Clinical pharmacy practice must support its practitioners-otherwise it is not worth practicing
By Ignatius J. Bellafiore, Professional Fees Michael A. Barletta and Andrew J . Bartilupci for Clinical Pharmacy Services
Over the past decade clinical pharmacists have developed a variety of patient-oriented services which contribute to better patient care beyond the traditional services of dispensing. 1- 3 These services are expected to give the pharmacist full professional acceptance on the health team. They are judgmental activities intellectually superior to previous product-oriented contributions.
he delivers a completed prescription product. There is a strong movement for the use of pharmacy technicians to separate the manipulative procedures of dispensing prescriptions from the judgmental or clinical functions of the pharmacist, but there is little accompanying movement to seek payment fOT the latter separately from payment for 'prOduct cost and separately from manipulative activities. Clinical services . like any other services cost money. "Unle·ss we can be compensated for what we do, there is no possible way we can provide these benefits," says White, 4 the pioneer of the office practice of pharmacy. The profession has made little effort to discuss the costs of these services and what would be a suitable fee for them. Rubin 5 pOints out that third-party payment insurers are unlikely to add reimbursement for clinical services to their current payment systems. Some groups whose "prescription benefit programs" are administered by Paid Prescriptions 6 endorse extra services such as the family record system by adding 10 cents to 25 cents to the professional fee for the pharmacies that provide these services. In a pharmacy where 100 prescriptions are dispensed daily, if 25 percent of the prescriptions are reimbursed by Paid Prescriptions under this plan, an extra 10 cents amounts to a return of $2.50 per day. In a pilot pro-
Clinical Services in Community Pharmacy Clinical activities are well organized in hospital pharmacy and there the cost of supplying these services becomes part of the general overhead of the hospital. Since improved patient care is an end in itself, there is no urgent impetus to place a direct monetary value on the cost of supplying clinical services in the hospital. Nonetheless, if clinical pharmacy is to achieve full professional stature, it is necessary for the pharmacist to have his contributions recognized by a system of fees similar to the fees already developed by other highly esteemed health professions. Without such a fee system clinical pharmacy will be economically weak, perhaps unconvinced of the value of its own efforts. In addition, a fee system will have the desirable effect of encouraging community pharmacists to enter more enthusiastically into clinical activities. Clinical services in community practices, as yet, have barely begun to emerge. To laymen in general, community pharmacy is the most visible part of the profession of pharmacy, yet it has not been strongly identified as a professional activity because it is practiced in a commercial atmosphere. The validity of a professional fee system for community pharmacy's prescription services is questioned by the public especially when it sees chain drugstores conspicuously advertising a non-fee system in pricing their prescriptions. Further, "crusading" newspapers and governmental agencies advise the public to shop for the lowest price when choosing a pharmacy to supply prescription needs. Clinical activities are a new area of practice for pharmacists yet they are still largely tied to the dispensing function. They are still largely built around the prescription order and the prescription product. A pharmacist fills out a profile card if and when a new patient presents a prescription order. He checks out drug interactions in terms of new prescriptions. He advises patients concerning proper use of medication and improved health care when
Vol. NS 16, No. 3, March 1976
gram of Paid Prescriptions in Spokane, Washington,7 pharmacies are offered $3.00 for each prescription order not dispensed due to an adverse drug reaction discovered by the pharmacist. A survey by Gagnon B found that 92 percent of the public favors a family record service if it costs them nothing, but 63 percent would not if it cost 25 cents per prescription. A hospital pharmacist with a PharmD spent "a large amount" of his own time researching the literature to successfully discover the reason for a patient's progressively serious deterioration under his physician's drug regimen. 9 His request for a "pharmacy consultation fee" from Blue Shield was refused payment with a definite "no"! 'Separation From Product-Oriented Activities Clinical activities are performed directly for the patient or the physician. If these activities are to win respect of patrons they should be clearly separated from the product-oriented activities which pharmacy technicians can handle. Clinical fees, separately recorded and reimbursed, like the fees of other health professions, should be ba.sed on competence, experience, stature and education, and they should be graduated according to the level of difficulty of each activity and the amount of time the particular activity requires.
Ignatius J. Bellafiore
Ignatius J. Bellafiore, MA, is professor of pharmacy at St. John's University college of pharmacy and allied health professions. He graduated from that school in 1935 and began teaching there in 1936. Bellafiore is a life member of APhA, and a member of AACP, The Pharmaceutical Society of the State of New York, Rho Chi, Phi Delta Chi and Rho Pi Phi. He is the author of Pharmaceutical Calculation as well as many professional and scientific papers.
