by Abby Beane, SDN Contributing Writer
Edited by Sean Parrish
Since October is National Pharmacists Month, now is an excellent time to examine the evolving role of pharmacists in the modern health care system. The profession of pharmacy is going through a period of vast development and change. Instead of being tied solely to the product of medications and dispensing, it is diligently recreating its image into an increasingly cognitive practice.
Pharmacists have become such an integral part of the health care team because they have the unique advantage of being among the most accessible health care professionals. As patients come in once a month to refill a prescription, the pharmacist tends to be the professional that they see the most regularly.
Unfortunately, due to the mandates of insurance companies, physician visits are growing shorter and shorter these days.
If a patient presents for an acute condition during a physician visit and that condition is addressed and cared for, there is generally little time left for the management and care of any chronic conditions. It is in the management of such chronic conditions that the cognitive services offered by pharmacists can be useful.
Chronic medical conditions are not uncommon across the country. Focusing on the Medicaid program alone, approximately 30 percent of recipients have a diagnosed chronic medical condition . Not only are these chronic conditions physically taxing for the afflicted individuals, but they also have significant financial impacts for the Medicaid system. Approximately 83 percent of spending for Medicaid is dedicated to people with multiple chronic conditions . As a result, new strategies have to be developed to deal with this sizable issue. In the state of Iowa for example, one strategy to combat chronic conditions is through a program called Pharmaceutical Case Management (PCM). A collaboration between physician and pharmacist, a patient is identified as being at high risk for potential drug interactions and/or adverse drug reactions based on the disease states and number of medications being taken. Through an interview and consultation process, pharmacists can thus help manage the long-term care of chronic conditions in an effective way.
Begun in 2000, the Iowa Medicaid PCM program has allowed pharmacy to take on a new role for patients. By looking at the pharmacy dispensing system and refill history, a patient is identified for eligibility. In order to qualify for the Iowa PCM program, patients must have one of 12 different chronic disease states and also be on four or more chronic medications. Additionally, they must not reside in a long-term care facility. When a patient is identified, eligibility for the program is verified by Iowa Medicaid which will pay for the services provided. After this step, the patient is contacted to come into the pharmacy for an interview. To enable the pharmacist to get a better understanding of the patient, a simple patient history form is filled out discussing disease states, hospitalizations, and common background questions. The interview then proceeds by reviewing the background paper, the medications, and the refill history of the patient. The goal of a PCM interview is to identify drug therapy problems such as:
- dose too high
- dose too low
- wrong drug
- untreated condition
- drug therapy for unidentified condition
- drug interactions with other drugs/food/labs
- adverse drug reaction and/or inappropriate compliance
Following this interview, a SOAP note is sent to the physician involved in the care of the problem. There is variety in how SOAP notes can be written. Some pharmacists like to focus on one patient problem at a time, while other pharmacists identify all the problems in one SOAP note. The SOAP note is documentation of the interview and also enables the pharmacist to communicate with the primary care physician and relay information from the interview to the physician.
The most intriguing portion of the Iowa Medicaid PCM program is that is based in a community pharmacy setting. Traditionally, community pharmacy has been driven by dispensing functions. However, as pharmacy continues to grow and expand services (especially cognitive services), PCM is going to be an increasingly important program. As mentioned earlier, community pharmacists are the most accessible health care providers for some patients. By providing this service in the outpatient and community settings, the focus can remain on the management of the chronic condition rather than being involved in the patient’s immediate hospital care needs.
With this new program comes special considerations for the practitioner as well. In order to provide PCM services to Medicaid patients, pharmacists must have completed one of two training modules. Either they must be a Doctor of Pharmacy graduate, or they must complete a training program through Iowa Center for Pharmaceutical Care (ICPC). The pharmacist then has to complete an application and submit five patient care SOAP notes completed in the past six months.
The Iowa Medicaid PCM program reimburses pharmacies for providing not only the initial interview but also any necessary follow-ups. Initial interviews are reimbursed at $75 with preventative problem follow-up assessments reimbursed at $25. The preventative problem follow-ups can be done once every six months. If a problem is identified, problem follow-up assessments can be completed and reimbursed at $40 per occurrence, up to four times in a 12-month period. If a new problem is identified, this can be reimbursed two times per year. In this way, the program is designed to provide long term follow-up and maintenance for the patient while truly managing the patient’s chronic condition.
