Optimizing Patient Care
by Establishing Pharmacists as Providers

"Well, let me see. It seems to me you are giving advice to people who shouldn't need it (physicians), and don't have to follow it, for patients who didn't ask for it but have to pay for it anyway. Now tell me again, what kind of druggist are you?"¹

 

Cognitive service is a component of pharmaceutical care that pharmacists have been providing for many years. Cognitive services is defined as, "services provided by the pharmacist for the patient or healthcare professionals for the purposes of promoting optimal health and/or drug therapy; not necessarily drug-product-related."⁷ These services primarily focus on optimizing a patient's drug therapy and ensuring appropriateness, safety, and efficacy.

COLLABORATIVE PRACTICE

The goals for collaborative practice are listed in Table 1. Some include enhancing quality, minimizing costs, and increased professional satisfaction by using their individualized skills while still allowing for both independent and cooperative decision-making.^8-10 Some responsibilities that pharmacists have in collaborative agreements with physicians include evaluating and rendering advice regarding a patient's drug regimen; implementing, modifying, and managing drug therapy; collecting and reviewing patient drug histories; basic physical assessment including vital signs; ordering and evaluating the results of laboratory tests directly relating to drug therapy; making decisions regarding refills, prior authorizations, and patient assistance for patients; and other patient care services as allowed by law and authorized under the collaborative agreement.^11,12 There are validated tools such as the Collaboration and Satisfaction About Care Decisions developed to assess the levels of collaboration in a practice setting.¹³

The author of Coming of Age states, "collaboration is the understanding that no one discipline has the knowledge or skills to provide single handedly the most effective assistance to the client."¹⁴ The Joint Commission on Accreditation of Healthcare Organization stresses the importance of collaboration when it states, "the patient and family education process is collaborative and interdisciplinary, as appropriate to the plan of care."^6,9 Several models currently exist including, but not limited to the nurse practitioner (NP), physician assistant (PA), and pharmacist. Within these professions there are several published examples on the efficacy of these models for a variety of disease states.

Table 1: Goals of Collaborative Practice72-74

To promote the most efficient and clinically appropriate use of resources To collect valuable outcomes and/or utilization data To increase satisfaction for patients, families, staff, physicians, and third-party payers To promote communication among members of the healthcare team To incorporate patient education, nursing care, pharmacy costs, laboratory utilization and social service needs as a part of the overall care of patients To reduce unnecessary variation between caregivers and effect standardized practice guidelines To serve as a marketing tool to attract patients, staff, or managed care organizations To achieve continuous quality improvement in patient lives and outcomes To ensure Joint Commission guidelines (JCAHO) are being met

NURSE PRACTITIONER / PHYSICIAN ASSISTANT MODELS

The role of a NP, a nurse working collaboratively with a physician, began during the 1960s – 1970s when society was experiencing economic recession and inflation. Programs such as Medicare and Medicaid expanded the affordability of private physician care, but surfaced during a time of decreasing physician availability. Additionally, several social movements including women's rights, civil rights, and antiwar led to an increased public autonomy in healthcare decisions. Nursing education capitalized on these changes and moved into colleges and universities, the first being the College of Nursing at the University of Florida in Gainesville.¹⁵

At this time, medical practice became more specialized and there was a shortage of practitioners in primary care, especially in rural and urban areas. Fortunately, the federal government granted large dollar amounts into the healthcare system to support more nurse and physician education programs. Two such programs were the graduate certificate NP program at the University of Colorado and the PA Program at Duke University in 1965. Once these programs began growing, the government (under Title X) began paying for the training and practice of NPs in rural and urban health clinics.¹⁵ Almost simultaneously, non-physician professionals were being relied on heavily in the armed services during this time of physician shortages.¹⁴

This was the start of negotiations between nurses and physicians to "work together, especially in a joint intellectual endeavor." The collaborative practice model was officially established in 1972 by the National Joint Practice Commission.⁸ On July 1, 1993, the House of Representatives passed Bill 564, which addressed collaborative practice agreements between physicians and registered professional nurses.¹⁶ As of January 2000, NPs could prescribe with no additional physician supervision and they are reimbursed 80%–85% of the fees charged to patients by physicians.¹⁰

Some NPs still choose to work in collaborative relationships, whereas many of have chosen to go into independent practice. Factors motivating NPs to choose collaborative practice include flexibility of being able to ask colleagues for a second opinion, need for affiliation and feedback, social interaction, and opportunity to improve themselves as teachers.⁸ Those who have chosen independent practice reported business advantages, freedom, lack of personality differences clashing and the drive to personal achievement.⁸ Despite legislative efforts, collaborative practice (for nurses) is not as uniform and widespread as the profession would like it to be.⁵