Andrew J. Bartilucci
Andrew J. Bartilucci, PhD, is dean and professor of pharmaceutics, and director of the Pharmaceutical Services Institute at St. John's University college of pharmacy and allied health professions. He is a graduate of St. John's, Rutgers University and University of Maryland. His professional affiliations include APhA, ASHP, ACA, NARD, AAAS, the New York Academy of Sciences and the Pharmaceutical Society of the State of New York. Bartilucci also serves as pharmacy consultant to the New York City Veterans Administration Hospital.
Michael A. Barletta
Michael A. Barletta, PhD, is assistant professor of pharmacology at St. John's University college of pharmacy and allied health professions . He earned his BS in pharmacy and MS in pharmacology at St. John 's, and his PhD in pharmacology at New York Medical College . Barletta is a member of APhA, AAAS and the American College of Clinical Pharmacology.
135
Professional Fees for Clinical Pharmacy Services
They should recognize the extensive knowledge required to make a difficult decision in a complex problem that seriously affects human well-being. Peer pressure in professions tends to hold fees at a high level-higher fees generally accompanying higher professional status-but the practitioner sets his own fees which his patrons are free to accept or reject. Clinical pharmacy is a full-time activity requiring full-time attention . Whether in the hospital or in the community pharmacy, it is clearly separate from the dispensing activities of pharmacy technicians . This patient-oriented disease-oriented pharmacy practice requires a high level of intellectual capacity, the ability to identify problems and to develop desirable solutions . Some of the vital elements of the new clinical services that are completely making over the practice of pharmacy in the community and in the institution are-Making rounds in an institution -Consulting with the physician face-toface or over the phone -Reviewing a patient 's progress whether in the patient 's home or in an institution -Evaluating a diagnosis -Following a course of drug therapy, modifying dosage, recognizing drug toxicity and drug reactions - Selecting drug products -Improving the use of drugs -Making an extensive search of the medical literature -Offering educational services to the public and to health professionals -Relating medical laboratory tests to both
diagnosis and drug use -Preventing interactions -Compiling a drug history -Using a patient profile system Ladinsky 10 describes the pharmacist as "the most educated person in the health field next to the doctor." This high level of education enters into the development of a fee system for the pharmacist's clinical services. At current salary rates, a dispensing pharmacist earns a salary of about $17, 000 per year 11 for what clinical pharmacists call "counting and pouring." A clinical pharmacist practicing the higher intellectual activities indicated above should earn much more than that. He has greater responsibility, he must study constantly, he must invest in and master expensive informational services, he must subscribe to many professional journals and maintain an extensive professional library. His earnings should approach those of other learned health professionals . He should have suitable fees for each service with impressive minimum fees and the fees should be scaled upward according to the specific service rendered. Compounding and dispensing fees have always been modest compared to the fees of other health professions. Several authors 12- 15 attribute this to the fact that the fees have been related to product costs rather than to the costs of services added to the product. Clinical pharmacy is no longer concerned with products, only services, so its fees should be based purely on services. In the past, the pharmacist was unable to survive by his professional
Location of Pharmacies (Continued from page 134) Danish example mentioned, consideration would have to be given to individual costrelated pricing systems, the use of a uniform cost accounting schedule, negotiation as is done in the United Kingdom by a pharmacy group-the Chemists Contractors ' Committee . Whatever the method .employed, it is increasingly obvious that certificate-of-need legislation is only the first step of many . steps required to rationalize pharmacy location , pricing service complement and pricing . Additional thought and research must be directed towards the issues of administrative feasibility-the number of levels of government involved, definitions of acceptable profit, manpower supplies, colleges of pharmacy, the use of paraprofessionals and the long-term impact upon the
health care delivery system's ability to optimally serve the patient. Certificate-of-need type regulation could have positive impact on the practice of medicine and pharmacy by correcting the alleged present locational imbalance . In pharmacy, it can make colleagues out of competitors and bring services to persons in poor, rural and other underserved areas.
