WASHINGTON, DC 17 August 2010—For Greensboro, North Carolina, primary care physician Art Green, the addition of a clinical pharmacist to the patient care team has brought essential services to some of the practice`s sickest patients and reduced overall medical costs.
"We don`t want our patients to take medications that they are not benefiting from in a substantial way. We`d like them to be free of adverse reactions, and we`d like our patients to be on the most cost-effective medication regimen," Green said during a July 22 workshop in Washington, D.C., sponsored by the Patient-Centered Primary Care Collaborative (PCPCC).
PCPCC, a coalition of more than 700 stakeholder groups, was created in 2006 with the goal of expanding access to comprehensive primary care services and enhancing patient care. The federal government`s health reform initiatives include support for the medical home concept and seek to determine whether this model of patient care is efficient and effective.
Green described himself as a longtime primary care physician with a focus on geriatrics. His six-physician practice serves about 2500 patients in an ambulatory care setting, plus about 1400 more in skilled-nursing facilities.
"There`s a lot going on with medications in both of these venues," he said. "If [the patient] believes that somebody`s looking out for their best interests and is not just hustling them out the door to get to the next patient, they may be more compliant and more likely to come back in a timely fashion," Green said.
He said that by having a pharmacist onsite, the practice`s patients "feel like they`re being taken care of by a specialist in their medicine—and, in fact, they are."
The program. About 250 patients in Green`s practice receive comprehensive medication management from clinical pharmacist Bryan Bray, who works under a collaborative practice agreement.
"It`s truly an integrated, coordinated approach that really does enhance the patient`s ability to meet treatment goals," Bray said. "Patients that tend to benefit the most are those with chronic disease states that are dependent on the most chronic medications."
A typical patient, as described by Bray and Green, might have type 2 diabetes mellitus complicated by hypertension, heart disease, and renal insufficiency, all controlled with 10–12 medications. Patients may have been newly discharged from an inpatient setting and require counseling to help them understand their therapy.
Bray`s task is to assess the appropriateness of each medication in the patient`s regimen and develop an individualized medication plan. Periodic follow-up ensures that new medication problems are discovered and resolved. Adjustments are made, when necessary, to ensure that the patient is meeting his or her therapeutic goals.
Other members of the patient care team, including physicians, physician assistants, and nurses, are consulted as needed and kept informed of each patient`s progress, Bray said.
He said four-year data on 31 patients receiving comprehensive medication management for diabetes show progress toward treatment goals.
During that time, the patients` average glycosylated hemoglobin values decreased to 7.1% from a baseline value of 8.6%. In addition, annual influenza vaccination rates doubled, to 95%; eye examination rates more than tripled, to 73%; cholesterol values improved; and blood pressure decreased to an average of 128/80 mm Hg from a baseline of 135/83 mm Hg.
Demonstrating value. After four years, the average combined annual drug and medical costs for each of the 31 patients were $7,918, compared with $12,280 at baseline, Bray said. The savings includes the $550 average per-patient annual cost for Bray`s services. "We have shown that we can do it," Green said of the cost savings, which resulted mostly from avoidance of hospitalizations.
Green said his practice recognizes the value of pharmacotherapy services in the fee-for-service primary care setting and has "done the right thing" by working to compensate Bray for his time with patients.
Green said all primary care environments would benefit from a pharmacist`s services.
"Within a managed care environment, you`d be stupid not to have a clinical pharmacologist managing medications. And if you`re a company that underwrites its own health care plan, I can`t imagine why you would not want a clinical pharmacologist involved in the care of your patients and promoting appropriate medical judgment in the use of medication," Bray said.
"I think ultimately you just have to ask yourself, why is a clinical pharmacologist not a part of the primary care practice team? And if reimbursement is the only reason, can this problem be fixed?" he said.
In addition to working with Green`s patients, Bray serves as chief operating officer of Medication Management LLC and vice president of the Piedmont Pharmaceutical Care Network. Through these venues, he provides patient care in additional physicians` offices and to home health care agencies and self-insured employers.
Bray said it takes "careful coordination within a physician practice model" to obtain even modest payment for a pharmacist`s cognitive services.
"You can`t make money in a physician practice under the current reimbursement model right now; it always loses money," he said.
A scientific approach. The PCPCC event featured the release of the task force report "The Patient-Centered Medical Home (PCMH): Integrating Comprehensive Medication Management to Optimize Patient Outcomes."
The report is part of PCPCC`s efforts to promote the appropriate and effective use of medications in the medical home setting and define best practices for managing patients` therapy. The document outlines 10 basic steps for achieving comprehensive medication management.
According to the report, which cites a variety of sources, medication-related illness and death cost the United States nearly $200 billion each year, more than the amount spent on the medications themselves. The report also states that medications account for just 10% of medical costs but, if properly used, have "enormous" potential to improve peoples` lives.
Linda M. Strand, professor emeritus at the University of Minnesota College of Pharmacy and vice president of Medication Management Systems of Plymouth, Minnesota, said the task force developed "a rational and systematic decision-making process" toward medication management.
"The process outlined here . . . starts with the question of appropriateness of drug therapy. Then effectiveness, because there`s no need to worry about effectiveness if the medications aren`t appropriate for the medical condition," Strand said.
"Then we worry about safety, which is a bit unusual because a lot of people like to start with safety. But safety doesn`t matter if you`re dealing with inappropriate or ineffective medications to begin with," she said.
Strand said compliance is the last step in the process because only 15% of the drug therapy problems in practice are a problem with nonadherence, while 85% involve the use of inappropriate, ineffective, and unsafe medications.
"If you`re not assessing a patient`s drug therapy in that logical order, you are going to be promoting adherence in patients on medications that are inappropriate, ineffective, and unsafe," she said.
ASHP is a member of the task force that produced the report but was not actively involved in drafting the document.
