Peter Gal

As concern over rising health care costs fuels a rapid transition toward managed care medicine, health care providers are experiencing an inevitable increase in levels of financial risk. They are also seeing an important shift from financial rewards accruing from a service/product-oriented approach to rewards that hinge on successful negotiation within a capitated system.

For example, 78% of Medicaid recipients currently participating in the Oregon Health Plan receive capitated care.¹ The program attempts to minimize patient visits by requiring disease prevention and disease management programs. Physicians must follow program guidelines and make every effort to reduce resource utilization, including that of their own services.

Traditionally, the pharmacist's role has been a balance of product preparation and service provision. Most pharmacists today realize that they can no longer define or plan financial success in terms of preparation of products, with increasing profits tied to increasing prescription volume. Clearly, monitoring drug use and costs and contributing cognitive services are the real keys to future success. The future of pharmacy in a health care system dominated by managed care plans may take various paths. Ultimately, the specific path will depend upon our ability to change, as well as our competence in delivery of high-quality cognitive services.^2-4

Different Futures

The influential Pew Health Professions Commission report, issued in 1995,² predicted that managed care would eventually cover 80%-90% of lives. In this environment, 50% of hospitals and 60% of hospital beds would close, cross-training would occur for many health professionals, and large reductions in the health care work force would inevitably ensue. By the year 2005, the projected work force reductions would include 100,000 to 150,000 physicians, 200,000 to 300,000 nurses, and 40,000 pharmacists.

As worrisome as these numbers sound, they are among the most positive projections currently being made for pharmacy. For example, the report of the Joint Commission of Pharmacy Practitioners from the Pharmacy in the 21st Century third strategic planning conference for pharmacy practice³ notes that while we currently employ 70 to 75 pharmacists per 100,000 people, managed care systems range in their need projections from 40 pharmacists per 100,000 enrollees (Kaiser Permanente) to as low as 28 pharmacists per 100,000 enrollees (Medco and Caremark). In 1994, we employed 175,000 pharmacists nationally; if the above estimates are correct, 82,000 to 110,000 pharmacists will be considered surplus.

Even more pessimistic is the projection by Borgsdorf et al.⁴ that if pharmacist practices do not change, only 29,200 pharmacist positions will remain. All reports^2-4 concur that reimbursement solely for drug dispensing will no longer support currently accepted pharmacist salary levels and that pharmacy practice must change to include cognitive services integrally.

Expanding the Scope of Pharmacist Functions

The 1995 Pew Commission report has been encouraging; it recognizes our profession as well-positioned for potential change, including pharmacy education's increased focus on clinical areas, systems management, and working with other health professions. The commission envisions four core activities that will expand pharmacist involvement in clinical, educational, and distributive activities, collectively referred to as pharmaceutical care. The four core activities of pharmaceutical care are participation in drug therapy decisions; preparing and providing drug products for patient use; providing drug information and education; and monitoring and assessing patients for drug therapy compliance, adverse reactions, and outcomes.²

Borgsdorf et al.⁴ demonstrated that cost savings and improved patient outcomes resulting from fully functional pharmaceutical care programs could actually justify increasing the number of pharmacists in health care. Their findings describe an opportunity for pharmacists to increase market share in a diminishing market. Pharmacists can position our profession now for the health care system of the future by developing a proper understanding of the needs of our broad range of customers, including patients, health care professionals, and health systems; and by accumulating data supporting the value of pharmaceutical care.

A Broad-Based Transformation

Despite managed care organizations' propensity to seek alternatives to employing pharmacists, they are not inherently opposed to pharmacy. Rather, MCOs look for ways to optimize productivity from all health care professionals. Other health disciplines are also required to make substantial changes during this transition. For example, physicians are being required to redirect their practices away from specialties and toward general practices.² Furthermore, physicians are enduring financial risk associated with capitation;⁵ resource utilization scrutiny, with possible loss of staff privileges through economic credentialing;^6,7 and heavy patient caseloads to meet financial expectations.

Pharmacists are also being asked to redirect their focus from being product-based providers to functioning as members of a service-based profession. In the future, reimbursement for the technical aspects of drug delivery will be minimal, and technological advances will make the physical act of drug dispensing and delivery a function performed by technicians.

