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The Expanding Role of Pharmacists: A Positive Shift for Health Care

Fri, 10 Jan 2020 17:21:53 GMT

When reflecting upon the impactful members of a patient’s healthcare team, much consideration is given to the patient’s nurses, primary care physician and specialists. However, with nearly nine in 10 Americans living within five miles of a community pharmacy, and four in five receiving prescription benefits through a pharmacy benefit manager (PBM), the role of the pharmacist in orchestrating a patient’s care on the front lines is often overlooked.

A recent New York Times article by Aaron Carroll highlights the frequently unrecognized role of pharmacists as critical members of the ever-changing healthcare system, and how pharmacists are uniquely positioned to oversee medications, both individually and in combinations, from the numerous prescribers one patient may have. Having the ability to coordinate the complete medication regimen of a patient allows the pharmacist the opportunity to suggest methods for accurately and effectively taking prescribed medications, discuss medication safety, identify and manage side effects, and assist in managing chronic health conditions.

Many patients in the community are unaware that pharmacists have been extensively trained to provide basic healthcare services such as providing blood pressure screenings, educating patients with diabetes on the effective use of glucometers, and ultimately providing an interpretation of these readings and diagnostic tools. Pharmacists can also be a quick-to-reach resource for recommending over-the-counter remedies for common ailments, without the cost and time of getting to a doctor’s office.

On a regular basis, pharmacists in the community, hospital, ambulatory, and managed care settings offer outreach or Mediation Therapy Management (MTM) services to prescribers and patients. If a pharmacist receives a prescription from a prescriber that appears to be unsafe to use with a patient’s other medications, if the dose or duration is inappropriate, or if the cost is overly burdensome, they have the ability to recommend appropriate alternatives by reaching out to the prescriber.

With 66% of adults taking five or more drugs per day and 27% taking 10 or more per day, a pharmacist’s review is critical in identifying when prescriber outreach and consultation should be performed for the safety and well-being of the patient. Due to disjointed healthcare systems, many prescribers are unaware of medications a patient may be taking that have been prescribed by another member of the patient’s healthcare team.

Some studies have shown that pharmacist intervention was successful in deprescribing “risky” medications in 43% of enrolled patients within six months, compared to 12% of patients where a pharmacist did not intervene.

In the managed care setting, pharmacists play a “behind-the-scenes” role in helping manage a patient’s medication regimen. Managed care pharmacists can provide a link between prescribers and patients through MTM services by engaging with patients in discussions regarding proper use of medications, the importance of medication adherence, and identification of high-risk medications. Pharmacists can also provide outreach to patients who are currently utilizing costly medications to provide appropriate alternatives, such as interchangeable generics or a comparable drug within the same class, or advise on elimination of redundant drug therapy.

The provision of MTM services can also assist in identifying gaps in care or dangerous drug combinations that may lead to disease exacerbations, additional medications or costs associated with nonadherence and side effects, or hospitalizations due to suboptimal care.

Aside from patient-specific interventions, managed care pharmacists also play an essential role in promoting cost-effective and clinically-sound drug therapy through the practice of formulary management, routinely utilized by health plans, PBMs, hospitals, and accountable care organizations. In the current landscape of rapidly increasing drug prices, the clinical expertise of pharmacists can assist in mitigating the costs incurred by payors due to growing utilization, innovations in drug therapy (e.g., cell and gene therapy), and lack of manufacturer competition in drug classes for rare disease states. Managed care pharmacists have the ability to assess and compare clinical consensus guidelines and drug-therapy recommendations, review data from clinical trials, and evaluate economic impact to develop appropriate treatment algorithms and frequently used formulary management tools, such as step therapy and prior authorization requirements. With the Food and Drug Administration (FDA) approving record numbers of new drug entities in recent years, the role of the pharmacist in reviewing new and complex drug technologies is critical in ensuring patients are receiving appropriate, cost-effective therapy on both the spectrum of individual and public health.

The role of the pharmacist in public health has been transforming and expanding in recent years. For example, in many states, including Massachusetts, pharmacists can become certified to provide injections such vaccinations and long-acting antipsychotics without the appointment and trip to the doctor’s office. In 2012, the number of vaccines administered by pharmacists was expanded from just the flu shot, to include a total of 10 adult vaccines for prevention of illnesses such as shingles, hepatitis A and B, meningitis, and more. In many cases, vaccines are available through prescription insurance without a copay or the cost of an office visit. In many states, pharmacists have the authority to recommend and prescribe routine medications such as smoking cessation agents and oral contraceptives, as well as interpret common diagnostic tools such as for influenza and strep throat. The trend continues to expand in many other states as the need for accessible and affordable healthcare continues to grow and an untapped resource of providers is being recognized.

Aside from the ability to independently prescribe basic medications in a community pharmacy setting, for many years pharmacists have been able to work in tandem with physicians through what’s known as collaborative practice agreements (CPAs), where pharmacists are involved in the provision of expanded direct patient care through comprehensive disease management. Examples of pharmacist responsibilities in these settings include performing patient assessment activities, ordering and interpreting laboratory tests, developing therapeutic plans, and ultimately utilizing prescriptive authorities to initiate, adjust, or discontinue drug treatment.