136
•
References 1. Elsasser, P.J., and Galinski, T.P .. " Certificate of Need: Status of State Legislati on," Hospitals, JAHA , 45 (2), 54 (Dec . 16, 1971) 2. Roseman, C., " Problems and Prospects for Comprehen. sive Health Planning, " Am. J. Public Health, 62 ( I ), 16 (Jan. 1972) 3. Havighurst, C.C., " Regulation of Health Faci lities and Services by 'Certifi cate of Need,' .. Va. Law Review, S9 (7), 1143 (Oct. 1973) 4 . Cohen, H., " Regulating Health Care Facilities: The Certif· icate of Need Process Re-examined." Inquiry, 10, 3 (Sept. 1973) 5. Gottlieb, S .. "Certi fication of Need: Potential Threat to Planning," Hospita ls, JA HA, 45, 51, (Dec. 16, 197 1)
income alone because it was too modest to support him. If clinical pharmacy still has the same drawback with 1a-cent, 25cent and $3 .00 fees , it will have no more attraction for practitioners than traditional pharmacy and it will achieve no greater level of prestige with the public and the other health professions . Clinical pharmacy practice must support its practitioners-otherwise it is not worth practicing . It performs a vital service and therefore it deserves a professional level of remuneration . •
References 1. Tyler, V., "Clinica l Pharmacy: The Need and an Evaluation of the Professional Concept," Am. J. Pharm. Educ .. 32,764 (Dec . 1968) 2. " Report of the Task Force on the Pharmacist's Clinical Role. " JAPhA , NS11 , 48 2 (Sept. 197 1) 3. Campbell , R.K .. " Student Pre· and Post-Evaluation of an Off·Campus Clinica l Clerkship," Am. J. P.~arm. Educ., 39,241 (Aug . 1975) 4 . White, E.V .. " Pills, Prunes and Perils, " JAPhA , NS15, 154 (March 1975) 5. Rubin, 1.. " Rx Services: You 'll Have to Decide - Soon! " editorial, Pharmacy Times, 40 (12),31 (Dec . 1974) 6. Personal communicat ion, Kaplan, J. (Sept. 25, 1975) 7. Campbell, R.K ., " The Implementation and Monitoring of Patient Re cords," Wash . Pharm .. 16 (I), 18 (Jan. 1974) 8. Gagnon, J.P., Linkup, (NACDS), 2 (3), 3 ( 1974) 9. Personal communication , Sisca, T.S . (Sept. 26, 1975) 10. Ladinsky. J., " Professionalism and Pharmacy Education in the Contemporary Period," Am. J. Pharm. Educ., 38, 684 (Dec . 1974 ) 11 . The Green Sheet, 24 (9), 1 (March 3,1975) 12. Provost. G.P .. " The Capitation System for Pharmaceutical Services." editorial. Am. J. Hosp. Pharm., 30, 493 (June 1973) 13. Wertheimer, A. I. , " The Retainer Fee Concept Applied to Pharmacy," Am. J. Pharm .. 144, 143 (Sept . 1972) 14 . Knapp. D .. in Evolutionary PaNerns in Pharmacy Practice. p. 4, reprint from the Wisc . Pharm. 43, (9) (Sept. 1974) 15. The Green Sheet, 24 (3). 3 (Jan. 20, 1975)
6. Curran, W .J., " A Severe Blow to Hospital Planning: Certificate of Need Declared Unconstitutional, " N. Engl. J. Moo., 228 (1 4),723 (April 5, 1973) 7. Stuehler, G., " Certification of Need-A Systems Analysis of Maryland 's Experience and Plan s," Am. J. Public Health, 63 (1 1), 966 (Nov. 1973) 8. Calvo, A.B., and Marks, D.H., " Location of Health Care Facilities: An Analytical Approach," Socioeconomic Planning Science, 7, 407 (Oct. 1973) 9. Havighurst, C.C .• Public Utility Regutation for Hospitals, Ameri can Enterprise Institute , Washington. D.C. (Aug. 1973) 10. Anonymous, "Certificate of Need Program ," N. Engl. J. Moo., 287 (6), 307 (Aug. 10, 1972) 11. Anonymous, Health Care Facility Franchising Laws: Revie w and Analysis, Ernst and Ernst for the Health Services and Mental Health Administration, Rockville , Md. (Oct. 1970) 12. Anonymous, " Education Costs," Med. Care Rev., 31 (4), 459 (April 1974) 13. Johnson, R.E., personal communicati on (Feb. 12, 197 4) 14. Foreign data were supplied by the individual ministries of health concerned 15. Petition to California State Board of Pharmacy. from Pharmacy Surviva l, to request investigation of practices of pharmacies and to stay issuance of new pharmacy licenses, San Rafael , Calif .. Feb. 20, 1974 16. Bloomfield, J.C., Study of General Practice Pharmacy, Federation Internationale Pharmaceutique. The Hague ( 1974)
Journal of the American Pharm aceut ica l Association
By Ignatius J. Bellafiore, Professional Fees Michael A. Barletta and Andrew J . Bartilupci for Clinical Pharmacy Services
Over the past decade clinical pharmacists have developed a variety of patient-oriented services which contribute to better patient care beyond the traditional services of dispensing. 1- 3 These services are expected to give the pharmacist full professional acceptance on the health team. They are judgmental activities intellectually superior to previous product-oriented contributions.