Financial Justification of Pharmacy Services

The cognitive aspects of drug distribution are often underappreciated and undervalued. A recent editorial in the Journal of the American Medical Association highlights the quiet, vital role pharmacists play in preventing hospital-based adverse drug reactions, along with the general lack of recognition of this important aspect of the distribution process.⁸ In the community, pharmacists who dispense prescriptions also contribute more than a physical act to the process. A large study involving 89 community pharmacies in five states showed that pharmacists intervened at the most elemental level to resolve prescribing-related problems in 1.9% of 33,011 new prescription orders. Each intervention prevented roughly $123 in additional direct spending on medical care, which, averaged over all new prescriptions, saved an average of $2.32 per new prescription.⁹

Studies have shown a wide range of benefits resulting from pharmacist interventions (Table 1). A 1989 American College of Clinical Pharmacy position statement cited almost 80 papers demonstrating the economic value of clinical pharmacy services.¹⁰ A follow-up report in 1996 cited an additional 105 original research projects addressing clinical impact.¹¹

Furthermore, when subject to cost/benefit analysis either directly (in studies) or indirectly (by inference through combining study results with other data), the pharmacist's value is clear (Tables 2 and 3).

Pharmacists, by collaborating with physicians and other health care professionals in implementing protocols to manage select disease states, also can reduce health care resource use. For example, Thompson et al. ¹⁴ described an experiment in management of nursing facility residents. For one year, all aspects of assessment and management were performed by pharmacists instead of a family physician. The pharmacists involved in the study possessed skills in physical assessment, laboratory ordering, diagnosis, and drug therapy. When one-year outcomes of patients under pharmacist management (67 patients) were compared to outcomes achieved with physician management during the previous year (60 patients), and to outcomes achieved in a parallel group of patients managed by internal medicine physicians (72 patients), the results were impressive for pharmacy. Pharmacist-managed patients were prescribed approximately two fewer medications. Eight patients had moved to a lower level of nursing facility care, compared to just two patients in physician-treated groups. Only two patients in the pharmacist-managed group had been hospitalized, compared to eight patients in physician-treated groups. The numbers of deaths in the pharmacist-managed groups were 50% lower than those reported in the physician-treated groups. Using estimated pharmacist salaries at the time and documented time committed by investigators, seven dollars in general health care cost savings were realized for each dollar spent on pharmacist salaries.

McKenney and colleagues^15,16 focused on more basic pharmacist roles in management of hypertensive patients. Pharmacists monitored blood pressure, provided general information about drugs and hypertension, and answered patient questions about adverse drug effects, compliance, and related issues. Hypertension control rates were markedly improved. In these projects, McKenney demonstrated that modest additional training for motivated community pharmacists can have a significant impact on chronic disease outcomes. Furthermore, pharmacists were able to perform this function with an average patient encounter time of 5.6 minutes.¹⁶

Short-term studies of hypertensives patients resulted in conservative estimates of reducing health care resources by more than two dollars for every one dollar spent on pharmaceutical care.^15-17 Analysis of financial benefits in these studies did not take into account the immeasurable but real costs associated with failure to control chronic hypertension.

Pharmacokinetic and pharmacodynamic services are also cost-effective, with estimated benefit-cost ratios greater than three reported in most studies (Table 3).^18-25 Finally, significant cost savings and cost avoidance can be demonstrated when hospital pharmacists document cognitive interventions. In one 850-bed hospital, the value of clinical interventions exceeded $500 million over 10 months.²⁶

Drug therapy is often viewed as relatively simple when compared to the diagnostic process. However, physicians and mid-level practitioners have limited pharmacologic training, and many freely admit the need for ready access to an expert in drug therapy. The pharmacists is often viewed as this expert.²⁷

Chronic disease management is a large component of health care. Pharmacists can reduce the amount of physician time required to follow chronic care patients. They can provide these patients with prompt access, since they are readily accessible in most communities. Recent reports show chronic diseases accounted for $425 billion in direct health care costs and $234 billion in indirect costs in 1990.²⁸ Since the greatest financial expenditures are on chronic disease, pharmacists must become expert in monitoring treatment of major chronic diseases such as hypertension, diabetes, and pulmonary disease.