As PCM is a new service provided to patients enrolled in Iowa Medicaid, the program has been evaluated with significant results having come out of the review. During the study period, pharmacists identified 2.6 drug related problems per patient. The most common recommendation of pharmacists was the addition of another medication, such as a beta-blocker or aspirin for a heart attack patient. While Iowa Medicaid paid a total of $94,170 for PCM services,there was no net increase in the health care utilization costs or charges for patients who received PCM services versus those patients who did not receive them.
By helping to manage the chronic conditions of eligible patients, the Pharmaceutical Case Management program has great potential to positively affect the Medicaid population. As health care continues to evolve and become more team oriented, pharmacists are going to be asked to take on more responsibility in the care for patients. Pharmacists in the community setting are poised to help manage patients at great risk to adverse events due to their medications. By demonstrating their success to both insurance companies and the greater medical community, hopefully services such as PCM will continue to grow.
1. Agency for Healthcare Research and Quality. Accessed Sept. 20, 2008. Available at http://www.ahrq.gov/qual/medicaidmgmt/medicaidmgmtint.htm
2. Agency for Healthcare Research and Quality. Accessed Sept. 20, 2008. Available at http://www.ahrq.gov/qual/medicaidmgmt/medicaidmgmtint.htm
3. Iowa Medicaid Pharmaceutical Case Management Program Final Report December 2002. Accessed Sept. 20, 2008. Available at http://www.iarx.org/Documents/PCM%20Final%20Report.pdf.
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October 9th, 2008 at 12:58 am
Do the pharmacists have the power to adjust a patient’s prescription? Or does the physician for the patient have to read the SOAP note and approve any adjustments?
October 9th, 2008 at 5:44 pm
John,
When I took the class to prepare for my PTCE (Pharmacy Technician Certification Exam), I know that the pharmacist have the power to adjust or change any subscription if the patient has an allergy to the prescribed drug. Also, they would provide an alternative for that drug.
Another thing, I am a pre-pharm student and not a pre-med student but shouldn’t the doctor read the SOAP note every time when giving out a prescribed drug?
October 10th, 2008 at 10:37 am
Pharmd321 and John,
The pharmacist’s ability to alter a prescription (not subscription) often varies based on different state laws. In general, no changes can be made without the authorization of the prescriber. In Illinios for example a pharmacist can make absolutely no changes without consent of the prescribing physician (e.g. capsules to tablets).
In regards to the SOAP note, it is used as a suggestion to the MD. Again, no changes would be implemented without action from the physician. However, it may be different when comparing a retail and hospital setting.
October 10th, 2008 at 7:41 pm
In some states ambulatory care pharmacists frequently adjust coumadin based on in clinic INR’s, adjust insulin based on pt journals and such. It completely depends on the state and setting. It’ll be more common in VA (Veteran’s Admin) and rare in retail.
October 11th, 2008 at 6:01 pm
In the near future pharmacists will not only gain the ability to prescribe, but also adjust prescriptions according to their judgment without prior approval.
October 12th, 2008 at 5:19 pm
It makes me shudder when I think about pharmacists adjusting scripts according to their own judgment. I have immense respect for their medication knowledge base, but they have no clinical training and so miss a huge component of medication decision making. As a resident, I sometimes get tired of having to justify my decision making to pharmacists who somehow think they know better than me. For example, one of them insisted that I should be giving a bigger dose of magnesium to a patient who with a low mag level but also had renal failure. Another time I was treating a pt with possible PCP pneumonia and they D/Ced my Septra order because he had renal failure. I had to get help from our ID service who promptly restarted my order. I sometimes think pharmacists are clinician wannabees.
October 12th, 2008 at 9:44 pm
There are those in every profession. Not justifying, just saying.
October 12th, 2008 at 10:19 pm
Teresa,
Did you calculate their renal impairment according to the Cockroft-Gault Forumula? Factor in age? It seems you lack a respect for pharmacists, which will limit you as a professional. You would be surprised how often consultant pharmacists run into cocky physicians, who are ignorant. It goes both ways.
October 13th, 2008 at 2:54 am
Dan,
I specifically stated that I have great respect for the knowledge base of Pharm Ds and consult them frequently. Cocky MDs tend to disrespect most other professionals, not just pharmacists. Regarding my order for Septra, I asked that pharmacy calculate the dose for renal impairment and was not expecting the med to be D/Ced. Ultimately, however, it is only the physician whose license is on the line. It is only the MD who will have to go to court, be sued, and tell the families that their loved one died if they are not managed properly.