he delivers a completed prescription product. There is a strong movement for the use of pharmacy technicians to separate the manipulative procedures of dispensing prescriptions from the judgmental or clinical functions of the pharmacist, but there is little accompanying movement to seek payment fOT the latter separately from payment for 'prOduct cost and separately from manipulative activities. Clinical services . like any other services cost money. "Unle·ss we can be compensated for what we do, there is no possible way we can provide these benefits," says White, 4 the pioneer of the office practice of pharmacy. The profession has made little effort to discuss the costs of these services and what would be a suitable fee for them. Rubin 5 pOints out that third-party payment insurers are unlikely to add reimbursement for clinical services to their current payment systems. Some groups whose "prescription benefit programs" are administered by Paid Prescriptions 6 endorse extra services such as the family record system by adding 10 cents to 25 cents to the professional fee for the pharmacies that provide these services. In a pharmacy where 100 prescriptions are dispensed daily, if 25 percent of the prescriptions are reimbursed by Paid Prescriptions under this plan, an extra 10 cents amounts to a return of $2.50 per day. In a pilot pro-
Clinical Services in Community Pharmacy Clinical activities are well organized in hospital pharmacy and there the cost of supplying these services becomes part of the general overhead of the hospital. Since improved patient care is an end in itself, there is no urgent impetus to place a direct monetary value on the cost of supplying clinical services in the hospital. Nonetheless, if clinical pharmacy is to achieve full professional stature, it is necessary for the pharmacist to have his contributions recognized by a system of fees similar to the fees already developed by other highly esteemed health professions. Without such a fee system clinical pharmacy will be economically weak, perhaps unconvinced of the value of its own efforts. In addition, a fee system will have the desirable effect of encouraging community pharmacists to enter more enthusiastically into clinical activities. Clinical services in community practices, as yet, have barely begun to emerge. To laymen in general, community pharmacy is the most visible part of the profession of pharmacy, yet it has not been strongly identified as a professional activity because it is practiced in a commercial atmosphere. The validity of a professional fee system for community pharmacy's prescription services is questioned by the public especially when it sees chain drugstores conspicuously advertising a non-fee system in pricing their prescriptions. Further, "crusading" newspapers and governmental agencies advise the public to shop for the lowest price when choosing a pharmacy to supply prescription needs. Clinical activities are a new area of practice for pharmacists yet they are still largely tied to the dispensing function. They are still largely built around the prescription order and the prescription product. A pharmacist fills out a profile card if and when a new patient presents a prescription order. He checks out drug interactions in terms of new prescriptions. He advises patients concerning proper use of medication and improved health care when
Vol. NS 16, No. 3, March 1976
gram of Paid Prescriptions in Spokane, Washington,7 pharmacies are offered $3.00 for each prescription order not dispensed due to an adverse drug reaction discovered by the pharmacist. A survey by Gagnon B found that 92 percent of the public favors a family record service if it costs them nothing, but 63 percent would not if it cost 25 cents per prescription. A hospital pharmacist with a PharmD spent "a large amount" of his own time researching the literature to successfully discover the reason for a patient's progressively serious deterioration under his physician's drug regimen. 9 His request for a "pharmacy consultation fee" from Blue Shield was refused payment with a definite "no"! 'Separation From Product-Oriented Activities Clinical activities are performed directly for the patient or the physician. If these activities are to win respect of patrons they should be clearly separated from the product-oriented activities which pharmacy technicians can handle. Clinical fees, separately recorded and reimbursed, like the fees of other health professions, should be ba.sed on competence, experience, stature and education, and they should be graduated according to the level of difficulty of each activity and the amount of time the particular activity requires.
Ignatius J. Bellafiore
Ignatius J. Bellafiore, MA, is professor of pharmacy at St. John's University college of pharmacy and allied health professions. He graduated from that school in 1935 and began teaching there in 1936. Bellafiore is a life member of APhA, and a member of AACP, The Pharmaceutical Society of the State of New York, Rho Chi, Phi Delta Chi and Rho Pi Phi. He is the author of Pharmaceutical Calculation as well as many professional and scientific papers.