As of 2011, CPAs between physicians and pharmacists were authorized by 44 state pharmacy boards, including Massachusetts. In a 2008 survey of prescribers who had worked collaboratively with pharmacists through these types of agreements, 96% of physicians who responded reported numerous benefits, including improved disease management outcomes and the allowance of the physician to shift their workload to more critical patients. Arrangements such as CPA’s take the pharmacist-prescriber consultative structure to a level of a healthcare partnership which integrates pharmacists as primary care providers, rather than responders to a predetermined decision.

As the healthcare industry shifts from a reimbursement structure based on volume towards a reimbursement structure based on value, the unsung role of the pharmacist as an integral healthcare team member will come to realization. As practitioners trained to assess the whole-patient picture, pharmacists connect the dots between prescribers and impact the clinical and economic effects of drug therapy in an ever-changing healthcare system. Professional medical and pharmacy organizations remain instrumental in advocating for the underutilized resource of pharmacists in any healthcare setting.

Partnering with a Pharmacist May Decrease Burnout Among Primary Care Providers

Fri, 10 Jan 2020 17:14:56 GMT

More than 50 percent of physicians experience burnout, which can lead to increased depression and higher rates of suicide; poor patient outcomes; and increases in medical errors. One suggested path toward reducing the rate of burnout has been to examine how teamwork can improve satisfaction on primary care teams.

In a recently published study in the Journal of the American Board of Family Medicine , a University of Minnesota-led research team researchers interviewed primary care providers (PCPs)—including physicians, nurse practitioners and physician assistants—to learn how the inclusion of pharmacists in primary care clinics impacts PCPs' clinical work, professional satisfaction and burnout.

Pharmacists in participating clinics provide a defined service called comprehensive medication management (CMM). Through CMM, all medications are assessed to ensure appropriateness, safety, and that they meet desired goals and can be taken as prescribed.

Kylee Funk, lead author and an assistant professor at the College of Pharmacy, Twin Cities, notes the research team found that PCPs described the pharmacist as a collaborative partner and a professional who contributes a complementary knowledge and skill set.

When pharmacists are embedded in a clinical team, PCPs experienced improvement in work-life aspects:

decreased workload;
satisfaction patients are receiving better care;
reassurance;
decreased mental exhaustion;
enhanced professional learning;
increased provider access;
achievement of quality measures.

These seven themes identified in the study center around how the pharmacist improved PCP work-life—which includes clinical work and professional satisfaction—were aligned with drivers of burnout previously documented in academic literature.

"As a medical community, we are very concerned about burnout," said Funk. "Our findings are promising for healthcare leaders who are seeking solutions to decrease burnout and improve joy in work. It is exciting to identify that working with a pharmacist may offer very important benefits for clinicians."

Previous research has already shown benefits to patients when pharmacists are part of a collaborative team with PCPs.

Funk notes the U of M study demonstrates that PCP teams that include a pharmacist embedded in the primary care clinic might be one strategy for addressing provider burnout. Future research will continue to focus on PCP-pharmacist working relationships in a more quantitative fashion to further investigate this finding.

Pharmacists Conducting Wellness Visits Spot Problems with Meds, Turn Profit for Practice

Wed, 07 Jun 2017 00:00:00 GMT

Pharmacists conducting Medicare annual wellness visits in medical practices frequently uncover problems with patients’ medications while generating a profit for the practice, according to a study from the University of North Carolina at Chapel Hill.

Researchers at the UNC Eshelman School of Pharmacy looked at what happens when pharmacists are tasked with conducting annual Medicare wellness visits in a medical practice. During the patients’ first visit, the pharmacists spotted at least one medication-related problem in more in than 90 percent of patients, the majority of which were able to be resolved by the pharmacist. During six- and twelve-month follow-up visits, they uncovered medication issues for all patients.

“Pharmacists performing annual wellness visits have a prime opportunity to provide comprehensive medication management, a much-needed service for older adults,” said Tasha Woodall, Pharm.D., lead author of the study and an assistant professor of clinical education at the School. “For every patient the pharmacist saw, there was something that could be done to make their medications work better for them.”

CMM ensures each patient’s medications are individually assessed to determine that each one is appropriate for the patient, effective for the medical condition, safe given the patient’s other conditions and medications and able to be taken by the patient as intended.

Wellness visits were created in 2011 as part of the Affordable Care Act. Medicare Part B covers an annual visit to the doctor for the purpose of developing or updating a personalized plan to prevent disease and disability. Pharmacists can conduct these visits under a physician’s supervision and be reimbursed by Medicare at the same rate. The visit includes activities such as administering a health survey, conducting a complete medication review and taking measurements of weight, blood pressure, and cognitive function.

The reimbursement received from Medicare for these visits exceeded the cost of delivering the care by more than 38 percent, the researchers found. Pharmacists lack what is known as “provider status” with Medicare and are not usually able to be reimbursed for services provided directly to patients. However, the annual wellness visit presents a special opportunity to improve pharmacists’ revenue generating potential.