October 22nd, 2008 at 8:58 am
I agree there are cocky professionals in all fields. I do think that’s it’s inconsistent to say, “I respect pharmacists” and in the next breath call them “clinician wannabees.” And Theresa, you are mistaken that it is only the physician’s license on the line. The pharmacist is also a licensed professional who is responsible, legally and ethically for their clinical judgments and outcomes.
October 22nd, 2008 at 12:35 pm
It is not at all inconsistent to say it like I see it. For the third time: there is no question that pharmacists have a great knowledge base regarding medications, side effects, drug interactions. I phone them regularly for advice. I draw the line, however, to someone who thinks they have the right to cancel my order based on their judgment which is training in pharmacy science. There is also something called ‘the art of medicine’ that impacts decision making in a way that doesn’t always adhere to what is included in your curriculum. I appreciate that you have a license with rules to be upheld, but I could never use the excuse “the pharmacist told me to do this” in court as an excuse for my medical decision making. If a pt dies, the MD is ultimately responsible for the care – NOT the pharm D.
October 23rd, 2008 at 9:25 am
Teresa,
If a pharmacist were to dispense your order and the patient were to die, not recover from the infection due to an inappropriate medication therapy, or develop worsened renal impairment, then the pharmacist(usually the clinical pharmacist in this situation) will be held liable, too. It’s as simple as that.
What is it that you think pharmacists do? It’s not just interactions, side effects, and general drug knowledge. In our professional programs, we are trained to manage medication therapy. Will we tell you how to make that bikini cut for your patient’s c-section? No. That’s not part of medication management, but the dosing of magnesium and the initiation of Bactrim are- without a doubt.
Your order was canceled, because the CLINICAL pharmacist did not agree with you. It may hurt your feelings to know that pharmacists can do that, but that’s how it is.
If you only knew how many interventions pharmacists make on a daily basis…
October 26th, 2008 at 11:06 am
I am a practicing critical care physician who runs a nationally ranked ICU. I ran into this discussion between pharmacists and future physicians and thought some of you would like to hear how its is in the real world where lawyers are looking to make a killing and your very home is on the line. Pharmacists have NO business cancelling or changing a physicians orders without contacting the physician to discuss their concerns first. They have no background in microbiology, hemodynamics, cardiovascular monitoring, clinical assessment, diagnosis and treatment. If I proposed that I could manage a crticially ill patient’s multiple medications without seeing the patient, reveiwing radiographs, nutritional status, hemodynamics, cultures,and interacting with consultants and nursing personel I would be the laughing stock of the hospital. This is what it seems that the pharmacist in this stream of interactions is contending. In critically ill patients I have to make a decision at times to institute medications with known potential side effects including renal dysfunction and potential drug allergies (a rash to penicillin doesn’t preclude using a cephalosporin in someone with gram neg pneumonia: being on zoloft doesn’t rule out using zyvoxx in someone with MRSA pneumonia). As my renal attending told me when I was a resident- you can’t put a corpse on dialysis. Pharmacists are part of a patient care headed by the physicans caring for and ultimately responsible for the outcomes. If a pharmacists changed an order I wrote on a patient without contacting me he would lose his job at the hospital I work at, and I would report him to the state board of licensure for practicing without a license.In court, if a bad outcome resulted, this pharmacist would be taken apart and probably never be able to get licensed again. I assure you the lawyers for the MD would love to have a pharmacist to throw to the legal wolves and get his client free. I can also assure you that as an employee of the hospital the pharmacist would have been fired long before court so that the hospital could cut its legal exposure.
The delivery of care is a team effort. Not everyone on a football team can take a “turn” at quarterback. No different in medicine, except that people’s lives are at stake. As Clint Eastwood said in his “Dirty Harry” series-”a man has to know his limitations”
October 26th, 2008 at 9:43 pm
“…being on zoloft doesn’t rule out using zyvoxx in someone with MRSA pneumonia”
“If a pharmacists changed an order I wrote on a patient without contacting me he would lose his job at the hospital I work at”
A local pharmacist lost her job after dispensing that combination because of the adverse event that resulted. The risk of Serotonin Syndrome is serious!
I won’t be taking that risk in the future… (regardless of what you say!)
October 27th, 2008 at 6:37 pm
Your responses to my e-mail only goes to confirm why pharmacists like you should stick with advising a physican (not canceling a physician’s orders). You have no training to know what the relative risks of “serotonin syndrome” are compared to the much higher risk of death from MRSA pneumonia where zyvoxx has been proven in clinical trials to significantly reduce the risk of DEATH. Lucky for you your training and legal exposure doesn’t require you to make these relative risk clinical decisions so don’t worry about “taking that risk in the future” and do the job you elected to do- dispense medications and advice physicians, not prescribe.
