Increasing the Role of Pharmacists in Patient Care

In the 1970s, a movement was started to allow pharmacists to provide more comprehensive care. Today, many feel the urgency for this to happen has never been greater. With 22 percent fewer general medicine physician graduates in the past 10 years, more medical graduates choosing fields other than primary care, and the addition of tens of millions of Americans who will be required to purchase health insurance in 2014 and beyond under the Affordable Care Act, it is predicted that there will be a dearth of providers to meet the needs of a growing number of insured and aging. But, by expanding pharmacists’ role to be more than drug dispensers, many hope this strain on the healthcare system can be alleviated.

The Need for an Expanded Role

“The days when pharmacists were responsible for merely the physical act of prescriptions has gone the way of rotary dial phones. There is now an expectation that pharmacists have a duty to not only fulfill prescriptions, but to contribute to the overall clinical picture of our patients,” says Amy Ehlers, BS, PharmD, BCPS, director of pharmacy at NuFACTOR Specialty Pharmacy. “Chronic disease care utilizes a large portion of healthcare’s financial and professional resources. Physicians are seeing more patients with less time, and with the increasing amount of information available on the Internet, patients have more expectations and questions. Pharmacists are filling those gaps that are being created. There is a movement in pharmacy toward medication therapy management, which gives pharmacists opportunities to have a comprehensive review of patients’ health and disease states and to address drug, nondrug and lifestyle changes that will give them the best chances of success in managing their diseases.”

Ehlers’ assessment is shared by many in the healthcare system. “I say it’s the 50-year debate that ended just in time!” adds Lucinda Maine, CEO of the American Association of Colleges of Pharmacy (AACP). “Thoughtful people both inside and outside of pharmacy have realized that, as our society ages and we have more chronic disease and more need for medications, we need a new proactive medication management model.”

According to Brian Meyer, director, government affairs at the American Society of Health-System Pharmacists (ASHP), the movement to change the medication management model “began in the late 1990s, when pharmacists were not being chosen to manage outpatient clinics that primarily involved medication therapy as the treatment plan in collaboration with prescribers because the clinics couldn’t bill for their services.” This is unlike other professions, explains Meyer. “For example, anticoagulation clinics were being managed by nurse practitioners since they were recognized by CMS [Centers for Medicare & Medicaid Services] as a provider.”

Pharmacists’ inability to be compensated because they are not yet recognized as a provider by Medicare Part D in the Social Security Act is one of the challenges to expanding the role of these specialists. “One of the impetuses for this push of pharmacists as providers is that hundreds of thousands of pharmacists don’t get paid [for services]. Their pharmacy gets paid, but they don’t,” says Donnie Calhoun, National Community Pharmacists Association (NCPA) president and owner of Golden Springs Pharmacy in Anniston, Ala. “If I have a national provider identification number and someone can identify that I am the one who provided the services, why does my pharmacy get paid but I don’t? Right now, we are only paid for dispensing.”

“Recognizing pharmacists as providers under the Social Security Act would be a huge acknowledgment of the services pharmacists currently provide and allow that role to expand even further,” says Ehlers. Right now, because “the Social Security Act does not recognize pharmacists as healthcare providers, services such as medication therapy management and consultations may not be billed to Medicare. Healthcare professionals such as dieticians, nurse practitioners, physician assistants, nurse midwives and clinical social workers are [recognized], so why not pharmacists?”

In fact, adds Ehlers, “pharmacists have long been the most accessible healthcare professionals and may be the first and last interaction that patients have in the healthcare system. Often, patients speak with their pharmacists regarding a health concern, and if pharmacists are unable to provide a solution, [they] will refer those patients to a provider for further evaluation. If prescriptions are provided, patients will return to those pharmacists. By including pharmacists in the Social Security Act, this will only drive further development of other opportunities in which pharmacists can have a positive impact. We’re not looking to replace the unique services of providers such as physicians, physician assistants or nurse practitioners, but merely to enhance and augment them.”

