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Payers realize value in partnering with pharmacists to manage medication-related complications
While clinical pharmacists have been around for decades, their role is gaining more prominence as the industry embraces team-based, coordinated care.
“The role depends on the practice setting that might drive dispensing or meeting clinical needs,” says Winston Wong, founder, W-Squared Group, a pharmacy consulting firm in Longboat Key, Florida. “For example, community pharmacists have always been clinical pharmacists who discuss drug therapy with patients. A pharmacist might have clinical skills and just not use them.”
In many respects, clinical pharmacists are the patient navigators of drug therapy, with much the same function of a patient navigator in an oncology practice, he adds. “Healthcare must be delivered using a team approach to be successful, and a pharmacist is a vital part of that team.”
A PwC study released on October 2016 found that if a healthcare organization were to put together a multi-disciplinary care team that includes a pharmacist, along with other healthcare professionals such as a dietician, physical therapist and mental health professional, the organization could save $1.2 million per each 10,000-patient panel.
The role of clinical pharmacists, says Terry Copeland, product leader, outpatient pharmacy solutions for Cardinal Health Innovative Delivery Systems, a global, integrated healthcare services and products company headquartered in Dublin, Ohio, includes:
· Working with physicians and other providers to recommend medications and dosing regimens tailored to each patient’s unique needs;
· Monitoring patients’ responses to drug therapy regimens;
· Providing education on medication therapy for providers and patients; and
· Counseling patients to help adherence, reduce readmissions, improve Hospital Consumer Assessment of Healthcare Providers and Systems scores, and achieve the desired treatment outcome as it relates to medication therapy.
Nicholas J. Ratto, PharmD, manager, consumer drug information group for First Databank, which provides drug information and insights to the industry, adds these responsibilities to the list:
· Switching a brand drug to a generic;
· Recommending a drug therapy combination that could increase adherence;
· Educating patients on properly taking their drugs;
· Avoiding drug duplications and side effects;
· Uncovering financial or access barriers to adherence; and
· Providing immunizations, infusion therapy, and cholesterol screenings in a retail setting.
“Pharmacists could, perhaps better than any other healthcare professional, address these medication issues as they have the most in-depth pharmacotherapy experience,” Ratto wrote in a recent blog. “They could move beyond their typical medication dispensing role and engage closely with patients on clinical care.”
Copeland agrees that clinical pharmacists are assuming more responsibility for direct patient care, focusing on medication history interviews with patients and handling medication therapy training, both during a patient’s stay and upon discharge.
“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.
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.