A recent project in Texas showed community pharmacists saved an average of $1,750 per patient for their $225 per patient per year consultation fee.¹⁸ The services included in the fee and provided by pharmacists were patient education and counseling and routine blood pressure and blood glucose checks. Prescription drug refill clinics focusing on chronic diseases save considerable physician time, improve health care access and quality, and save money.²⁹

Studies indicate that after diagnosis, patients with serious chronic diseases comply with their medications only 50% of the time,^30-32 and the consequences of noncompliance reportedly cost our health care system $100 billion each year.³⁰ Adverse drug reactions also occur frequently, accounting for more than 10% of hospital admissions in the elderly.³³ The cost of drug-related adverse events has been estimated to range from $20 billion³⁴ to $76.6 billion³⁵ annually.

The areas of medication non-compliance and adverse drug reaction monitoring have been, and can continue to be, viewed by clinicians as the pharmacistÕs area of expertise. We must foster an environment where patients develop an expectation and perceive these roles as essential and protective to well-being.

A recent news report³⁴ described pharmacists' failure to handle appropriately several prescriptions involving important drug interactions. Reports like this damage our profession's image and decrease public confidence. They must serve as a stimulus to increase competence in our ranks. Other reports describe pharmacists who have knowledge gaps regarding proper use of metered-dose inhalers or are unwilling to provide counseling to asthmatics.³⁶ Low practice levels justify the lowest of manpower projections described above and may contribute to rapid loss of up to 50% of established pharmacy positions over the next five to 10 years if left unaddressed.

Expanding Opportunities

Providing excellent, comprehensive pharmaceutical care can give consultant pharmacists a head start as we redefine our unique role on the health care team, and hard data supporting the cost savings and quality-of-life benefits associated with our services are finally beginning to emerge.

A recent study by Bootman et al., for example, demonstrated that consultant pharmacists exert an enormous impact on treatment outcomes and costs in the nation's nursing facilities by conducting monthly, restrospective reviews of residents' drug regimens to identify and correct drug-related problems such as improper drug selection, improper dosing, and use of drugs without valid indications.⁵³

Bootman's research indicates that each year, consultant pharmacists' drug regimen review activities reduce costs associated with drug-related problems in the United States from $7.6 billion to $4 billion and increase the proportion of residents experiencing an optimal therapeutic outcome by 43%.

In addition, a wealth of studies and pilot programs have been conducted in community, hospital, and ambulatory settings; it takes very little imagination to develop ways of applying these same pilot program results and principles to the consultant pharmacy setting.

Opportunities abound, starting with self-care.³⁷ Increasing availability of over-the-counter drugs and diagnostic agents resulted in over $20 billion in sales in 1995.³⁸ Pharmacists who provide either no advice or free advice regarding product selection should consider expanding their services.

A 1993 survey of community pharmacy patrons showed that 61% seeking advice could not find anyone to ask. Consequently, 74% (45% of the total) left without a purchase.³⁷ These represent important missed opportunities for patient contact and sales.

Furthermore, a 1995 survey of pharmacy patrons showed that 78% were willing to pay pharmacists five dollars or more per visit for providing disease management services, including over-the-counter drug advice.³⁹

Over-the-counter drug counseling by pharmacists is rapidly increasing, averaging 49 encounters per week in a recent survey.⁴⁰ In many cases, the pharmacist's advice is sought to avoid a physician office visit, thus avoiding the health plan co-pay. Health advice from other health professionals is not free; pharmacists must revisit their history of providing free health advice.

Issues for Implementing Change

In the era of managed care, pharmacists must address several important issues to implement pharmaceutical care correctly. These issues include:

• Improving pharmacists' opportunities for education to upgrade skills
  
• Redesigning work flow to encourage patient interaction time
  
• Re-engineering the pharmacy to allow private patient encounters
  
• Offering expert assistance to consumers making over-the-counter drug purchases
  
• Improving documentation skills
• Increasing efforts to work with patients, physicians, and managed care plans to justify reimbursement
  
• Making diligent efforts to measure outcomes of pharmaceutical care in each individual patient
  
• Participating actively in research related to pharmaceutical care
  
• Seeking and employing reimbursement mechanisms for pharmaceutical care
  
• Collaborating with state and national pharmacy organizations to advance pharmaceutical care.

