Why pharmacists might be a new call point for med/surg sales reps
Is the pharmacist’s place behind the counter? Increasingly, pharmacists don’t think so. Rather, they believe that given their expertise in pharmaceuticals, wellness and care for the chronically ill, they belong upfront with the rest of the caregivers. That could mean that pharmacists might be a new call point for med/surg sales reps.
“The demand for pharmacists in ambulatory care is the highest we’ve ever seen,” says Kristy Butler, PharmD, BCPS, BCACP, FASHP, manager of clinical pharmacy specialists for Providence Medical Group, part of Providence Health & Services in Oregon. “That is largely due to the changing healthcare landscape in general, with its emphasis on preventive health and ambulatory services.
“In healthcare today, of course, we want to make sure that patients receive the highest care when they are in our hospitals, but ultimately, we want to keep patients from having to be in any hospital as much as possible. So the opportunities for pharmacists across a wide variety of settings are increasing.”
“Pharmacists [are] in a position to positively improve patient health outcomes, especially related to the use of medications,” adds Douglas Scheckelhoff, MS, FASHP, vice president office of practice advancement, American Society of Health-System Pharmacists (ASHP). “The way they interact with patients, where they interact and how often will vary based on the needs of the patient and their setting.”
Pharmacists are likely to be found in physician office practices, accountable care organizations, patient-centered medical homes, specialty pharmacies, clinics and clinics within health systems, says Scheckelhoff. Pharmacists stationed in clinics within health systems of more than 300 beds are most likely to be found in anticoagulation (69 percent), oncology (68 percent), medication therapy management (45 percent), diabetes (44 percent) and family medicine (39 percent), according to the 2015 ASHP National Survey, he points out.
At its Ambulatory Care Summit in 2014, the Society adopted the definition of ambulatory care used by the Board of Pharmacy Specialties: “Ambulatory care pharmacy practice is the provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. This is accomplished through direct patient care and medication management for ambulatory patients, long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. The ambulatory care pharmacists may work in both an institutional and community-based clinic involved in direct care of a diverse patient population.”
Says Scheckelhoff, “In some cases, the care [provided by pharmacists] is associated with a retail pharmacy. In other cases, pharmacists are assigned to manage medication therapy for a disease or patient population regardless of setting – so the same pharmacist may spend part of her time caring for inpatients and part of her time with ambulatory patients.”
The medical home
The patient-centered medical home is an ideal place for the pharmacist’s services, says Butler, who is a member of the ASHP Ambulatory Care Conference & Summit’s Consensus Recommendations Panel. In fact, the U.S. Department of Veterans Affairs, Indian Health Service, pharmacy schools and HMOs figured this out a long time ago. With some exceptions, traditional health systems have been slower to catch on. “Providence Health & Services has had pharmacists in the ambulatory care clinics for almost 19 years in the Oregon region – but that’s not the norm.
“At first, patients have a lot of questions, like, ‘What do you mean, I’m going to meet with a pharmacist?’” she says. “But once they do, they generally are appreciative of our help and recognize that we are a vital part of the care team, with a unique expertise.”
The pharmacist’s scope of practice is determined at the state level, says Butler. Nearly all 50 states have some sort of collaborative practice agreement whereby the physician and pharmacist together can define the pharmacist’s role in medication and care management. But direct billing for services provided under Medicare’s fee-for-service system – with the exception of the annual Medicare wellness benefit – remains elusive.
“As healthcare reimbursement changes, I think this will be a great opportunity for pharmacists to continue to expand their role, as we move away from physicians getting paid based on how many patients they see, and move toward reimbursement for the quality of care they provide,” she says. “My health system bought into that a long time ago, and that’s why we have a large group of pharmacists in our medical home.”
In the ASHP Research and Education Foundation’s recently published “Pharmacy Forecast: 2016-2020,” nearly 80 percent of the pharmacist panelists predicted that at least 25 percent of health systems would have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients.
“In our health system, pharmacists were in advanced roles before we widely employed nurse practitioners or physician assistants,” says Butler. “We pharmacists have positioned ourselves in our medical group as medication experts. We don’t make diagnoses, but we see patients with chronic medical conditions who need long-term follow-up. We adjust medication for patients with diabetes, chronic obstructive pulmonary disease, asthma, high blood pressure and other conditions where medications are frequently used. We meet with those patients between their visits with the doctor, reinforce the messaging they get from their physician, and follow up on different things. By doing so, we allow the primary care physician to focus their time on patients who need other care.”
Scheckelhoff points out that the opening paragraph of the recently published ASHP Minimum Standard for Ambulatory Care Pharmacy Practice describes best what has happened to the pharmaceutical profession in the recent past.
“Payers have created incentives to decrease hospitalization rates and length of stay, making way for a new shift toward pay-for-performance, outcomes-based reimbursement, and accountable care,” reads the document. “There is also an increasing focus in medicine on preventive health, patient education, and care transitions. Yet, the number of patients with multiple chronic medical conditions that require longitudinal and integrated care management across a continuum of care settings is growing.
“Appropriate medication therapy in the ambulatory care setting is often the most common and most cost-effective form of treatment, yet the consequences of adverse drug events (ADEs) and the inappropriate use of medications in this setting can be catastrophic. Ambulatory care pharmacy services are therefore an essential component of any comprehensive healthcare delivery system.”
Colleges of pharmacy are catching on.
“Students see practitioners providing care in ambulatory settings, and many are able to have experiential rotations with preceptors in these roles,” says Scheckelhoff. “Many are excited by the patient interaction and opportunity to improve care. A growing number are also pursuing residency training with a focus on ambulatory care, either as a PGY1 [postgraduate year one] or PGY2 resident. In fact, the number of ambulatory care residencies is growing faster than any other PGY2 residency program type.”
ASHP has long supported a section for members practicing outside of an acute care setting, he continues. “The ASHP Section of Ambulatory Care Practitioners is well positioned to provide the education, practice resources, advocacy, and networking needs of members practicing in or transitioning into ambulatory care practice environments.”