The impact of these NP collaborations in a Canadian model was assessed by Way and colleagues. Two primary care practices with 2 NPs and 4 family physicians (FPs) participated and provided information on their patient encounters and interviewed patients after obtaining consent. The results showed that the most common reason for visiting a NP was routine health exams whereas the most frequent reason for visiting a FP was cardiovascular disease (other than hypertension). FPs provided more curative and rehabilitative services whereas NPs provided more disease prevention and supportive services with health promotion being similar between the two groups. The study also showed that NPs are more likely to refer to an FP and not vice versa.¹⁷

Some successful examples of collaborative NP-physician relationships are in the areas of bipolar disorder (a side study off the VA Cooperative Study called the Bipolar Disorder Program), hemodialysis, oncology, pediatrics, rheumatoid arthritis (RA), and pain management.^{9-10, 18-23} In patients with RA, multidisciplinary teams are more effective than outpatient care with respect to disease progression, functionality, reduction in costs, and increased patient satisfaction.¹⁹ In oncology, the NP has evolved to meet medical and nursing needs of outpatients and NPs in hemodialysis settings have improved the standard of care for patients in end-stage renal disease while working along side other nurses and physicians.^{10, 21}

There are also community-based programs that are run entirely by nurses such as the Escalante Health Partnerships Program. This program focuses on fitness, health education, hypertension, cholesterol, and diabetes and arthritis screenings using the goals for Healthy People 2010. In this model, they were able to show (based on the SF-36 and other tools) that patients reported better health, performance, and social functioning while also having less doctor visits and hospital days per year.¹⁸ EverCare is another program that has been shown to deliver excellent collaborative care to the elderly in nursing homes.²⁴

An ineffective collaborative effort was observed in the outpatient management of eating disorders. In this study, a physician (also responsible for patients' psychotropic medication management), nutritionist, and mental health professional met regularly with patients and shared information and strategies for patient success. The major problem identified in this study was lack of efficient communication, which resulted in the patient siding with one professional over the other.²⁰ Halcomb demonstrated a similar ineffective collaborative model in heart failure with an intensive primary care intervention team that actually resulted in greater hospitalization rates for unknown reasons.^22,25 Pharmacists could have an impact in the treatment of heart failure by recommending evidenced based interventions in patients who are undertreated.

PHARMACIST MODELS

Despite advancements to the profession, pharmacy, unlike medicine, has not found the resources to maintain a well-organized targeted reformation to the status of the occupation.²⁶ A Cochrane database review showed that pharmacist intervention can improve patient adherence, physician prescribing, decrease drug-related morbidity, and decrease healthcare costs.^27-30 Pharmacists' ability to provide pharmaceutical care and implement quality therapeutic interventions has remained an area of controversy. This was reviewed by a panel of physicians and pharmacists who randomly selected patient records to evaluate the credibility and efficacy of pharmaceutical care interventions. Patients were referred to pharmacists for assessment and a pharmaceutical care note was completed for each encounter. Over 5700 drug therapy problems were resolved in the collaborative setting, therapeutic goals increased from 74%—89%, and the panel agreed with the decisions in 94.2% of cases. The authors concluded that pharmacists working in collaboration with physicians are credible and provide high quality of care.²⁷

Many Australian studies have shown that medication-related problems can be resolved with collaborations. One such Australian study used home medication reviews where pharmacists visited each patient to discuss mediation-related problems that he/she had or that his/her general practitioner (GP) raised. Pharmacists documented all information and clarified any medication education. Following the visit, the pharmacist and the GP met and discussed the plan for the patient. This medication management service was successful at resolving, managing, or improving 81% of problems in patients at high risk of drug-related events.³¹

Community pharmacists are positioned to be integral members of the primary healthcare team because they can identify undertreated patients and patients at risk for improper management. They can also offer education and advice to patients in areas such as cardiovascular disease and smoking cessation.³² Pharmacists are currently educating patients on the risks and benefits of treatment, adverse drug events/effects, drug interactions, monitoring, and encouraging compliance.³² In some instances, this role can be expanded to include authorizing pharmacists to decide if refills should be given, a practice that is currently used by several pharmacists working in physician offices.

