Health plans have not really bought into pharmacists’ claims that they can do more than pour, count, lick, and stick and that their role should be expanded into medication management or other aspects of patient care. Yet there is mounting pressure for health plans to do more to improve medication outcomes and to demonstrate value for pharmacy benefits. Thus, health plans face the challenge of determining if, where, and how they are going to improve pharmaceutical care.
Several models of expanded pharmacy practice have been tested. One model — embedding pharmacists in patient-centered medical homes — has recently received increased attention and support.
The idea is that pharmacists can have the greatest effect on medication outcomes when they are part of a care team.
“This model establishes an essential relationship between the patient, the primary care provider, and the pharmacist,” says Marie Smith, PharmD, a pharmacy professor at the University of Connecticut. “Pharmacists have relationships with patients and with physicians or nurses, but often not simultaneously.”
She described the role of pharmacists in medical homes in a recent Health Affairs article.
The core services of pharmacists in medical homes are:
- Review of current drug usage
- Assessment of the efficacy of, and the patient’s adherence to, each medication
- Development of a medication care plan
- Education of the patient and care team about that plan
These activities clearly define the pharmacist’s role in a team approach, as opposed to other expanded-practice activities such as immunizations.
Smith explains that there is a powerful advantage for pharmacists when there is direct contact with patients and the health care team. “How do you build trust with patients and physicians? It’s through visibility and direct contact. For patients, when a relationship is established, patients will share valuable information they may not give to their doctors.
“Among health care professionals, immediate availability and the opportunity to see how you function are important for good collaborative relationships.” The evidence for having pharmacists in medical homes includes programs where there has been a direct effect on improving medication outcomes for chronic conditions. One of these programs was the Asheville Project where pharmacists improved blood pressure control and lowered cholesterol, cutting downstream medical costs and generating a return on investment of 12.6 percent.
There are at least two significant barriers to this approach. The first is building and proving the business case — financial feasibility. Direct fee-for-service payment from private health plans is rare and would have to be in the range of $2 to $3 per minute. Capitation and per-patient care coordination fees have been suggested as alternatives. But payers have been reluctant to create a payment methodology for their services.
The second hurdle is having all states adopt reasonably uniform pharmacy practice regulations to govern the services of pharmacists in community-based settings.
Smith says that in spite of these hurdles, some provider organizations, such as Minnesota’s Fairview Health Services, have moved ahead by integrating pharmacists into their practice and clinic sites.