Make pharmacists a strong part of your disease management team
Active case manager role is wave of future, experts say
The key to more effectively managing your chronically ill patients could be right under your nose, experts say. The benefits of incorporating pharmacists into a comprehensive disease management team can be tremendous, but traditionally, their potential contributions have been overlooked.
Now, however, disease managers in innovative programs across the country are taking a second look at these health care professionals. In these programs, pharmacists still make sure patients get the right pills in the right bottles, but now they also provide patient education, medication monitoring, data collection, and utilization review. In short, the pharmacist has become a proactive provider, responsible for patient care in the same way as the physician, nurse, social worker, dietitian, or other member of the health care team.
"The current use of pharmacists is a tremendous waste of social resources," says Bob Cipolle, PharmD, director of the Peters Institute of Pharmaceutical Care at the University of Minnesota's College of Pharmacy in Minneapolis. "These are professional people who are paid very well and have the opportunity to pay society back by addressing a real social need. Putting 50 pills in a bottle is not a real social need."
Between 40% and 50% of all people who walk into a pharmacy have some kind of drug therapy problem that a pharmacist could probably resolve, Cipolle says. Most of those people have a problem that could be fixed with appropriate drugs, but one in four is either taking the wrong drug or an unnecessary drug. And that leads to $75 billion worth of drug therapy problems in the United States, Cipolle says.
Cipolle and his colleagues are training pharmacists to treat their work as a practice, just as a physician does. A three-year study of the practice model followed 1,000 patients who were seen at least three times in one year and found significant positive increases in outcomes for all diseases suffered by the patients. At the beginning of that year, patients' treatment goals were met about 55% of the time. By the end of the program, that number was over 70% with no changes made in treatment other than the addition of the pharmaceutical care. More than 75% of the time, the drug therapy problems were resolved between the pharmacist and the patient without requiring additional physician visits.
Other pharmacists around the country are delving into disease management, as well. Managed care organizations are looking to pharmacists as a new hope in solving some old outcomes problems Chain pharmacies and networks of independent pharmacies are devising disease management programs, and companies are springing up to help pharmacists change their role in patient care.
"There's a lot of stuff starting up. It's a new care model," says David Nau, RPh, PhD, assistant professor of behavioral and administrative pharmacy at West Virginia University in Morgantown. Nau helped develop an outcomes monitoring program at the University of Florida and is now working to start pharmacy networks in West Virginia. He says the new role of the pharmacist is to be an active case manager, whose duties include:
· Educate patients on the use of medications.
· Monitor medication use to ensure patients are achieving desired therapeutic endpoints.
· Collect data such as weight or lab values about patients that can be shared with physicians and MCOs to help them track patient care.
· Do utilization reviews to make sure patients are getting optimal therapy. The pharmacist, for example, can make sure appropriate asthma patients have an inhaled corticosteroid.
"Pharmacists have long been consulted in the development of clinical guidelines, and some hospitals use highly trained pharmacists in a clinic," Nau says, "but hardly anybody uses community pharmacists."
Why is this happening right now? Nau says it's a convergence of forces. Many managed care organizations wrestling with improving outcomes have seen that big results come when you change the way care is provided, not when you send out a pamphlet or mail a set of guidelines to a physician. "At the same time, you've got a bunch of pharmacists who are trying to change their role and trying to have a care-based relationship with patients rather than just drug dispensing. Simultaneously, these things have moved in the same direction. Both groups are moving toward the same goal of improving outcomes of patients."
It only makes sense to Nau and other experts that the pharmacist is in the best position to improve outcomes. Patients already come to them monthly for prescription refills and they wouldn't have to go to a different site at a different time for the extra services. "Patients with chronic disease states need additional education and monitoring," Nau says. "It's best done by someone they know, by someone they're going to see on a frequent basis rather than someone calling them whom they've never seen. That's more likely to produce a positive impact."