Collaborative practice can also be achieved in hospital pharmacy. In 1992, Fairfax Hospital achieved this by reorganizing their pharmacy structure. The pharmacy department was restructured into four patient care divisions with technicians, pharmacists, managers, and clinical coordinators in each section so that pharmacists were empowered to make clinical judgments and provide pharmaceutical care. All divisions reported to an assistant director of that division, and they each created a new position called the technical manager to oversee the operations, inventory, human resources, and drug distribution services.³³

Pharmacists have also demonstrated effective collaborative practice models in the areas of primary care and family medicine.^34-37 Depression and chronic pain management are successful models whereby pharmacists are utilized in the team improving patient outcomes and decreasing costs.^34-37 In addition, Kaiser Permanente has developed collaborative practices in areas requiring aggressive medication management and followup in diabetes, asthma, hyperlipidemia, anticoagulation, and depression.³⁴ One study for depression in a large nonprofit staff-model HMO allowed pharmacists to have limited prescribing privileges to modify dosages of antidepressants, to start adjunctive therapy, and to make recommendations to the primary care provider (PCP). The PCP referred all patients in the intervention group (n=91) to the pharmacist-managed clinics, where they completed an interview and followed up with the pharmacist at 6 weeks and 24 weeks (telephone contact occurred in the meantime); the control group (n=129) had usual care. Success of primary care pharmacists was supported by a higher level of adherence (76% versus 51%, P <.005), higher overall satisfaction, and a decreased number of PCP visits (39.4% versus 12.2 % decrease, P=.007) justifying the potential role of pharmacists in primary care.³⁴

Similarly Gammaitoni and colleagues completed a study evaluating the benefits of pharmacist collaboration in the management of chronic pain (n = 74).³⁵ They used a palliative care company, PainRxperts, to provide specialized prescription services to the intervention group compared to usual care (control). The intervention group had pharmacists assess their pharmacotherapy, make recommendations to PCP when necessary, monitor for adherence and adverse drug reactions, and evaluate their quality of life. Patient satisfaction (using the Pharmacotherapeutic Pain Inventory) improved in every category in the intervention group, whereas the control group remained the same or declined. The study also showed that telephone contact reduced the average length of visit time with the PCP as well as a reduced frequency of patient calls to the provider.³⁵ This demonstrates another role: palliative care trained pharmacists for providing pharmaceutical care in collaborative arrangements.

Ratka describes the role of a pharmacist in ambulatory cancer pain management in greater detail.³⁶ An effective team for managing cancer pain includes anesthesiologists, neurologists, psychologists, psychiatrists, pharmacists, nurses, social workers, physical therapists, occupational therapists, and neurosurgeons. The justification for having pharmacists as part of this team is that pharmacologic management is critical in pain control and it is necessary to have experts in pharmacology to manage this. Pharmacists can provide services to cancer patients that include education, counseling, assuring adherence, surveying satisfaction, and alleviating concerns. In addition, they can provide multidisciplinary teams with services, such as providing recommendations, monitoring, designing patient-specific regimens, documenting adverse effects and drug interactions, facilitate the prescribing of controlled substances, provide information on patient assistance, serve as a liaison to insurance companies and pharmacies, and participate in research on pain pharmacotherapy.³⁶ However, creating relationships with multidisciplinary teams is a challenging task.

In May 2004, a study conducted in Iowa examined the working relationship between pharmacists and physicians using a personal interview and a survey.³⁸ Participants included 12 community pharmacists and the physicians they collaborated with. Information was collected about the extent of collaboration between pharmacist and physician and variables believed to influence the development of collaboration. The study found that pharmacists were likely to initiate the relationships by identifying the needs of the physicians. Other key elements for a successful relationship were the development of an effective bidirectional communication, level of convenience, addition of value to both parties, and the level of care towards patients. Other important considerations (but not discriminating) included trust, proximity, patient satisfaction, successful conflict resolution, formal collaborative agreement, the behavior of the pharmacist, and the history of the professional or social relationship between pharmacist and physician. They also found that collaborative agreements are more likely to occur if pharmacists can avoid or even reduce costs to the physician.³⁸

A survey in 1996 (n=32) showed that collaborative practice is being viewed positively on effecting pharmacists' relationships with physicians (50% of all responders viewed it as a positive impact; 46% viewed it as very positive) and patients (60% of pharmacists felt it was positive versus 32% who indicated no impact). This survey also assessed pharmacist job satisfaction. Results showed that pharmacists in collaborative practices were very satisfied in 48% of states and 44% of states with this legislation.³⁹ In the state of Washington, pharmacists (95%) and physicians (98%) are generally satisfied with the collaborative protocol arrangements.⁴⁰

Zillich and colleagues also examined the influential characteristics of pharmacist/ physician collaborative relationships in 2004.⁴¹ This study was conducted via mailed surveys to 1000 primary care physicians in Iowa. The survey consisted of questions from the Physician/Pharmacist Collaboration Instrument (PPCI). Although there was only a 34% responder rate, the study demonstrated that the most important factor in physician collaboration with pharmacists is relationship initiation, trustworthiness, and role specification. Relationship initiation begins with the pharmacist. