Cost Analysis of Telepharmacy Programs for Diabetes Mellitus Patients at Pharmacy

Diabetes mellitus is silent killer with an increasing prevalence every year. This study aims to analyze the cost of telepharmacy services among patients with diabetes mellitus at the pharmacy using the ABC method of observational research calculated based on the activities carried out and BEP to determine the advantages and disadvantages of the pharmacy. The calculation results using the activity-based costing (ABC) method, the average cost for telepharmacy service costs was Rp. 12,612.- and the average cost incurred to run a telepharmacy services program were Rp. 124,574.- After being analyzed the pharmacy that have provided telepharmacy services, most of them still experience losses, this is because pharmacy have not been able to cover all operational costs.


Background
Diabetes mellitus is a long-term condition that has an impact on severe morbidity and death.(Bunga, 2017) The prevalence in 2021 is estimated at 10.5% and will continue to increase to 12.2% in 2045.(Cousin et al., 2022) Indonesia is ranked 7th out of 10 countries with the most sufferers of 10.7 million and Indonesia is the only Southeast Asian country that has a major contribution to the prevalence of diabetes mellitus.(Dayan et al., 2021) Treatment of diabetes mellitus has a variety of therapies with the aim of controlling blood sugar levels, including HbA1c.(Eberle and Stichling, 2021) The success of diabetes therapy is influenced by many things, one of which is adherence.(Eze, Mateus and Cravo Oliveira Hashiguchi, 2020) Nonadherence can thwart therapy which indirectly worsens the patient's condition slowly which causes no effect of therapy and can increase the risk of complications.(Insani et al., 2013;Iftinan, Wathoni and Lestari, 2021) One alternative to increase adherence in patients with diabetes mellitus is the telepharmacy program in the therapy of diabetes mellitus.(Kementriankesehatan republik indonesia, 2020) The success of the telepharmacy program can increase blood sugar levels in diabetics with therapeutic success reaching 17.01% on glucose 2 hours postprandial.(Li et al., 2022) The telepharmacy program is part of telemedicine which refers to the provision of pharmaceutical services by pharmacists to address pharmaceutical service needs.(Martyn, 2006;McManus et al., 2021) The presence of telepharmacy that has a positive impact requires careful initial preparation, especially when preparing for program procurement in pharmacies because the telepharmacy program is regulated in the Regulation of the Minister of Health of the Republic of Indonesia no. 14 of 2021, where this service can be carried out at pharmacies in the form of online retail or marketplaces with special pharmaceutical features.(Permenhub, 2013;Raafi, Saryono and Sari, 2021) So it is necessary to identify the cost components needed to provide tele pharmacy program services with a cost analysis of the program services.

Method
This observational study on community pharmacy managers was conducted using electronic and or direct surveys to the pharmacy managers.This study was performed in both Cilacap Districts (As Salam pharmacies, Barokah Farma, 3S'mart, Arianti Farma Adipala, Adjie Farma Kroya, and Lestari Farma Buntu) and Banyumas District (Kita Farma Kemranjen, and Kimia Farma 133 Purwokerto), Central Java.The survey was completed electronically to collect all the relevant data regarding the telepharmacy services from the pharmacies.The survey was performed from November through December 2021.Eight pharmacy managers, both responsible pharmacist and telepharmacy provider, willing to participate in this study and informed consent was collected from them.The diabetic patients who did not receive telepharmacy services and pharmacists who quit during the trial were excluded.
Primary data including patient name, address, number of patients, number of services, cost of reading prescriptions, credit/internet, advertisements, electronic device sales, and patient medicines were collected.Consulting services and assumption data like retail prices and distance-based transportation charges are also calculated due to the actual value of the costs.The data is calculated using the ABC (Activiy Based Costing) method with the total cost of the activity per total number of services provided, and by calculating the BEP (Break Event Point) to see the advantages and disadvantages of the pharmacy.(Saeedi et al., 2019)