“Having pharmacists conduct annual wellness visits is a win-win for patients and the medical practice,” said Suzanne Landis, M.D., M.P.H., a co-author of the paper and a recently retired MAHEC physician. “It results in a positive return on investment for primary-care practices and frees up physicians to focus on patients’ chronic and acute illnesses.”

Fifty-three patients at Mountain AHEC participated in the study. Their average age was 82, and each had three or more chronic medical conditions and were taking from three to 27 medications with 12 being the median number of meds taken. Thirty-nine were women. The pharmacists saw the participants in March, April and May of 2013. The study was published in the American Journal of Health-System Pharmacy.

Researchers found a total of 278 medication-related problems among the study participants. For nearly 33 percent of patients, the drug they were on was not the right one for their condition. More than 25 percent of patients weren’t being monitored as required for the medication they were taking. Nearly 17 percent weren’t receiving enough treatment for their condition, and almost 16 percent weren’t getting the right amount of medicine or not getting it at the right time.

In a 2014 study, UNC researchers examined the feasibility of using wellness visits as a way for physicians to pay for adding a pharmacist to a medical practice. They calculated that 1,070 wellness visits a year—or approximately six visits per day — are needed to cover a $120,000 pharmacist’s salary and would require about 40 percent of a pharmacist’s time to complete. The approach works best in larger medical practices, they found, which are more likely to have the needed volume of patients.

MAHEC started a pilot program in 2012 where a pharmacist took over the wellness visits for three physicians. Patients received information about the scope and purpose of the visits before coming in, which helped keep the visits focused and on schedule. Today, all wellness visits at MAHEC are conducted by pharmacists.

The Role of the Pharmacist in Health Care Expanding and Evolving

Thu, 01 Jun 2017 00:00:00 GMT

Differences of opinion remain surrounding the future of healthcare in this country. Recent action and inaction by Congress has contributed greatly to the question of how health care will be delivered and paid for by the American people. Despite this uncertainty, it appears clear to most that the approach we are currently taking is neither financially sustainable nor sufficient in the consistent delivery of quality care to all Americans. At the same time, all payers of health care are rethinking reimbursement models including shifting from a fee for service to a fee for performance approach. What role will the health care professions play in the evolution of these new models of care? How will physicians, nurses, pharmacists, and other health care providers work together to optimize the efficiency and quality of care? How will our professions capitalize on the unique strengths of the education and experiences of all health care professionals as they explore and implement strategies that capitalize on the value of team care? How will our professions adjust from a fee for service to a fee for performance or value reimbursement model? And finally, how will this and the next generation of pharmacists contribute to this new value based care model?

This issue of the NCMJ focuses on these and other emerging opportunities and challenges facing the pharmacy profession, and will attempt to address new ways in which the pharmacy profession can add value to the care of the citizens of North Carolina. Over the past several decades, schools of pharmacy have been preparing their students to accept expanded practice roles in health care systems, primary care clinics, and community pharmacies. Health care reform initiatives have accelerated these changes and created an environment favorable to new, innovative pharmacy practices and roles that have the potential to add significant value to the provision of advanced medication therapy management. This issue discusses many of these new roles within the context of the shift from fee for service to fee for performance reimbursement models.

Evolving Practice Models

As discussed by Farley et al [1], medication misuse, underuse, and overuse contributes to approximately $300 billion, or 10%, of the health care costs in this country. The article discusses the rationale and early learnings from two active research projects taking place in North Carolina that were designed to describe and assess best practices in the delivery of patient centered services. These projects were intended to optimize medication use and control costs while building a business case to enable effective programs to be scaled and sustained. Consistent with the development, implementation, and evaluation of new pharmacy practice models, Easter and DeWalt [2] present critical healthcare delivery elements important in medication optimization and integral to the effectiveness of new value-based models. In addition, the role of enhanced team-based care and interdisciplinary education are discussed as important components to the achievement of patient centered care. Several challenges associated with the implementation and sustainability of such initiatives are discussed, as well as strategies toward the advancement of team-based care. Trygstad [3] presents the history of the pharmacy profession within the context of a performance-based marketplace and the challenges and opportunities that lie ahead. He emphasizes the importance of the profession of pharmacy to build sustainable practice models that partner with other healthcare colleagues in order to optimally serve their communities and add value to the care of patients. This point is further amplified by the paper from Urick et al [4] where they discuss the role pharmacists are playing in optimizing advanced medication management therapy within state Medicaid programs. By focusing pharmacists attention on the most clinically complex patients, significant improvement in both the quality and cost of healthcare can be realized. These authors report on some of the innovative work being performed in this area to a number of states across the country.

Expanding Roles

Delivery

Over the past four decades, the role of the pharmacist has evolved from an individual who was primarily responsible for safely and accurately distributing a medication product to a patient, to an individual who works side-by-side with physicians, nurses, and other healthcare professionals in sophisticated, highly specialized practice settings to assure appropriate medication therapy management. Bush and Daniels [5] discuss the changes that have taken place within health care systems, an environment that demonstrates the diverse and extensive advanced distributive and clinical services within institutional pharmacy practice. As population health management becomes an increasingly more important element of health care, greater importance is being placed on successfully transitioning the care of patients between sites and settings within an interdisciplinary environment. The implications on health care systems are enormous as patient readmissions linked to poor transitions of care have huge financial implications on the health care system. Since improper medication use is one of the most significant reasons for patient hospital readmissions, the importance of integrative pharmacy care that optimizes compliance and minimizes drug adverse events has created a vital opportunity for pharmacists to close the weak link in a highly vulnerable ecosystem. Scott et al [6] and Hemberg et al [7] provide excellent examples of pharmacists performing critical roles in both ambulatory care and community pharmacy settings in support of post hospitalization transition of care, with particular emphasis on the optimization of advanced medication therapy management.