October 27th, 2008 at 6:44 pm
A physician unlike a pharmacist is trained to weigh these risk benefit clinical decisions. The risk of death from MRSA pneumonia being markedly more likely then the zebra serotonin syndrome. The physician needs to be made aware of unseen drug interactions by the pharmacists and then make the tough decisions of risk benefit. No one expects you to “take the risk” you think you will be taking, just advice, document and dispense the medication to the patient as the physician requests and you will spend no time in court as a defendant. Do otherwise and you will be risking your future
October 29th, 2008 at 5:05 am
You had better make yourself available to consultation if you’re going to be writing that, especially for outpatient purposes. Problematic prescriptions have a tendency to show up at the most inopportune times- like 3 o’clock in the morning or in the middle of a Saints game on a
Sunday afternoon. Pharmacists don’t get to leave at 4:30pm every day, and they fill scripts on the weekends too…
October 29th, 2008 at 6:26 pm
Do you live in the real world? Pharmacists work a 40 hour work week. I work 80+ a week. Do you really think you or any of your 40 hour a weekers associates are going to be available at 3am. I am (or my partner if I’m not on call). I have missed my son’s birthday, opening christmas presents on Christmas morning, fourth of July fireworks and picnics, and many kids school and sporting events. Never once did my patient care suffer because a pharmacist wasn’t up or working. Check out “epocrates” and “up to date”. I don’t need a pharmacist’s “consult” in a pinch and if I really did need a pharmacists “consult” most of the time they would be sleeping comfortably at home while a pharm tech is filling out the MDs orders. You significantly overestimate your value, necessity and availability (and ability)
October 30th, 2008 at 5:26 am
As long as you’re available… else they won’t get it until it’s been cleared.
October 31st, 2008 at 1:34 pm
Dr. Mark – A pharmacy technician cannot “fill out” physician orders while the pharmacist sleeps at home. All hospital orders and prescriptions dispensed in the community must be checked by a licensed pharmacist before they go to the floor or to the patient. In my state (and many others) the pharmacy must close if there is no pharmacist on site.
November 4th, 2008 at 12:21 pm
Dr. Mark- I am appalled at the discussion above, but would like to take this as a lesson. Please tell me: do pharmacists at all interact with the patient?
Is it like the doctor just tells the pharmacist what to do and the two never talk again?
I’m very confused from all of the arguments above.
November 29th, 2008 at 11:49 am
Wow Mark it sounds like your life really sucks, you should have been a pharmacist.
December 18th, 2008 at 2:44 pm
Teresa and Dr. Mark, please step off the invisible pedestal.
January 8th, 2009 at 7:13 am
As a pharmacy student from the UK I am appalled at the level of disrespect for other healthcare professionals shown by some physicans here. Pharmacists are trained for their role and I agree that by doing anything outside of their competence is puting their neck on the line. However if the physician doesnt respect the training a Pharmacist has had then those potential interactions, or side effects will occur, will not be prevented or explained and the patient will suffer do to the lack of respect shown.
Surely a go away and do as your told attitude is not only unhelpful but it is actually insulting.
May 9th, 2009 at 11:00 pm
IOM reports showing medication errors as one of most significant sources of poor patient outcomes (death) must be made up. Let’s all sacrifice the quality of patient care for the sake of our misplaced egos. Everyone knows that in the third semester of medical school student physicians are given the magical spells and enchantments (exclusively available in medical school) making them gods of patient care. I don’t care if you have a PhD in microbiology and wipe your ass with all the pages of your CV that contain entries from publications in JAMA and Nature, there’s no way you can comprehend drug resistance on the level of a freshly minted medical resident. These titans of treatment don’t need to look into the training of other professions with whom they interact with in the clinical setting. They innately know that pharmacy schools are basically a glorified community college preparing students for McJobs. The fact that pharmacy students generally begin training involving direct patient care in the first semester and continue on to rotations for the last 1-2 years of their curriculum is irrelevant. Furthermore, post graduate training in the form of pharmacy residencies, fellowships and board certifications consists of little more than getting coffee for the physician pantheon. What the hell else are these human vending machines going to do with all those years dedicated to the study and practice of pharmcotherapy?
Oh Mark, be a sport and go kill some ALL kids blindly dosing mercaptopurine. I wouldn’t want you to burden your wisdom with the pharmcogenomics developed by pharmacists needed to properly use it.