What Is and Needs to Be Done

Currently, pharmacists work in collaboration in varying degrees with physicians in 46 states.1 For instance, some states have a collaborative effort to administer vaccines such as the flu vaccine, while others don’t allow administration. “There are a few states, notably California and Kentucky, that are seeking revisions in state law. However, recognition in the Social Security Act can stimulate other payers, both public (states) and private, to follow suit,” says Meyer.

The Congressional Budget Office says formalized patient-pharmacist counseling has been shown to produce as much as a 12-to-1 return on investment,2 and the U.S. Surgeon General, Regina Benjamin, has published a letter in support of the report titled Improving Patient and Health System Outcomes through Advanced Pharmacy Practice — A Report to the U.S. Surgeon General, 2011. That report is one of “a number of studies that outline the value of pharmacist-provided patient care services. These include medication reconciliation and transitional care services for patients being discharged from the hospital, helping patients adhere to their medication regimens and, in general, managing patients’ medications for treatment of chronic disease,” says Joseph M. Hill, director, federal legislative affairs at the ASHP.

However, there is only so much money to be had, and adding pharmacists into the mix of providers is being met with some resistance. According to Maine of the AACP, the “demand for pharmacy services while working in close collaboration with other providers [can be met] … if we can secure regulatory authority and the payments to make this work — both big hurdles.”

Much more work needs to be done for this effort of inclusion of pharmacists as providers to come to fruition. One bill that is being looked at is the Medication Therapy Management Benefits Act of 2011 that would offer patients better access to medication reviews and face-to-face counseling with licensed pharmacists. In addition, there is a nationwide movement to have the Social Security Act changed for this inclusion, which is seeing much support from many sides. Arguments by proponents that pharmacy services are already included in the essential health benefits package, as well as other parts of the new healthcare reform law, and that patients’ overall quality of care will improve seem to be making traction. “This has become a major platform issue for a lot of major pharmacy groups,” says Calhoun. “We are seeing a lot of state pharmacy associations giving legs to these grass-roots issues. By working together, we can make it a reality. We believe in this healthcare change. It’s the right thing to do.”

The ASHP argues that pharmacists who provide a more comprehensive and coordinated effort in patients’ care must successfully demonstrate competencies through practice-intensive continuing education, pharmacy practice and specialty residencies. They also say that the role of pharmacists should be well defined within a scope-of-practice document or a similar tool developed by a healthcare organization.3 “We view the evolution of pharmacist-provided patient care as one which is done in coordination with other healthcare providers. As care delivery moves toward team-based approaches, we don’t view pharmacist patient care services as those done in a vacuum, but rather as part of a coordinated effort among all caregivers who are communicating with each other to provide the best, most cost-effective care possible,” says Hill.

Since 2004, the standard accreditation for students in pharmacy school is a doctor of pharmacy, or PharmD, although those who graduated prior to that year were able to matriculate with a bachelor’s degree. Currently, there are about an equal number of licensed pharmacists with either a bachelor’s degree or a PharmD practicing, with about 60 percent of those employed by pharmacy chain stores. The AACP is currently revising its educational standards guideline, as it does every 10 years, and Maine says in addition to a rock solid foundation of anatomy, chemistry and biology, the core curriculum expectations that were simplified and set in 2004 (to provide pharmaceutical care, develop and manage systems of medication use to enhance public safety, and contribute to public health) will likely call for “soft skills” to be heightened such as making sure students can express compassion and have a cultural competency, as well as critical thinking and the ability to problem solve. “There are many tools in the toolbox,” says Maine, where gaining educational and real world experience is concerned, including residencies, certifications and continuing education. In addition, adds Meyer of ASHP, “students are learning through their rotations and other course work that team-based, collaborative interdependent care with other health professionals will require them to function in new payment and delivery systems.” Through its Pharmacy Practice Model Initiative, educational programming, and other initiatives, ASHP is providing opportunities for pharmacists to upgrade their skills and provide a range of services to patients.