Access

In addition to the expanding role of the pharmacist in the delivery of health care in a variety of practice settings, the community pharmacist has more opportunities to make a significant impact on the populations they serve. As the needs of society have changed in relation to the provision of health care, the pharmacist is positioned as one of the most accessible health professionals and his/her role has evolved to provide a variety of services for the health of both individuals and the community.

Pharmacists can enhance the health of individuals through the art and skill of compounding. Through compounding, the pharmacist partners with prescribers and patients to meet unique medication needs that are not met by commercially available products. Compounding is an age old art of the profession of pharmacy, which is utilized today to provide personalized medication therapies. In her commentary, Burch [8] describes patient care needs that can be met by compounding as well as reviews some of the regulations and best practices governing pharmaceutical compounding.

The significant role of the pharmacist in the management of individual health requires access to the pharmacist and other providers who provide this care. In her commentary, Nye [9] describes the utilization of telehealth to enhance the care of diabetic patients that are from rural communities. The ease of access via technology extends the reach and impact of the pharmacist into communities that need it the most.

Public Health

Beyond the care provided to individual patients, pharmacists have expanded their reach to influence the public health of communities. Trotta [10] describes the increased access to immunizations and increased immunization rates as a result of pharmacist provided immunizations in North Carolina. The effect on public health through increased immunization rates is a function of the unparalleled access patients have to pharmacists within the community.

More recently, the pharmacist has been at the forefront of addressing the public health crisis caused by opioid abuse. Muzyk et al [11] discuss the various ways the pharmacist facilitates appropriate prescription opioid use as well as provides access to naloxone, an opioid antidote, through the state-wide standing order. Management of opioids is complex, and the pharmacist is a critical partner in the process of treating pain and mitigating adverse events and/or the risk of abuse.

Another public health issue where pharmacists contribute is in the arena of disaster response. In their commentary, Moore and Kenworthy [12] provide an overview of the roles that the pharmacist plays in disaster response and preparedness, including providing continued medication therapy and/or acute care for patients affected by disaster. In a disaster response situation, the role of the pharmacist may not be limited to the more traditional roles of medication selection, proper storage, and distribution, but may include expanded roles such as education opportunities, triage, or immunizations. These roles in public health expand the impact of the pharmacist beyond the pharmacy counter and have significant impact in their community.

Conclusion

In a rapidly evolving health care system with increased demands for results and personalized care, the pharmacist is a critical partner in the provision of care. The skill set of the pharmacist provides a unique opportunity to deliver optimal medication utilization to manage acute and chronic diseases as well as many other roles that are beyond an outdated view that limits pharmacy practice to the distribution of medication. The pharmacist is uniquely positioned to provide disease state management through appropriate medication therapy management that has been demonstrated to improve patient outcomes and decrease overall health care costs. This role is more important than ever as the environment is demanding new practice and payment models that are required to further optimize care and outcomes while addressing the unsustainable increases in health care costs. While the role of the pharmacist on the health care team for optimal management of medication has been appreciated, the positive impact on wellness, outcomes, and overall health care costs through a full scope of practice highlights the significant contribution pharmacists make and can make in the ever changing health care system.

The Integral Role of the Clinical Pharmacist Practitioner in Primary Care

Mon, 01 May 2017 00:00:00 GMT

The unique purpose of the pharmacist is to optimize health outcomes by ensuring safe and effective use of medications. Although pharmacists are an accessible health care professional, they are also considered an under-utilized member of the health care team [1]. Many patients perceive the pharmacists' role as dispensing medication; however, pharmacists' scope of practice includes the provision of direct patient care services in primary care settings. According to the American Society of Health-System Pharmacists, pharmacists perform patient assessments; develop collaborative practice agreements with physicians; order, interpret, and monitor medication therapy-related tests; coordinate care for wellness and prevention of disease; deliver immunizations; provide education for patients and caregivers; document care processes in the medical record; and bill for cognitive services (see Table 1) [2]. In North Carolina, pharmacists can be approved by the North Carolina Board of Pharmacy as clinical pharmacist practitioners (CPPs), which allows for medication initiation, modification, and discontinuation under the supervision of a physician in the context of interprofessional teams. This article explores successful team-based models of care that incorporate pharmacists into primary care.

The Impact of Pharmacists on Health Care Outcomes

A vast body of literature supports the value proposition for incorporating pharmacists into interprofessional primary care teams. The National Governors' Association [3] and the Patient Centered Primary Care Collaborative [4] highlight the benefits of pharmacists for patients and health care systems. A Report to the US Surgeon General titled Improving Patient and Health System Outcomes through Advanced Pharmacy Practice provides an evidence-based review of comprehensive patient care services that pharmacists provide [1]. Overall, pharmacists lower health care costs, improve the quality of care provided, and increase patient satisfaction with services [1].

