Pharmacists have the opportunity to make an impact on community health during the first global pandemic in most of our lifetimes.
We've been saying for years that we are the 'most accessible' healthcare provider and sometimes the ONLY healthcare provider in medically underserved communities.
What counts as a "medically underserved" community?
Medically underserved is defined as "areas or populations designated by Health Resources & Services Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty or a high elderly population."
This HRSA map shows the many areas of the country defined as medically underserved.
Earlier this month I wrote about how pharmacists can impact cost savings for patients, payers, and providers and I still believe that pharmacies are being under-utilized, but that is changing rapidly.
As many of our family and friends are being asked to work from home or not at all until further notice, pharmacists are actually being called into action to serve our community members during this time of uncertainty.
I wanted to quickly share some ideas for how community pharmacists can step FORWARD and SHOW the value of pharmacist-led services.
For more ideas about pharmacist-led clinical services that impact patient care, register for our upcoming ONLINE Elevate Pharmacy Virtual Summit.
Here are a few ideas for how pharmacies can help to educate patients and alleviate some societal pressures to be hyper-vigilant about community health.
Post signage on the door that encourages people that are high risk (over the age of 60, those with a fever or symptoms or anyone who may be immune-compromised) to avoid coming inside the pharmacy.
Also, encourage calling prescriptions ahead of time and reserve the "waiting" area only for those with acute needs.
Sharing flyers, posters, bag stuffers and educational materials on social media like how to protect yourself, is an easy step to implement immediately.
I would love to see independent pharmacy owners reaching out to local health departments, hospitals, and primary care clinics to offer to serve on committees or disaster response teams.
The more we are seen as a partner in the healthcare system, the stronger we can foster an organized, inter-professional response.
IMPLEMENT SOCIAL DISTANCING MEASURES
Offer patients alternative pickup methods like drive-through, home delivery or curbside pickup to limit person to person contact.
Avoiding sharing pens or passing around debit cards or other publicly used inanimate objectives if possible.
NO EMPTY REFILL BOTTLES. This has always been a pet peeve of mine, but my staff knows not to accept any empty medicine bottles from the patient's home.
If your dispensing or clinical services platform allows, provide telehealth consults with the pharmacist so that people can receive counseling or be referred to other healthcare providers.
PROVIDING POINT OF CARE TESTING SERVICES
This may be one of the more controversial ideas, but I do feel pharmacists who can provide testing services to help identify the need for screening and advanced testing.
At the very least, pharmacies should share online screening tools with patients.
UAMS Health created an online screening tool for patients, that I would encourage pharmacies to share with their patients.
Pharmacists can offer patients point of care testing for the traditional flu virus as well as strep testing to help rule out other viruses and illnesses to help lessen the burden of primary care and emergency rooms.
Of course, the pharmacist should have personal protective equipment to offer these types of services and be appropriately credentialled and CLIA certified.
SUPPLYING CHRONIC AND ACUTE MEDICATIONS
In the state of Arkansas, the legislation allows for emergency refills. Emergency refills for 30-day supplies, when appropriate can help patients with chronic conditions continue to stay healthy.
Know your state's exemptions and legislation regarding emergency refill authorizations.
We must assure patients they will have access to their medications and the pharmacy will be there to support them through the pandemic.
I went back and forth on whether I'd dispense a 90 day supply and for most patients, I would say that at this time it is unnecessary. I am concerned about the impact on the global drug supply chain and I think it would be more prudent to limit refills to 30-day supplies in the interest of public health.
Providing people with OTC product recommendations will be important as ever, but pharmacies should consider limiting the quantities sold per person on a case by case basis to limit another "toilet paper-like" run on medications.
Of course, 90-day supplies and OTC product sales would be at the pharmacy's discretion and made on a case by case basis.
We should be thinking about policies and procedures to put in place now in case the crisis stretches on for months.
As this recent article on the drug supply chain mentions, "Worry itself can lead to behavioral changes and risk."
Either way, we need to assure patients we will be there to provide patient care, help them get their medications and/or make recommendations on alternative medication therapies and ensure patient compliance to chronic medications.
THE ECONOMIC IMPACT
One of the things that concerns me most about the pandemic is the global impact on the economy.
Our patients, particularly the elderly and patients with limited financial means, will be especially impacted by the crisis.
We must be aware of the financial pressure this will put on our patients.
Pharmacists are compassionate and capable.
We are here to support our patients and to help calm their fears.
The Ohio Department of Health put out a COVID-19 readiness checklist for pharmacies that is will help pharmacists to put measures in place to ensure the safety of our staff members.
What are some things you are doing to impact population health in your community?
The American Pharmacists Association annual meeting scheduled for March 20-23rd has been cancelled due to travel and gathering restriction recommendations.
If you are a pharmacist looking for new ideas about how to serve your patients in innovative ways join the 2020 Elevate Pharmacy Virtual Summit on April 8-12th.
It is a free, online virtual pharmacy conference for pharmacist-entrepreneurs and those in consulting practices.
You can register for free using your email address at ElevatePharmacySummit.com
About Blair Thielemier, PharmD
Last month, I wrote an article highlighting the current reality in pharmacy.