Results and Discussion
Telepharmacy service rates costs incurred by pharmacy to support telepharmacy services are listed in table (1).Based on the table, the average expenditure for telepharmacy services outside of drugs is Rp.124,574,-.The highest expenditure at the Barokah Farma Pharmacy is Rp.433,500 and the lowest Apotek As Salam is Rp.13,957,-, while for telepharmacy services with the highest drug expenditure at Barokah Farma pharmacies of Rp. 926,300,-and the lowest is also at the As Salam pharmacy for Rp.15,746,-.This incurs different costs due to the different needs of each pharmacy because of the more complete the pharmacy operations, hence the higher the costs.(Saibi, Romadhon and Nasir, 2020)  The cost of telepharmacy services to determine the cost of each patient using the activity based costing (ABC) method and the results of this calculation obtained data on the cost of telepharmacy services that must be paid for each patient in the table 2. The highest drug-free service rate at Apotek 3 S'mart is Rp.30,470,-and the lowest rate was at the Kita Farma pharmacy without drugs for Rp.5,326,-Service with medicine for Rp.60,117,-at Lestari Farma pharmacy and services with drugs for Rp.7,251,-at Kita Farma.The cost of consulting services showed on table 3 with the highest was Rp. 10,000,-at the Apotek 3 S'mart and the lowest was Rp. 250,-at the Arianti Farma pharmacy.For determining the cost of pharmacist consulting services based on the characteristics of the patient.(Sen, 2021)  Pharmacies were said to be profitable if the income is greater than the capital issued and vice versa.Table 1 pharmacy that benefits Adji Farma pharmacies of Rp. 34,377, -and Apotek Kita Farma for Rp.68,830,-.The biggest profit is obtained from drug profits and drug delivery costs.Meanwhile, other pharmacies do not carry out drug delivery activities so that profits can only be obtained from reading prescriptions, services and drugs.Therefore, to increase revenue, it would be better if in this service drug delivery activities were carried out.In addition to increasing income, it will also make it easier for patients.(Sun et al., 2019(Sun et al., , 2022) )  A BEP (Break Event Point) calculation is carried out for pharmacies that do not experience losses, this is done so that at least the pharmacy must get income according to expenses and to determine the target number of patients so that the amount of income is at least proportional to the amount of expenditure.BEP without drugs has the highest value in Lestari Farma pharmacy at IDR. 1.232,-this is because the cost of the pharmacy was very small so it takes a lot of services to cover all operational costs.
Pharmacies that show negative results are due to the negative service contribution margin so that these services do not help drive an increase in total revenue because they do not set special rates for telepharmacy services.Profits are only obtained from the sale of drugs, so that pharmaceutical services cannot cover the operational costs of telepharmacy services, therefore pharmacies are still experiencing losses.(Syafrawati, 2017;Tahhan et al., 2020) The effectiveness of telepharmacy services in patients receiving telepharmacy services has a change in HbA1c with an average of -1.14%, while in the group receiving services at diabetes clinics it is 0.88% and in patients receiving services in primary care = 0, 21% (p=0.061).As many as 43.75% of patients with telepharmacy intervention experienced a decrease in HbA1c, in the diabetes clinic group as many as 35.71% patients experienced a decrease and in primary care it decreased by 26.09% (p=0.51).Based on these studies, it can be concluded that telepharmacy services can reduce HbA1c levels in diabetic patients.(Wifaaq U. Putri, 2018;Zhang, 2021)

Conclusion
The average cost of telepharmacy services at pharmacies is Rp.12,612,-.Most of the pharmacies that run telepharmacy programs have not benefited from telepharmacy services for diabetic patients.Because it has not been able to cover the capital issued.To cover the capital costs, these pharmacies must provide an average of 115 services in 1 month.

Table 1 .
Pharmacy Operational Costs

Table 2 .
Telepharmacy service cost for each patient

Table 3 .
Cost for consulting services

Table 4 .
Break Even Point