The Asheville Project

North Carolina pharmacists have served as pioneers for innovative care models. In the 1990s, the City of Asheville partnered with pharmacists to provide medication therapy management services for employees with diabetes in what came to be known as The Asheville Project [5]. Patients saw their pharmacists monthly to focus on effective self-management, adherence strategies, basic nutritional concepts, and prevention of diabetes complications. Results demonstrated statistically significant decreases in hemoglobin A1c and LDL, improvements in HDL, decreased sick days, and decreased total health care costs compared to baseline [5]. The Ten City Challenge replicated the Asheville Project, and demonstrated that quality metrics for blood pressure, lipid panels, and hemoglobin A1c improved, and vaccinations and eye exams increased [6]. Moreover, the interventions made by the pharmacists decreased health care costs by $1,079 per patient [6]. Medication management is now an integral component of pharmacy education and practice across the nation.

Clinical Pharmacist Practitioners

CPPs are advanced practice pharmacists in North Carolina who establish a collaborative practice agreement with a supervising physician to manage populations of patients. This North Carolina practice model is highly regarded across the nation as one that promotes pharmacists practicing “at the top of their licenses.”

A survey of CPPs published in 2015 indicated that there were 87 active CPPs across North Carolina [7]. The majority (76%) practiced in ambulatory care clinics, including hospital-based clinics and physician group practices [7]. Only 7% of CPPs practiced in rural communities, and 43 rural counties did not have a CPP. The top 5 therapeutic areas of focus included anticoagulation (63%), hyperlipidemia (50%), diabetes (46%), respiratory diseases (35%), and hypertension (33%) [7].

The experiences of 30 University of North Carolina at Chapel Hill (UNC) Medical Center CPPs who practiced in endocrinology, pain management, family medicine, cardiology, geriatrics, transplant, and primary care have been described in a report titled Prescribing pharmacists in the ambulatory care setting: experience at the University of North Carolina Medical Center [8]. CPPs provided multiple services including managing medications, responding to consultations, writing medication-related policies and procedures, contributing to continuous quality improvement initiatives, assisting patients who could not afford their medications, educating staff and providers, and counseling patients [8]. By focusing on clinical tasks associated with medication management, CPPs allow physicians to spend more time to perform the diagnostic and procedural responsibilities that are unique to medicine.

Annual Wellness Visits

The Affordable Care Act created the Annual Wellness Visit (AWV) in 2011. The AWV is a free benefit for Medicare recipients, and focuses on disease detection, health prevention, and coordination of screening tests through the development and implementation of a personal prevention plan [9]. Under Medicare rules, a licensed practitioner working under the direct supervision of a physician is eligible to perform the AWV [9]. Because pharmacists are skilled in disease prevention and management, there has been interest in utilizing them to conduct these visits.

A CPP completed AWVs for 98 patients along with other patient care responsibilities over the course of 10 months in an internal medicine clinic. Each visit lasted a mean of 73 minutes, and 4.5 interventions were made per patient during the encounter [10]. Interventions included referrals to other providers such as nutritionists and physical therapists; education interventions about topics such as advance directives and home safety; laboratory tests; immunizations; and medication initiation [10].

Another study evaluated the effectiveness and financial benefit of pharmacist-led AWVs along with comprehensive medication management provided for high-risk elders who received primary care services in a retirement community [11]. In addition to completing the AWV for 53 patients, the CPP identified 278 medication-related problems for the cohort, including suboptimal medication use (32.7%), insufficient therapeutic monitoring (25.2%), and under-treatment of a chronic condition (16.9%). Generated revenues exceeded the cost of the pharmacist's time by 38.1% [11]. AWVs performed by pharmacists can decrease risk of polypharmacy, underprescribing, and adverse drug events, and help practices achieve quality metrics required by Medicare accountable care organizations.

It is feasible for practices to cover the cost of the pharmacist by utilizing them for AWV visits. Pharmacists should complete 1,070 AWVs annually to cover the cost of their salary, which is approximately 40% of the pharmacist's time in clinic if seeing patients full-time [12]. The remaining time could be used for population health initiatives that are important focus areas of the practice but which yield lower reimbursement rates [12].

Transitions in Care

High readmission rates for patients discharged from hospitals remain a quality of care concern. Medicare has recently decreased reimbursement rates for hospitals with high 30-day readmission rates. Transitions in care is a suitable area to incorporate pharmacists since medication changes occur frequently in the hospital setting.

A retrospective observational study of 140 patients compared readmission rates between two models of care, including a physician only group and a physician/CPP group [13]. Patients in the physician-only arm had a 30-day readmission rate of 34.3%, compared to the physician/CPP group rate of 14.3% (P < 0.05) [13]. The patients who saw the physician/CPP team were more likely to receive new medications, discontinue a medication, and have nonadherence addressed [13].