These recommendations were incorporated in the JCPP report "Pharmacy in the 21st Century III."³ Although many respondents questioned the feasibility of these suggestions, the profession of pharmacy has no choice but to embrace change. Promoting the value of pharmaceutical care within our profession is the first step; promoting its value to our customers should follow directly. Many pharmacy leaders have started this process. We should learn from their examples.^27,41-45

Education

Proper training to perform clinical functions is vital to the credibility of such programs, and certification in areas of practice would be ideal. Commitment to educational approaches that test participants' true application knowledge using case-management situations and pursuit of certificate-level programs must become part of the pharmacist's professional standards. Managed care programs look for verification of competence. Certification programs can provide the measure of verification they need.

The Reimbursement Issue

Regardless of profession, service reimbursement rates vary with provider experience and among health care organizations. Health care administrators are often ignorant of the clinical and financial benefits of pharmaceutical care. A recent study by Horn et al.⁴⁶ showed that intuitively cost-reducing measures, such as increased drug co-payments, emphasis on generic drug use, and tight formulary restrictions, actually increased health care costs for some diseases. Patients used other resources, such as visits to physician offices, emergency departments, and hospitals, to avoid or circumvent restrictions. As a result of these policies, total expenditures increased. Some of these findings were actually predictable from similar analyses of drug policies implemented in select state Medicaid programs.^47-49 Health care administrators generally do not understand the full impact of their policies toward pharmacist reimbursement for cognitive services, simply because so much remains uncertain.

Pharmacists must educate these administrators by presenting the types of information most suited to their understanding, such as cost-benefit ratios.⁵⁰ It is doubtful that other disciplines can produce data to match the benefits noted in Tables 2 and 3.

Our discipline is not better suited than those of nurses, nurse practitioners, or physician assistants to performing routine assessments of patients in a cost-effective manner that can help free physicians to deal with more complex cases. Our profession does, however, uniquely complement the services of physicians and mid-level practitioners by providing support in an area of acknowledged weakness for all these groups: medication management.

As members of the health care team who can function as extenders to primary care providers, we are deserving of reimbursement. We must act the part and assert our value in public, business, and professional forums.

Billing for pharmaceutical care and receiving appropriate reimbursement are complex issues. In the fee-for-service structure, pharmacists must submit charges using Current Procedural Terminology (CPT) codes that are used by other health professionals, or the "Pharmacist Care Claim Form" published by the National Community Pharmacists Association in 1995. With either approach, documenting each intervention and its impact carefully, billing appropriately, having a form agreeing to services provided, and obtaining a release of information signed by the patient are essential to success. There are several standardized forms that pharmacists may use to facilitate these procedures.

Pharmacist-managed disease management programs are also reasonable and cost-effective ways to develop and expand billable services while providing a valuable service to patients. Pharmacist counseling is the most economic of all counseling approaches.⁵¹ L.L. Braden has compiled an excellent discussion of reimbursement for cognitive services⁵² for the reader who would like further incentive or justification for community-based pharmaceutical care programs.

Time for Change

Changes fueled by managed care's influence on our health care system can be intimidating. Nevertheless, these changes appear inevitable, and the survival of the profession of pharmacy depends on a significant number of pharmacists rising to the challenge and accepting the idea that reimbursement for product dispensing will be insufficient to support pharmacist salaries, and that many will be at risk for layoffs.

Pharmacists may challenge the practicality of the proposed changes in this article. However, several papers^27,41-45 demonstrate that re-engineering pharmacy is feasible and is a key element of survival.⁵² Reassessing work as we know it and shifting technical work to technicians can save time and money. Small steps could readily change the pharmacist's image and role. These include locating the pharmacist in an easily accessible position for patient consultation, creating private consultation rooms, and displaying signs advertising consultation services provided by the pharmacist with the fee structure. Without such re-engineering, pharmacies are likely to see dwindling income as prescription contracts are moved to the cheapest service.