Pharmacists are being pushed to work harder, faster and with less support than ever before, and the results are dangerous for our patients.
Stressed pharmacists are making mistakes and filling prescriptions incorrectly, resulting in side effects, hospital visits and — in some cases — death.
All to save money and increase profits.
Now, I have no problem with having a profitable business. In fact, I advocate for it by empowering pharmacists to think like entrepreneurs, but I believe the current business model in pharmacy is set up for failure.
Instead of pushing pharmacists to work dangerously fast (some required to fill a prescription in a minute or less, aka McPharmacy!), how about we leverage our skills to generate some REAL value?
I’m talking about cost savings.
I believe pharmacists can achieve cost savings for patients, providers, and payers.
According to this article, the average patient visits their pharmacy 35 times per year versus visiting their primary care physician only four times per year.
That is over eight times more frequently a patient will interact with a pharmacist than with a physician. And with all pharmacists graduating with a Doctorate level degree since the early 2000s, chances are, your pharmacist is a doctor.
So how can pharmacists help patients save money?
One way pharmacists can help patients save money is through weaning off inappropriate medications or by practicing alternate methods of treating conditions.
Deprescribing is the process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects.
This can be achieved by adding a “stop date” to medication therapy.
This article looks at the single drug class of proton pump inhibitors and shows that 68.8% of patients are being inappropriately prescribed a PPI on discharge from an inpatient hospital setting. The article estimates this one drug class, with long term use creating a cascade of downstream negative consequences for the patient, accounts for $10 billion in healthcare spending alone.
If a patient has a legitimate indication for medication use, there’s still hope, however.
Non-drug therapy, also known as “lifestyle modification” is an effective way to help the patient decrease their dependence on medication as well.
Exercise and therapeutic nutrition plans, for example, can result in weight loss and lower blood pressure, reducing dependence on insulin or blood pressure medication.
And pharmacists stand at the ready to help support patients with successful discontinuation strategies.
In these cases, pharmacists can step in with information about evidence-based treatment regimens that factor in things like insurance coverage and the difficulty of acquisition.
For example, a family member messaged me the other day asking about alternatives for an expensive, brand name COPD medication they were getting. The brand name inhaler was not on the insurance formulary and the patient was left without their medication until the prescriber could be contacted, the insurance plan satisfied and the new prescription is sent back to the pharmacy. This process is sometimes taking up to 72 hours.
Unfortunately, because of the way inhalers are packaged, there’s no way to dispense only a short term supply of this type of medication.
If there had been a legal document in place called a “therapeutic substitution collaborative practice agreement,” it would have allowed the pharmacist to quickly identify which inhalers were on the patient’s insurance formulary and simply switch to an equivalent product.
This not only saves the patient money but can also reduce the risk of a COPD exacerbation and hospitalization due to a lack of medication access.
Which brings me to my next beneficiary for the value pharmacists can provide.
Payers can indicate a number of organizations. This could be a private employer-sponsored plan. This could be a self-funded health system insurance plan, also known as a provider-sponsored health plan.
Or it could be the largest third-party payer organization in the United States, the Centers for Medicare and Medicaid.
No matter the size, whether public or private, pharmacists can help payers save money by improving overall patient outcomes and helping patients avoid costly hospitalizations.
Medication adherence is defined by the World Health Organization as "the degree to which the person's behavior corresponds with the agreed recommendations from a health care provider."
But it’s the patient’s choice whether or not to follow medical advice, so why does it matter to payers?
Let’s take the example of blood pressure medication.
The pharmacist filled a patient’s blood pressure medicine 40 days ago and gets a “medication therapy management” (MTM) alert that the patient is overdue for a refill.
The pharmacist calls the patient and the patient shares they don’t need a refill because they have stopped taking the medication due to swelling in their legs. The patient is not due to see their doctor again for another three weeks so the pharmacist decides to contact the prescribing physician and request an alternative antihypertensive, less likely to cause swelling.
The pharmacist is able to quickly identify a breach in adherence and correct the issue before the patient experiences a devastating health crisis like heart attack, stroke or a hypertensive crisis.
If payers want to leverage truly impact adherence, they need to invest more in their biggest ally, the pharmacist.
Preventative care benefits everyone in the system: the patient, the payer, and the provider.
When a patient’s dependence on medication is reduced, they have better health outcomes.
When a patient’s adherence is monitored, they have better health outcomes.
This reduces the amount paid out by the payer, resulting in cost savings.
But what if we could do more for our healthy patients?
There’s a growing trend in functional and integrative medicine.
Integrative medicine is a form of medical therapy that combines practices and treatments from alternative medicine with conventional medicine.
What I like about integrative medicine is that it provides a safe opportunity for patients without a “major diagnosis” to explore non-drug, alternative therapies to optimize their health and keep them healthy.
From a personal standpoint, as a healthy 33-year-old, I feel completely left out of the healthcare system.
My preventative annual visits are practically a waste of my time. At best, I’m told if my weight or cholesterol levels are creeping up. At worst, I’m asked why I’m there and what my chief complaint is, to which I answer, “I have none, I’m just trying to stay healthy.”