A transitions of care service was established in a family medicine clinic for patients transitioning into care from the hospital [14]. A team-based approach was adopted that included a pharmacist, physician, and nurse care manager. The CPP met with the patient and/or caregiver by phone to assess medications and coordinate care of the patient. The team approach to transitions decreased 30-day hospital readmissions from 14.2% to 5.3%, which was a 62.6% reduction [14].

Rural Pharmacy Practice

Patients in rural communities have less access to both primary and specialty care, including clinical pharmacy services [7, 15]. Significant health disparities exist in rural communities compared to their urban counterparts, including increased rates of tobacco abuse, chronic illness, and poverty [15]. Access to health care services is limited and is expected to worsen due to the primary care physician shortage and the aging population [15]. It is important to ensure that patients in rural communities have access to comprehensive medication management provided by pharmacists in a team environment, and that health care transformation is scalable to rural America. Current legislation in Congress seeks to recognize pharmacists as providers under the Social Security Act to increase patient access to clinical services in rural and underserved areas, and to create a reimbursement model that parallels nurse practitioners and physician assistants [16]. This legislation would not change the scope of pharmacy practice, but would establish a financially sustainable business model for incorporating pharmacists into team-based care [16].

A new rural health initiative at the UNC Eshelman School of Pharmacy has been developed to prepare pharmacists for practice, service, and leadership in rural communities. This initiative seeks to recruit students from rural North Carolina and return them to rural communities to practice, create new team-based models of care that incorporate CPPs into primary care clinics in small towns, and to improve the quality of care for rural populations.

Pharmacists and Telehealth

Telehealth has been utilized to deliver pharmacist-managed anticoagulation services [17]. Clinical video telehealth (CVT) technology was used in a Veterans Affairs medical center for 151 patients in a community-based outpatient clinic a distance away [17]. A telehealth technician performed point-of-care International Normalized Ration testing, and the pharmacist conducted the medical history and evaluated warfarin outcomes via CVT. The mean time in therapeutic range was comparable before and after telehealth implementation. The mean score on a five-point Likert scale for the question, “I would rather use telehealth to receive this service than travel a long distance to see my provider,” was 4.9 [17].

An analysis of a pharmacist-managed diabetes clinic provided via telehealth in the Veterans Affairs system indicated that the intervention decreased the hemoglobin A1c by a mean of 2% over 6 months, and that the percentage of patients achieving the goal A1c increased from 0% at baseline to 38% at 6 months [18]. These studies indicate that pharmacists who provide chronic disease management in primary care by telehealth improve quality metrics and patient satisfaction, which are important components of the quadruple aim. The quadruple aim includes improving the quality of care, lowering healthcare costs, improving the patient experience, and increasing provider satisfaction.

A Practice Model Example

The Mountain Area Health Education Center is the home of family medicine, obstetrics/gynecology, surgery, psychiatry, dental, and pharmacy residency programs. In 2001, a CPP joined the organization to provide comprehensive medication management. The initial areas of focus included development of a pharmacy clinic to manage anticoagulation and asthma, and triage medication assistance concerns [19]. As health care transformation progressed, CPPs were incorporated into team-based osteoporosis clinics, and diabetes and pain management group models. Recently, delivery of pharmacist services has expanded beyond the pharmacy managed clinic to include a productivity model and a complexity of care model. In the productivity model, a CPP partners with a physician in a clinic, allowing the team to see 4 more patients per half-day. In the complexity model, a CPP partners with physicians in a pod model to see the patients in clinic that day who are in highest need of comprehensive medication management.

Reimbursement

Development of a sustainable business model for incorporating pharmacists into the primary care setting is challenging. Because pharmacists are not yet recognized as providers by Medicare, billing is frequently limited to level 1 (ie, nurse) visits [20]. Utilizing pharmacists in AWVs can offset the cost of the pharmacist while also improving quality metrics [11, 12], and incorporating pharmacists into transitions of care visits can decrease hospital readmissions [13, 14]. Although reimbursement of pharmacists for services is beyond the scope of this article, the reader is referred to the textbook, Building a Successful Ambulatory Care Practice: a Complete Guide for Pharmacists [21].

The Physician Perspective

Primary care physicians, whose average panel is 2500 patients, do not have enough time in a patient visit to diagnose acute problems, manage chronic illnesses, and implement prevention guidelines while still maintaining a positive relationship with their patients. In the average non-team based care practice, a physician spends 10.6 hours per day managing and documenting encounters [22]. Incorporating a CPP onto the primary care team improves the efficiency of the physician. The CPP is not a physician extender, but rather a valuable team member with expertise in pharmacotherapy that is more extensive than the training and skills of most physicians, thus enhancing the care for the patient and allowing more time for other services unique to medicine.

Conclusion

The role of the pharmacist has transitioned beyond dispensing medication to include direct patient care roles in primary care that complement the skill set of the physician. Pharmacists are valuable team members who decrease the cost of care and improve the quality of care. Rear Admiral Scott Giberson, Chief Professional Officer for Public Health Service Pharmacists, has stated, “I firmly believe that one of the most evidence-based and cost-effective decisions we can make as a nation is to maximize the expertise and scope of pharmacists, and minimize expansion barriers to successful health care delivery models the right thing to do for our patients” [1].

