Reducing Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus - Episode 6

The Pharmacist as a Member of the Managed Care Team

Dennis P. Scanlon, PhD: We talked earlier about the care team—dietitians, educators. What’s the role, or is there a role for a pharmacist?

I know in a lot of clinical states, [pharmacists are] helping to sift through the evidence [to] understand what may work for patients. We see pharmacists assisting clinicians with making these decisions on drug therapy.

John A. Johnson, MD, MBA: For us at WellCare, the answer would be, yes. Our pharmacists are a part of our interdisciplinary care teams. A lot of times when you’re managing members with multiple comorbidities there’s drug-drug interactions, there’s creatinine clearance issues that need to be factored in, and there’s communication back with the primary care provider because he may not have a line of sight into the medications that were written by the specialists if it’s in a different health system.

So, at the health plan level, we can see a composite of our members. At the top of everybody’s license—the physician, the nurse, the pharmacist—[the stakeholders are] partnering together to inform health outcomes in a collaborative way. And so, yes, pharmacists are definitely a part of the team.

Dennis P. Scanlon, PhD: And is that true in practice as well?

Michael Gardner, MD: I think in some practices, yes. I actually do a lot of hospital medicine and it is very valuable in the hospital. You see the care teams now containing pharmacists (PharmD’s), who are reviewing the medications every day, as well as the interactions and the days on antibiotic. They actually do that job much better than we do.

Zachary T. Bloomgarden, MD, MACE: I live in the outpatient world. I must say that although we want this to be the case, the reality is that we have so much feedback of meaningless interactions. At a certain point, this really, if anything, interferes with the ability to truly perceive what might be of concern.

This morning I got a call from a nurse, a visiting nurse, who was very interested in the outcome of a patient. “Well, this patient is on a SSRI (selective serotonin re-uptake inhibitor) and an anxiolytic. Do you know there’s an interaction?” “Yes, but these are appropriate drugs together.”

So, many drugs that we use for diabetes have interactions with other drugs which may be associated with hypoglycemia. Every time I prescribe a beta-blocker and any diabetes medicine, a flag comes up in my ordering system.

That’s a little bit unnecessary and it detracts from the ability of these systems to truly offer value. Perhaps, if we had a pharmacist who was really a member of the team, and was involved in helping us to understand what medicines a person was taking and what were the clinically meaningful interactions, we could get around this. But, it’s almost as though we’re at the earliest stage and we need to go up several levels to get these approaches to work.

John A. Johnson, MD, MBA: I think the other advantage in the outpatient world is the pharmacists in your local pharmacies. [For example], leveraging them more to help with medication awareness and interactions outside of the finite amount of time you may have in your office. We’ve seen models where that’s worked as well.

Robert Gabbay, MD, PhD, FACP: Sure. I think there have been models where it works well. I think the challenge has been a couple of things. One, there are probably not so many pharmacists that want to do it that way—or at least within their current pharmacy, [are able to] engage at that level. I think where there have been pilots, it’s been quite successful and data is quite impressive. But, most of the chain pharmacies haven’t moved in that direction. There are pockets.

Michael Gardner, MD: My local pharmacies certainly do.

Robert Gabbay, MD, PhD, FACP: Right.

John A. Johnson, MD, MBA: We use CVS as our pharmacy benefit manager. A lot of their pharmacies will lean forward and educate our members on their medication profile and then communicate that to the PCP (primary care physician) or specialist to make them aware of potential drug-drug interactions.

Zachary T. Bloomgarden, MD, MACE: I’m waiting for the day when every patient who walks in the emergency room with a cold and is on a statin is not given a Z-Pak automatically. Or, if they get it, the pharmacist will say to the prescribing emergency room doctor, “Look. That can cause rhabdomyolysis. Did you know that?”