorization (SA) process--found that implementation of the SA practice is costly and causes inequity in access, underutilization, and delays in treatment for urgently required therapies, all potentially leading to negative health outcomes. We present potential solutions and a set of recommendations for decision-makers to base reimbursement decisions on the best clinical evidence, eliminate regional variability in access, ensure timely access to urgently required treatments, and monitor the impact of reimbursement policies on health outcomes.

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