The Role of Medicare Services in Pharmacists’ Expanding Scope of Practice

Tue, 07 Mar 2017 00:00:00 GMT

Pressures such as increased competition and inadequate prescription reimbursements from pharmacy benefit managers (PBMs) are causing independent community pharmacies to look for other ways to increase margins and provide added value to patients.

Fortunately, Medicare is starting to recognize the valuable role pharmacists can play in patient care. More opportunities are arising for pharmacists to expand their scope of practice and actually get paid for the services they provide.

By partnering with physicians in their communities, independent community pharmacists can be reimbursed by Medicare for services that meet certain requirements.

And, it’s a win-win. Physicians benefit from these partnerships as well. Collaborating with pharmacists allows them to provide better care and achieve improved patient outcomes, which is becoming increasingly important due to new value-based payment models implemented by the Centers for Medicare & Medicaid Services (CMS).

Opportunities for pharmacists
Medicare services that pharmacists and physicians can bill for include chronic care management (CCM), transitional care management (TCM) and annual wellness visits (AWV).

There are multiple models pharmacists can use to work with physicians on providing these services. For example, a pharmacist could be directly employed with a physician practice and share in the practice’s revenue. Or, a pharmacist could provide the services at clinics and be paid by the hour, per service, or as a percentage of what the clinic is reimbursed.
But to use the billable codes associated with these Medicare services, providers must meet certain requirements. Here’s a breakdown of each service.

Chronic care management
CCM services are non-face-to-face care management or coordination services provided to Medicare beneficiaries with multiple chronic conditions. They offer a way to improve health outcomes and the care provided to individuals with chronic conditions. They can also help reduce overall health care costs.
These services usually involve pharmacists calling patients to follow up with them about their chronic diseases and to provide medication management. The physician practice or clinic can then bill Medicare for the pharmacist’s non-face-to-face-time using CCM codes.
Additionally, by providing CCM services, pharmacists can identify gaps in care patients are experiencing and use that information to help physicians improve their patients’ overall health outcomes. For example, a pharmacist may notice that a patient is not up-to-date on his immunizations.

The flexibility of non-face-to-face CCM services present a great opportunity for independent community pharmacists. Pharmacists don’t have to be directly supervised in order to meet the CCM code requirements, meaning they don’t have to be physically located within the practice to provide the services.
By collaborating with a physician practice on CCM services, independent pharmacists can help bring in added revenue for the practice and themselves while achieving better patient outcomes.

Transitional care management
TCM services ensure patients with a chronic or acute illness experience a smooth transition from an inpatient hospital setting to a community setting.

Typically, the services are delivered over a 30-day period post-discharge from the inpatient setting, and include three primary components:

Initial contact with patient within two days of discharge
Non-face-to-face services
Face-to-face visit within a required time frame

In order to meet TCM codes, the pharmacist must conduct the face-to-face visit under direct supervision, and the patient has to have contact with the physician at some point during the visit. Non-face-to-face services during the 30 days may be conducted under general supervision.

Having pharmacists available to assist with TCM services, especially the non-face-to-face component, is crucial to improving outcomes. As the medication experts, they’re more equipped to handle medication management and ensure patients are properly adhering to their regimens.

Though more collaboration is necessary as both pharmacists and physicians must be present for part of the TCM services, both parties can benefit from the additional revenue and reduced hospital readmissions.

Annual wellness visit
An AWV is a yearly appointment to discuss a patient’s plan of preventive care for the next year. AWVs can also help providers identify potential patients in need of CCM services.

For Medicare to reimburse the service, the AWV must be conducted under direct supervision in the physician’s office.

When pharmacists are involved in AWVs, they can help the physician meet quality measures by reviewing medication-related problems, identifying gaps in care and creating a more effective prevention plan.

And, once physicians understand the added value pharmacists bring to AWVs, it can open the doors the other opportunities, such as CCM and
TCM services.

Looking to the future
With more changes to CCM codes this year, it may be even easier for independent community pharmacists to further expand their scope of practice by implementing these services.

Key improvements for CCM in 2017 include:

Increased payments and additional codes
Reduced requirements associated with initiating care and increased payments when extensive initiation work is necessary
Significantly reduced administrative burden
General supervision in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Learn more about these changes here.

Independent community pharmacists can take advantage of these improvements by reaching out to the physicians in their communities who they’ve established good relationships with.

With more pharmacist/physician collaboration and the implementation of Medicare services, pharmacists may finally start to see an increase in margins for their businesses while improving patient outcomes and meeting quality measures.

6 Ways to Improve Physician Outreach (And Boost Star Ratings)

Mon, 22 Jun 2015 00:00:00 GMT

As health care evolves and the role of the pharmacist expands, establishing good relationships with your local physicians is more important than ever.

As health care evolves and the role of the pharmacist expands, establishing good relationships with your local physicians is more important than ever.
Health care reimbursement is changing, and the entire system is shifting toward quality—not quantity—based payments. The Centers for Medicare & Medicaid Services use the Five-Star Quality Rating system to hold health plans and providers accountable for quality. Many measures are specifically related to pharmacies, including metrics for medication adherence, medication safety and, starting in 2016, medication therapy management.

