“Clinical pharmacists are behind the scenes, behind the pharmacy benefits card,” says Colleen Haines, vice president, clinical and specialty pharmacy services for Anthem. “They treat patients holistically rather than just looking at a single prescription.”
Haines adds that they ensure members receive the right drug, paid for by the right benefit (medical or pharmacy), in the right setting (home, infusion site).
Anthem has access to members’ medical/pharmacy data enabling the insurer to review medical evidence and new drug guidelines, and determine what to cover on formulary.
“Our goal is to give providers as much information as possible before they write a prescription,” Haines says. “Providers are at the center of care but are willing to accept information and review it so they can take care of a member. Clinical pharmacists aren’t replacing physicians, just partnering with them. And we want it to be seamless for patients.”
For example, in managing the use of opioids at Anthem, clinical pharmacists provide member drug histories, establish prior authorizations, ensure patients are taking the right quantity and determine if the medication is the best course of action.
Jessica Frank, PharmD, vice president of quality at OutcomesMTM, a Cardinal Health company based in West Des Moines, Iowa, that designs, delivers and administers medication therapy management programs, says pharmacists are uniquely positioned within the healthcare system to coordinate care across multiple providers, especially for patients with many complex, chronic conditions or during a transition in care.
Copeland says this is particularly important during hospital discharge, at which time clinical pharmacists could provide medication services in an effort to improve patients’ access to care, adherence with medication regimens, and patient satisfaction.
More settings, more value
The role of clinical pharmacist is also changing to become more specialized, says Wong. “They are focusing on particular therapeutic areas such as chronic care, long-term care, or cancer, to stay up with new treatment options. “With increasing technology in new products, the days of a generalist are long gone,” he says.
He adds that large group and oncology practices are now including pharmacists as part of the team, providing patient counseling and patient support as well as managing at-risk populations to evaluate and determine cost effectiveness in treatment options and establish formularies and treatment pathways within a practice.
Wong says the role of a clinical pharmacist exploded when Medicare Part D and its medication therapy management (MTM) requirement launched in 2006.
“Although the value of pharmacists is slowly being realized, they have not been able to show ROI to payers, and chain drugstores are still driven by productivity. Many of the chains promote MTM, but they are not staffing adequately to free up pharmacists,” he says. He believes that as more practices realize that drug therapy selection, compliance, and patient follow-up could significantly impact performance measures, the need for pharmacist services will increase. “For the pharmacy profession to grow, it means taking pharmacists away from the bench and allowing them to be true clinicians,” he says.
Frank adds that the shift to a value provides opportunities for pharmacists to demonstrate their ability to improve patient adherence rates, close gaps in care, mitigate medication therapy problems, and coordinate care transitions. “Payers are entering into performance-based contracts with pharmacies where incentives and penalties for pharmacy performance have been introduced.”
Pharmacists are also making strides to gain provider status, she adds. “Every year, pharmacists are presented with an increasing number of MTM opportunities as payers realize the value in partnering with pharmacists to manage medication-related complications.”
In addition, CMS, using its Five-Star Quality Rating System, has adopted five performance measures directly affecting pharmacists, including patients taking oral diabetes, blood pressure, and cholesterol-lowering medications as directed; and the number of members aged 65 or older taking medications with a high risk of side effects.
Haines says the landscape for drug benefits has changed as the cost of specialty drugs has eaten away at the budgets of healthcare organizations. In addition, consumer advertising, a greater understanding of drug benefits by members, and a demand for better and longer term outcomes, such as the effect of blood pressure medications on the risk of having a heart attack or stroke, have changed the pharmacy environment. “Pharmacists have drug evidence that hits home with patients,” she says.
Mari Edlin, a frequent contributor to Managed Healthcare Executive, is based in Sonoma, California.