Evidence-Based Diabetes Management

Pharmacists as Healthcare Providers: Integration Into the Mainstream

Published Online: July 22, 2014
Panel discussion with Jan Berger, MD, MJ; Rebecca W. Killion, MA; Edmund Pezalla, MD, MPH; Starlin Haydon-Greatting, MS, BSPharm, FAPhA; Geoffrey Joyce, PhD
The healthcare world perpetually faces the problem of ease of patient access to the primary care physician (PCP). Patient and doctor typically don’t spend enough time together to establish a rapport. The pharmacist, however, is an untapped resource who can at least partially fill that void—if there is enough collaboration between the patient’s physician and his pharmacist to help manage his healthcare. Currently, that doesn’t happen frequently enough.

Berger, a physician by training, acknowledged that she was humbled by the tremendous resource that a pharmacist can prove to be. And she noted that as the number of PCPs decline, alternatives are needed and she pointed to pharmacists as a great resource. However, she emphasized that the programs Haydon-Greatting and Joyce had presented prior to the panel’s discussion would, to be successful, need increased collaboration and mutual respect between physicians and pharmacists.

Said Berger, “We’re in a world where the healthcare consumer, the patient, the member, whatever you want to call them…more and more times they have to reach into their pocket and become a paying part of this stakeholder group. So, for each of you, who do you think should be paying, how should it be paid, is it fee-for-service, is it value-based, outcomes-based?”

Killion, who has type 1 diabetes and is a patient representative on FDA panels, responded by saying that the dichotomy of saving money versus improved health is unfortunately oppositional. Despite being well insured and well networked, she herself has had problems with access to adequate healthcare because of the issues presented by her diabetes, and, she noted, a majority of the diabetic population does not even have the luxury of coverage and contacts. This results in a destructive dynamic in need of intervention, said Killion.

Pezalla agreed, adding that we pay for healthcare not because it’s cost-effective, but because it improves health. However, resource constraints make the situation more difficult. The enormous manpower shortage is an additional and growing issue, he said, suggesting that a solution in both the short and long term could be to “import” quality physicians trained in the Commonwealth.

He then turned to the current insurance climate, emphasizing that employer-based insurance is here to stay, despite the rise of healthcare exchanges following passage of the Affordable Care Act (ACA). Some exchanges have steep deductibles, and the providers need to demonstrate the value of their service, not just to the payer, as is traditional, but also to the patient, who might have to shell out a high out-ofpocket maximum. Pharmacists might be able to play an important role here, as could physician assistants and nurse practitioners, said Pezalla. “It’s all about relationships,” he noted, “and all of these people do a better job because they spend more time with patients and help patients understand things better.”

Pezalla believes that managed care companies need to yield some power and that accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) should have more influence. ACOs and PCMHs can drive more efficient regional efforts, he said, adding, “What we need is for managed care companies to back off a little bit and do a little less management here and for providers to come to the fore more.”

Joyce immediately noted that moving away from the fee-for-service structure would be beneficial, and that coordinating pharmacists and/or nurse practitioners would definitely prove economical. He pointed out the excitement that surrounded the issuance of provider status to pharmacists in California.1 The pharmacists expect that they could bill for the services offered, but Joyce is skeptical. Joyce believes that the integrated care model followed by Kaiser Permanente and the Veterans Health Administration helps them retain patients and deliver more efficient care.

Hayden-Greatting believes that consumers need to invest in healthcare, just like in retirement plans, to be ensured of adequate, life-long healthcare; enrollment under the ACA will accomplish just that, she said. “Employers need healthy people who show up and are productive so that we can produce and be a country that offers employment, which increases the chances of people being able to afford insurance, and goods, and services. So in order to do that, the employers need to invest in healthy employees,” said Hayden-Greatting. She believes strongly that investing early in healthcare benefits, through employer-based plans or the current ACA-led exchanges, is vastly preferable to waiting until retirement for Medicare benefits.

In addition to insurance coverage, lifestyle changes are extremely important, said Killion. “We have to overcome the short-term focus in order to have the long-term goal, and that is so challenging,” she noted.

Berger discussed the problem that the various sectors of our healthcare system are “siloed” and that there’s a growing need to “build bridges” among them, to increase communication and to make data more accessible and visible.

Joyce presented the example of the Oregon Health Study to show that increased access does not necessarily translate into improved health. Baseline health plans are essential, but they need to be made affordable to everyone, with financial incentives for the individual as well as the provider.

Pezalla agreed with Berger that the current system restricts efficient movement of data. “It’s a great idea to have things go on at a pharmacy counter, but if they don’t know what’s going on in your doctor’s office or [what went on] the last time you were in the hospital, then it’s in a silo and it’s not helping,” Pezalla said. Problems also arise “if the physician doesn’t have access to the records that show that the patient actually hasn’t filled that prescription for quite a long period of time.” Electronic medical records are a great way to get the systems networked.

However, Killion reiterated the “connecting with the patient” paradigm, emphasizing the importance of time. “How do you engage a patient in their care? You have to spend the time, right? And yet, that’s the one thing nobody has extra of, and it’s the thing that costs you the most,” she said. Killion acknowledged that she herself had only recently realized the tremendous resource that a pharmacist can be to a patient. A pharmacist can engage in conversation with a patient, typically answering all the questions a doctor may not have time to address. “When you have engagement, you have education, you have better compliance, you have better control,” Killion emphasized. “You have patients feeling empowered.”

To close, Haydon-Greatting mentioned some of the practical issues associated with data integration. EMRs carry proprietary information, for instance; this major hurdle in having systems connect to one another needs to be overcome. But change is on the way, she said, as pharmacy chains like Walgreens and CVS/ Caremark address such problems. EBDM

Reference
1. Provider status is here! California Pharmacists Association website. http://www.cpha.com/Advocacy/Pharmacist-Provider-Status. Accessed June 5, 2014.
Issue: Patient-Centered Diabetes Care: Putting Theory Into Practice 2014
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