Many of these measures are dependent on your ability to successfully work with physicians to improve patient outcomes. If a patient doesn’t adhere to his or her medications due to negative side effects, for example, then you can work with his or her physician to find a suitable alternative—and improve your pharmacy’s performance on adherence measures. But if a physician doesn’t want to collaborate, then your pharmacy’s performance could suffer.

Don’t let poor relationships with local physicians hurt your pharmacy’s performance on quality metrics. Here are six tips to improve your relationships with physicians—and boost your Star Ratings.

1. Introduce yourself in-person
A good relationship begins with a face-to-face introduction. By reaching out to physicians in-person, you’ll establish the foundation for a relationship built on mutual trust and respect. Stop by their office to say hello, or invite them for a quick coffee to get to know each other.

2. Educate
Many physicians might not be aware of the services your pharmacy offers. Educate them on how your pharmacy’s services and products can help patients, and why they should send patients to you.
Also, be sure to let them know when you add a new service, like free delivery, or when you start selling new products, like diabetic shoes. They’ll appreciate the update and know to send patients your way.

3. Serve as a resource
When introducing yourself to local physicians, explain how you can be a resource for them and their patients. As an independent community pharmacist, you’re an important member of a patient’s health care team. Emphasize that you’re available to help when they have questions about medications, and that you’re dedicated to working with them to improve patients’ health.
4. Find out their preferences
Ask your local physicians how they prefer to be contacted. Some might want you to call them when there’s an issue, while others might just prefer to receive a note by fax. Just by making the effort to contact physicians the way they prefer, you’ll make communicating easier and faster.

5. Be clear and complete
Don’t beat around the bush. When communicating with physicians, be clear about your purpose for contacting them, why it’s important and what you need from them. Offer a recommendation for the physician to accept or reject if you spot an issue with a prescription, or offer information that could help them make better prescribing decisions.

6. Be professional
Treat physicians with respect, and don’t say anything that might negatively influence a patient’s opinion of them. Handle issues like prescribing errors in a professional way, and hopefully they’ll do the same if there’s ever an issue on your end.

A strong relationship with physicians is essential for getting to new patients, boosting your Star Ratings and providing the best possible patient care. Don’t neglect your local physicians— reach out today.

Wellness Visits Pay the Way for Pharmacists in Medical Practices

Sun, 03 Feb 2013 00:00:00 GMT

Physicians seeking a way to pay for the expertise of a pharmacist in their medical practices could look to Medicare annual wellness visits to help cover the cost, according to a study from the UNC Eshelman School of Pharmacy.

Medicare Part B covers an annual visit to the doctor for the purpose of developing or updating a personalized plan to prevent disease and disability. Pharmacists can conduct these visits under a physician’s supervision and be reimbursed at the same rate. The visit includes activities such as administering a health survey, conducting a complete medication review, and taking measurements of weight, blood pressure, and cognitive function.

Bigger is Better

It takes 1,070 wellness visits a year—or approximately six visits per day—to cover a $120,000 pharmacist’s salary, the study’s authors calculated. Their findings were published in the Journal of the American Pharmacists Association.

For a large medical practice (fifteen physicians), at least 18 percent of its eligible patients must complete an annual wellness visit with a pharmacist to reach $120,000 in reimbursements.

A medium-sized practice (five physicians) needs at least 54 percent of its patients to come in.

A small medical practice with two physicians would not have enough patients to afford a pharmacist funded by wellness visits alone.

UNC Eshelman School of Pharmacy and UNC School of Medicine faculty based in Asheville, North Carolina, conducted the study. They assumed that each practice has 2,000 patients per physician with 20 percent on Medicare. The hypothetical pharmacist in the study is available to see patients nearly thirty-eight weeks a year. The study also accounts for the fact that a patient’s first wellness visit is reimbursed at a higher rate than subsequent visits.

Here’s the Catch

Only 11 percent of eligible patients nationally actually use their wellness visit benefit, according to a 2013 report from the U.S. Department of Health and Human Services. That’s up from 9 percent in 2012. The wellness visits were created in 2011 as part of the Affordable Care Act.

The study authors practice at the Mountain Area Health Education Center clinic in Asheville. MAHEC would be a large practice in the study based on the number of patients seen. Physicians there started conducting wellness visits in 2011 and found them difficult to complete in the fifteen minutes allotted.

MAHEC started a pilot program in 2012 where a pharmacist took over the wellness visits for three physicians. Patients received information about the scope and purpose of the visits before coming in, which helped keep the visits focused and on schedule, says Courtenay Wilson, PharmD, senior author of the study and a MAHEC pharmacist.

“I can listen to their concerns and make sure that patients know that I’m hearing their concerns,” Wilson says. “I then schedule a follow-up visit with a physician who will know all of the issues that we have identified and have up-to-date records for the patient. It’s a nice partnership.”

By January 2013, all wellness visits at MAHEC were automatically scheduled with a pharmacist.

“From the doc’s perspective, the wellness visit takes a fair amount of time,” says Lisa Ray, MD, another author of the study and a MAHEC physician. “Handing it over to someone who is extremely competent frees us up to see other patients in those time slots. The added bonus is that every one of our Medicare patients has a pharmacist looking over their medication list.