And, of course, there's something in it for the pharmacist, too. "It's best for them because it's really their means of future survival," Nau says. "Reimbursement for dispensing drugs is to the point now where you can barely keep a pharmacy going unless you're a large chain that can do deep discounting. For financial viability, it's better to be reimbursed for providing care. Also, a lot of pharmacists find it more professionally appealing to make a meaningful difference in patients' lives rather than being stuck counting pills and answering phone calls."
Randy McDonough, MS, RPh, assistant professor in the college of pharmacy at the University of Iowa in Iowa City, is helping a network of independent pharmacies band together to offer a benefits package to self-insured employers that will provide appropriate drug therapy for their employees. (See related story, p. 76). "Pharmacy is in such a transition right now that I think we have to do whatever we can to help the practices make it out there," he says. "There's a lot of quality in these pharmacies, and we need to make sure other health care providers realize the training these pharmacists have been through and their abilities to affect patient outcomes in a positive way. Pharmacists are transitioning into being more patient-focused instead of just product-focused. They are trying to be an active member of the health care team."
Seeing the need for transition in the field of pharmacy, Wendy Munroe, PharmD, began her own company to help pharmacists prepare for their role in patient care using a disease management approach. MedOutcomes, based in Richmond, VA, has done pilot projects with a number of pharmacies, including CVS in the Richmond area and Big B in Birmingham, AL. The company offers comprehensive programs for asthma, diabetes, hypertension, high cholesterol, depression, and hormone replacement therapy that are tailored to each site. Pharmacists undergo a training program with home study and a four-day on-site session that includes mock patient work-ups. Once they begin the program, they provide disease-specific patient education, systematic patient monitoring, feedback and behavior modification. They also work with patients on their non-drug-related therapy needs such as diet and exercise, and they communicate regularly with the physician.
A study published last year that looked at the economic impact of the MedOutcomes program among 188 Blue Cross/Blue Shield patients found that savings in total monthly medical costs ranged from $143.95 per patient per month to $293.39 per patient per month.1 The cost of providing the pharmacist interventions was $27 per patient per month. Monthly medication costs remained the same, except in the case of asthma patients, whose costs increased because of more appropriate use of medication, Munroe says.
"In the past, physicians have prescribed drugs and hoped for the best," Munroe says. "We haven't been giving patients the tools they need to take care of themselves, and that's where the pharmacist can step in to help the physician. It's unbelievable what patients are doing because they don't know any better."
Munroe says that with the dissatisfaction with managed care some patients and payers feel, the push to hold down costs, and the misuse of money spent on drug therapy, something needs to change. She says pharmacists are underused and can make a positive impact with little cost to the system.
"The folks who are out there doing this now are real pioneers. It's tough," says Munroe. "It's a whole change in mindset in terms of patients' and third-party payers' perception of the pharmacist. But it makes too much intuitive sense. Hopefully it's going to catch on more and more."
[For more information on pharmacists and disease management, contact:
· Bob Cipolle, PharmD, director, Peters Institute of Pharmaceutical Care, University of Minnesota College of Pharmacy, Minneapolis. Telephone: (612) 624-5187. For information on how to get a copy of Pharmaceutical Care Practice, contact Ken Schiumo at McGraw-Hill. Telephone: (212) 337-6073.
· David Nau, RPh, PhD, assistant professor, West Virginia University School of Pharmacy, WVU Health Sciences Center, Morgantown, WV 26506-9510. Telephone: (304) 293-1453.
· Randy McDonough, MS, RPh, assistant professor, 5513 College of Pharmacy, University of Iowa, Iowa City, IA 52242. Telephone: (319) 335-8623.
· Wendy Munroe, PharmD, president, MedOutcomes, P.O. Box 6813, Richmond, VA 23230. Telephone: (804) 359-3995, ext. 11.]
Reference
1. Munroe et al. Economic evaluation of pharmacist involvement in disease management in a community pharmacy setting," Clinical Therapeutics 1997; 19:113-123.
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