Andrew J. Bartilucci
Andrew J. Bartilucci, PhD, is dean and professor of pharmaceutics, and director of the Pharmaceutical Services Institute at St. John's University college of pharmacy and allied health professions. He is a graduate of St. John's, Rutgers University and University of Maryland. His professional affiliations include APhA, ASHP, ACA, NARD, AAAS, the New York Academy of Sciences and the Pharmaceutical Society of the State of New York. Bartilucci also serves as pharmacy consultant to the New York City Veterans Administration Hospital.
Michael A. Barletta
Michael A. Barletta, PhD, is assistant professor of pharmacology at St. John's University college of pharmacy and allied health professions . He earned his BS in pharmacy and MS in pharmacology at St. John 's, and his PhD in pharmacology at New York Medical College . Barletta is a member of APhA, AAAS and the American College of Clinical Pharmacology.
135
Professional Fees for Clinical Pharmacy Services
They should recognize the extensive knowledge required to make a difficult decision in a complex problem that seriously affects human well-being. Peer pressure in professions tends to hold fees at a high level-higher fees generally accompanying higher professional status-but the practitioner sets his own fees which his patrons are free to accept or reject. Clinical pharmacy is a full-time activity requiring full-time attention . Whether in the hospital or in the community pharmacy, it is clearly separate from the dispensing activities of pharmacy technicians . This patient-oriented disease-oriented pharmacy practice requires a high level of intellectual capacity, the ability to identify problems and to develop desirable solutions . Some of the vital elements of the new clinical services that are completely making over the practice of pharmacy in the community and in the institution are-Making rounds in an institution -Consulting with the physician face-toface or over the phone -Reviewing a patient 's progress whether in the patient 's home or in an institution -Evaluating a diagnosis -Following a course of drug therapy, modifying dosage, recognizing drug toxicity and drug reactions - Selecting drug products -Improving the use of drugs -Making an extensive search of the medical literature -Offering educational services to the public and to health professionals -Relating medical laboratory tests to both
diagnosis and drug use -Preventing interactions -Compiling a drug history -Using a patient profile system Ladinsky 10 describes the pharmacist as "the most educated person in the health field next to the doctor." This high level of education enters into the development of a fee system for the pharmacist's clinical services. At current salary rates, a dispensing pharmacist earns a salary of about $17, 000 per year 11 for what clinical pharmacists call "counting and pouring." A clinical pharmacist practicing the higher intellectual activities indicated above should earn much more than that. He has greater responsibility, he must study constantly, he must invest in and master expensive informational services, he must subscribe to many professional journals and maintain an extensive professional library. His earnings should approach those of other learned health professionals . He should have suitable fees for each service with impressive minimum fees and the fees should be scaled upward according to the specific service rendered. Compounding and dispensing fees have always been modest compared to the fees of other health professions. Several authors 12- 15 attribute this to the fact that the fees have been related to product costs rather than to the costs of services added to the product. Clinical pharmacy is no longer concerned with products, only services, so its fees should be based purely on services. In the past, the pharmacist was unable to survive by his professional
Location of Pharmacies (Continued from page 134) Danish example mentioned, consideration would have to be given to individual costrelated pricing systems, the use of a uniform cost accounting schedule, negotiation as is done in the United Kingdom by a pharmacy group-the Chemists Contractors ' Committee . Whatever the method .employed, it is increasingly obvious that certificate-of-need legislation is only the first step of many . steps required to rationalize pharmacy location , pricing service complement and pricing . Additional thought and research must be directed towards the issues of administrative feasibility-the number of levels of government involved, definitions of acceptable profit, manpower supplies, colleges of pharmacy, the use of paraprofessionals and the long-term impact upon the
health care delivery system's ability to optimally serve the patient. Certificate-of-need type regulation could have positive impact on the practice of medicine and pharmacy by correcting the alleged present locational imbalance . In pharmacy, it can make colleagues out of competitors and bring services to persons in poor, rural and other underserved areas.