Whether pharmacists have a bachelor’s degree and more experience or are new PharmD graduates, Calhoun believes they have good experience and practice in communicating and understanding patients’ needs, especially at the community pharmacy level where they may know their customers as neighbors. “I believe that pharmacists have the counseling skills because they already use them daily,” he explains.

The Benefits of an Expanded Role

It is estimated that about 75 percent of the $2 trillion spent on healthcare is spent on the management of chronic diseases. The average adult fills about 12 prescriptions annually before the age of 65. After 65, that number jumps to more than 30. And, it’s not just adults; Medco Health Solutions found in an evaluation of prescription data that 30 percent of children age 19 and under take at least one chronic medication.⁴

Pharmacists can keep an eye on patients’ use of medications and make sure they are taking them appropriately and, in some cases, remembering to take them at all. Studies show that only about half of patients take their meds as prescribed, and lack of adherence results in $290 million in medical costs annually.¹ “Communication and compliance are the keys to a successful and satisfied patient,” explains Ehlers. “Patients who openly and willingly speak with their pharmacist about concerns or issues have the best chance to have the best outcomes. It is important for patients to know that there is not a ‘one-size-fits-all’ model for their care. For instance, if patients are having side effects, there are often alternatives or interventions that may be tried. But, if patients don’t let their pharmacists know, pharmacists won’t know to make changes. Also, patients need to be willing and able to follow the prescribed medication regimen. If patients are having difficulties with compliance for specific reason(s), that also needs to be discussed. Even the perfect medication regimen can’t work if patients are unable or unwilling to follow it.”

Pharmacists also can provide an educational component for patients who are unclear about why they are taking certain medications —a far cry from the 1950s and 1960s, when pharmacists had to refer patients back to their physician for any questions about their condition and the medications prescribed. “Pharmacists bring a strong set of needed skills to a patient’s comprehensive care program,” says Ehlers. “They are trained to be the drug experts and to have a thorough understanding of drugs and how they work—both within the body and with each other. By not taking advantage of this vast pool of information, providers are doing a disservice to both themselves and their patients.”

Pharmacists trained at the doctoral level manage complex drug therapies, can interpret diagnostic laboratory results, and can refer patients to specialists, among many other duties. It is estimated that 92 percent of pharmacist recommendations in outpatient, inpatient and nursing home settings were approved by the patient’s provider.⁴

“The VA has had a long history of including pharmacists in patient care,” says Virginia Torrise, deputy chief consultant at the U.S. Department of Veterans Affairs Central Office. “In 1995, the Under Secretary of Veterans Affairs for Health authorized pharmacists to prescribe medications, and since then, pharmacists have had advanced roles in patient care and those roles continue to be expanded.” The VA’s comprehensive inclusion of pharmacists in patient care has allowed their role to change from disease-based to medication management-based care, where “providers refer patients to clinical pharmacists who help manage their clinical needs. There are as many as 40 different specialty care areas” [in which pharmacists have an integrated role in patient care].

“When we look at core practice areas, pharmacy specialists manage medications and more complex care such as blood products and transplant medications,” says Julie Groppi, national director, Clinical Pharmacy Policy and Standards at the VA. Clinical pharmacists also review dosing and pharmaco parameters for patients. “Physicians are comfortable referring patients to pharmacists,” adds Groppi. “They manage complex medications and help improve access to physicians. Patients appreciate the services the pharmacists provide, and they help reduce poly-pharmacy.”

The VA is seeing the increased access to pharmacists as having a positive effect on their patient care and patient satisfaction. “A J.D. Power survey of both mail-order and brick-and-mortar pharmacies showed the VA had a high level of customer satisfaction, and pharmacists are at the heart of that,” says Torrise.