The system isn’t set up to help healthy people stay healthy. It’s certainly not set up to help healthy people improve their health.
That is why I, and many others like myself, have turned to integrative medicine.
Pharmacists recognize there is a time and place for medications, but we have a healthy respect for them and believe they should be used as sparingly as possible.
Right now, payers have a reactive approach to healthcare. Pharmacists are waiting and willing to help shift mainstream healthcare’s focus to a proactive one.
Providers and pharmacists have traditionally suffered from somewhat ‘strained’ relationships, but I want providers to know that pharmacists are eager to change this dynamic.
Though we often share the exact same patients, we don’t share much information with one another about those patients.
Providers view pharmacists as ‘bothersome’ when they request endless amounts of paperwork in the form of prior authorizations, refill requests, therapeutic substitutions (mentioned above) and not to mention questioning any “creative” dosing strategies for our patients.
Pharmacists have the impossible task of questioning a prescriber on inappropriate dosing with a perfect blend of respectfulness and firmness.
Since pharmacists have no access to the prescriber’s notes, we have no way of knowing ahead of time if the dosing was in error or in fact intentional on the part of the physician.
If patient data were shared between providers and pharmacists, (a novel idea to be sure!) it could save the providers time and money through improved quality measures and productivity metrics.
If a patient’s insurance plan, for example, stipulates it won’t pay the physician full reimbursement until a patient’s diabetes is under control, the physician will receive less money for a patient that isn’t reaching the optimum goal.
Pharmacists, working as a Quality Coordinator for a physician, can help the primary care provider achieve these metrics by implementing services like Chronic Care Management, Continuous Medication Monitoring, Annual Wellness Visits, and Preventative Care Services like Tobacco Cessation counseling that are aligned with the quality metrics chosen by the clinic.
Pharmacists are trained in programs like tobacco cessation and because of our background in pharmacokinetics, we know that nicotine is an enzyme inhibitor in the cytochrome P450 system.
This means as we help patients quit tobacco, we expect medications to be impacted and are trained to adjust dosing based on the increased effects of enzyme activities on narrow therapeutic window medications.
By leveraging a pharmacist’s pharmacology and medication therapy management skills, patient outcomes may improve, increasing revenue for the physician without much additional effort required by the overseeing physician.
With increased productivity comes better revenue and cash flow for the clinic.
It can also equate to less paperwork as the in-office pharmacist can be a “bridge” between the community pharmacist, the patient, the payer, and the provider.
One of my favorite opportunities for increasing productivity is explained in this publication in the Journal of the American Pharmacists Association “Evaluation of a pharmacist-physician covisit model in a family medicine practice.”
“Compared with physician billing alone, covisits generated an additional $4924.41 in 14 half-days or $158,291.04 over 1 year. Compared with separate visits, the covisit model increased estimated clinic revenue by $2757.89 over the 14 half-days and $88,646.47 over 1 year.
“During the pilot period of the covisit model, the pharmacist and physician combined billed a total of 189 visits, compared with 164 visits on matched days with separate visits. With covisits, more high-complexity codes and initial Medicare Annual Wellness Visits were billed.
“The physician was able to see an additional 1.3 patients per half-day in the covisit model compared with separate visits, and there was an average of 3.2 open physician appointments per half-day with covisits compared with 1.4 with separate visits.”
And that study was just looking at covisits.
Now, for 2020, CMS has expanded the number of services that pharmacists can offer under the general supervision of a physician to include services like Chronic Care Management and Remote Physiologic Monitoring services that can be offered by a pharmacist without the direct supervision of the physician.
Talk about a productivity hack!
Why Aren’t Pharmacists Being Leveraged?
The primary reason pharmacists aren’t currently being leveraged in these areas is that we aren’t healthcare providers under Medicare and, therefore, don’t have a way to bill for these services.
But there is hope!
Within the Pharmapreneur Academy, we are working on building a model to solve this exact problem and show the value of pharmacist-led clinical services.
As a way to get paid for the services mentioned in this article, pharmacists could work directly with cash-paying patients, contract with third-party payers and/or working with primary care clinics to achieve better patient outcomes.
The sooner we shift pharmacists into these roles, the sooner we can have an impact on overall healthcare spending.
If you are a patient, payer, provider or pharmacist, I would like to invite you to join the 2020 ElevatePharmacySummit.com to see how pharmacists are working in practice models today that provide a huge amount of value and cost savings for the healthcare system.
You’ll hear from pharmacists like Jesica Mills of Owensboro Family Pharmacy and Wellness in Owensboro, Kentucky about the integrative medicine services she’s offering her patients.
Or from Nancy Myers, a pharmacist working with patients and providers in a Comprehensive Primary Care Plus (CPC+) clinic in Searcy, Arkansas.
Or Jennifer Shannon, a pharmacy owner in Georgia who has partnered with Emory University Hospital to offer a Transitions of Care program making a huge impact on patient readmission rates.
You can register for the free, virtual conference event, LIVE April 8-12th, 2020 at ElevatePharmacySummit.com
About Blair Thielemier, PharmD