Outcomes research is relatively new, statistically complex, and, considering its importance to our profession, best performed in conjunction with experienced researchers. Consider a recent experience in which a pharmacist was placed in a medical office with four family practice physicians and two mid-level practitioners. This practice is part of a large independent practice association. The pharmacist provides cognitive services only, and charges for those services. The issues discussed in this arrangement included how charges for these services would be billed, and what reimbursement rate could be expected. The discussion then moved to how reimbursement would work if most health plans capitated patient care, a change that was expected to occur within the next few years.

The participants agreed that the pharmacist had to prove that the cost savings for patient care were sufficient to offset the cost to the physician practice of hiring the pharmacist. This data would have to be generated on a continuous basis. This research requires training and discipline; adequate, accurate documentation is essential to demonstrate success. This pilot program, which was initiated by the author in conjunction with a community pharmacist, has had results impressive enough to justify the pharmacist's continued employment by the medical group. She works three days weekly, managing several chronic disease patients.

Every pharmacist must work to create a sufficient body of evidence in favor of our positive impact on health care, and to justify continuation of contracts to reimburse for all types of services. If physicians must endure economic credentialing (i.e., if performance is measured against a cost acceptable to the managed care organization for evaluation or management of defined diseases), it is likely pharmacists also will. However, in the capitated system, physician practices can elect to carve out a pharmacist reimbursement (e.g., a fee per patient life covered per month). For a physician group with 20,000 patients, this brings an annual income of $240,000 to the contracting pharmacist. This is a good investment if savings for the physician group exceed $600,000, as projected in the Borgsdorf study.⁴

In many communities, large local businesses are using mail-order systems for pharmaceuticals in their health plan. This is regrettable for local pharmacies; important business is lost. However, it is intuitively a good business decision for the health plan. Pharmacists who develop or maintain research skills can challenge this policy by creating a research opportunity that may appeal to health plan managers, especially if the risk is primarily to the pharmacist. For example, a proposal to have a significant number of these employees work with the local pharmacy to receive pharmaceutical care, then comparing health resource utilization and work days missed in the community pharmacist-managed group and the group using mail-order pharmacy services, might show the importance of direct pharmacist contact.

Further, proposing that the pharmacist's financial reward be a percentage of the savings generated removes risk for the industry, and it may yield substantial rewards for the pharmacist. This requires initiative and self-confidence on the part of the pharmacist and, possibly, collaboration with a pharmacist with advanced training to assure appropriate data design and maximize possibilities for success.

Without willingness to show the impact of clinical services and to establish research projects of this nature, pharmacies will surely lose business. Alternatively, if pharmacists show a substantial benefit, an infusion of thousands of patients to local pharmacies could occur, and new capitated contracts for cognitive services could ensue.

Conclusion

Managed care will continue to play a major role in health care, and it is likely that much reimbursement will be on a capitated basis. Rapid changes in health care mean that those professions that adapt quickly to provide needed services in a cost-effective manner will survive the health care revolution.

These changes will occur over a five- to 10-year period, leaving little time for pharmacists to cling to the status quo. Those who change and document their value will survive; those who hesitate and do not aggressively seek the skills necessary for survival will lose their professional status and, ultimately, lose their jobs in a downsizing health care system.

The good news is that pharmacists who accept the risk and expense of re-engineering and retraining have a good possibility of success. Pharmacists consistently have proven their competence and cost-effectiveness in clinical trials. Pharmacists must convince themselves, and their patients, of their value. They must then educate business and physician practices as to what pharmacy has to offer. Risk taking will be necessary; however, the alternative is resignation to a career change in the next five to 10 years.

Providing direct patient care is an exciting and rewarding professional experience reminiscent of pharmacy practice in the 1940s and 1950s. Pharmacists have much to offer patients already. Their widespread availability makes them valuable personnel for health care. They can be trained to offer even more. It is time to step forward. It is time to live up to our potential. It is time to show others that pharmaceutical care is an exceptional value.

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Peter Gal, PharmD, FCCP, BCPS, FASHP, is the director of the Greensboro Area Health Education Center in Greensboro, North Carolina. Copyright ) 1998, American Society of Consultant Pharmacists, Inc. All rights reserved.