From a financial standpoint, a Congressional Budget Office report released a new finding that changes in prescription drug use will bring about a change for medical services spending. Offsetting a 1 percent increase in the number of prescriptions filled will cause Medicare spending to fall by one-fifth of 1 percent, and thus have a positive impact on healthcare spending.⁵ The VA reports similar results, with every $1 invested in clinical pharmacy services resulting in a $4 benefit, which can be extrapolated using average salary data to show a $368,000 savings benefit per provider of clinical pharmacy services.⁶

According to Ehlers, studies have shown that the more pharmacists are involved in direct patient care, “medication ‘misadventures’ are decreased, outcomes are improved, and the overall cost of healthcare is reduced. According to a 2007 article in the Journal of General Internal Medicine, there were $3.5 billion in hospital costs saved by pharmacists coordinating medications from multiple prescribers.”

Calhoun believes that if the Social Security Act is changed for the inclusion of pharmacists as providers, it will bring the cost of healthcare down: “If passed, an easy place for this to start is with immunizations. We’ve already been doing it for years and years, but now pharmacists would get paid. Next, we’d look at other places where we could provide overall help, such as when a diabetic patient is discharged from the hospital. They would see a diabetes educator, who could then turn them over to a pharmacist who can monitor them and follow up with the patient’s physician. We can grow that market basket of services pharmacists can perform. We won’t have to be constrained by those four walls. A pharmacist who is a diabetic expert could have appointments set up at 10 different clinics, and that is how we are going to keep costs down —with more collaborative care.”

The number of pharmacists certified to administer vaccinations has quadrupled since 2007, according to the American Pharmacists Association. It is estimated that 18.4 percent of patients who received a flu shot in the 2010-2011 season did so by their pharmacist.7 Other areas where pharmacists are making an impact include providing health promotion and disease prevention guidance, and performing some limited physical assessments and supervising medication therapy with appropriate collaborative drug therapy management (CDTM) authority. CDTM allows pharmacists to enter into an agreement with a physician for the care of patients who have a confirmed diagnosis, enabling them to work with patients in defining an appropriate medication therapy and adjust that therapy as needed.³

However, not everyone is entirely happy about the push to increase a pharmacist’s role in patient care, particularly with regard to writing prescriptions. The American Association of Family Physicians (AAFP), for one, supports pharmacists as an “integral part of an integrated team-based approach to care”; however, the association urges caution. “Only licensed doctors of medicine, osteopathy, dentistry and podiatry should have the statutory authority to prescribe drugs for human consumption”⁸ it argues, because allowing pharmacists to prescribe drugs will further fragment the already fragile healthcare system and limit integrated and accountable care.

While medication management programs are a positive for patient healthcare, and those programs oftentimes are run by pharmacists, it is the association’s belief that pharmacists should not prescribe medications. “This is an important issue as we move forward with new models of patient care,” says Jeff Cain, MD, president of AAFP. “If everyone on the team collaborates, we will have better coordinated care, and that means better quality of care for patients, as well as reduced costs.” However, Cain fears, if healthcare is “fragmented” or there are more individual players, patient care will be hampered by many instances of duplication of care. “If we fragment care, it adds to the complexity,” he adds. “We will see increased testing, increased orders for X-rays, increased orders for labs and increased errors, and that will increase the frustration levels of patients, and they will have more unmet medical needs. We won’t be recognizing the whole person. This will lead to more unnecessary rehospitalizations and ER visits.”

A Collaborative Effort

Cain says that by working collaboratively, there will be enough providers to cover the influx of new patients under the Affordable Care Act: “These are all high-quality members [of the medical team] working together to reach common goals. There are some very good examples of high collaboration with very good primary care, which increases the functionality of each team member.”

“It’s dicey,” says Maine of the challenges that lie ahead. “We’ve got to have a dialogue with organized medicine. Medicare Part D, billing authority — it’s a bowl that [financially] is not getting any bigger.” However, as the flood of people pour in with the Affordable Care Act, “it’s going to be all hands on deck! We sense a stronger commitment by more organizations than in the past, and we must work together with cohesiveness and commitment. There really is no time frame [for moving forward legislatively]; however, those who are the most aggressive in their thinking would like to see something in terms of an ‘ask’ not an ‘outcome’ by the end of 2013.”