136
•
References 1. Elsasser, P.J., and Galinski, T.P .. " Certificate of Need: Status of State Legislati on," Hospitals, JAHA , 45 (2), 54 (Dec . 16, 1971) 2. Roseman, C., " Problems and Prospects for Comprehen. sive Health Planning, " Am. J. Public Health, 62 ( I ), 16 (Jan. 1972) 3. Havighurst, C.C., " Regulation of Health Faci lities and Services by 'Certifi cate of Need,' .. Va. Law Review, S9 (7), 1143 (Oct. 1973) 4 . Cohen, H., " Regulating Health Care Facilities: The Certif· icate of Need Process Re-examined." Inquiry, 10, 3 (Sept. 1973) 5. Gottlieb, S .. "Certi fication of Need: Potential Threat to Planning," Hospita ls, JA HA, 45, 51, (Dec. 16, 197 1)
income alone because it was too modest to support him. If clinical pharmacy still has the same drawback with 1a-cent, 25cent and $3 .00 fees , it will have no more attraction for practitioners than traditional pharmacy and it will achieve no greater level of prestige with the public and the other health professions . Clinical pharmacy practice must support its practitioners-otherwise it is not worth practicing . It performs a vital service and therefore it deserves a professional level of remuneration . •
References 1. Tyler, V., "Clinica l Pharmacy: The Need and an Evaluation of the Professional Concept," Am. J. Pharm. Educ .. 32,764 (Dec . 1968) 2. " Report of the Task Force on the Pharmacist's Clinical Role. " JAPhA , NS11 , 48 2 (Sept. 197 1) 3. Campbell , R.K .. " Student Pre· and Post-Evaluation of an Off·Campus Clinica l Clerkship," Am. J. P.~arm. Educ., 39,241 (Aug . 1975) 4 . White, E.V .. " Pills, Prunes and Perils, " JAPhA , NS15, 154 (March 1975) 5. Rubin, 1.. " Rx Services: You 'll Have to Decide - Soon! " editorial, Pharmacy Times, 40 (12),31 (Dec . 1974) 6. Personal communicat ion, Kaplan, J. (Sept. 25, 1975) 7. Campbell, R.K ., " The Implementation and Monitoring of Patient Re cords," Wash . Pharm .. 16 (I), 18 (Jan. 1974) 8. Gagnon, J.P., Linkup, (NACDS), 2 (3), 3 ( 1974) 9. Personal communication , Sisca, T.S . (Sept. 26, 1975) 10. Ladinsky. J., " Professionalism and Pharmacy Education in the Contemporary Period," Am. J. Pharm. Educ., 38, 684 (Dec . 1974 ) 11 . The Green Sheet, 24 (9), 1 (March 3,1975) 12. Provost. G.P .. " The Capitation System for Pharmaceutical Services." editorial. Am. J. Hosp. Pharm., 30, 493 (June 1973) 13. Wertheimer, A. I. , " The Retainer Fee Concept Applied to Pharmacy," Am. J. Pharm .. 144, 143 (Sept . 1972) 14 . Knapp. D .. in Evolutionary PaNerns in Pharmacy Practice. p. 4, reprint from the Wisc . Pharm. 43, (9) (Sept. 1974) 15. The Green Sheet, 24 (3). 3 (Jan. 20, 1975)
6. Curran, W .J., " A Severe Blow to Hospital Planning: Certificate of Need Declared Unconstitutional, " N. Engl. J. Moo., 228 (1 4),723 (April 5, 1973) 7. Stuehler, G., " Certification of Need-A Systems Analysis of Maryland 's Experience and Plan s," Am. J. Public Health, 63 (1 1), 966 (Nov. 1973) 8. Calvo, A.B., and Marks, D.H., " Location of Health Care Facilities: An Analytical Approach," Socioeconomic Planning Science, 7, 407 (Oct. 1973) 9. Havighurst, C.C .• Public Utility Regutation for Hospitals, Ameri can Enterprise Institute , Washington. D.C. (Aug. 1973) 10. Anonymous, "Certificate of Need Program ," N. Engl. J. Moo., 287 (6), 307 (Aug. 10, 1972) 11. Anonymous, Health Care Facility Franchising Laws: Revie w and Analysis, Ernst and Ernst for the Health Services and Mental Health Administration, Rockville , Md. (Oct. 1970) 12. Anonymous, " Education Costs," Med. Care Rev., 31 (4), 459 (April 1974) 13. Johnson, R.E., personal communicati on (Feb. 12, 197 4) 14. Foreign data were supplied by the individual ministries of health concerned 15. Petition to California State Board of Pharmacy. from Pharmacy Surviva l, to request investigation of practices of pharmacies and to stay issuance of new pharmacy licenses, San Rafael , Calif .. Feb. 20, 1974 16. Bloomfield, J.C., Study of General Practice Pharmacy, Federation Internationale Pharmaceutique. The Hague ( 1974)
Journal of the American Pharm aceut ica l Association
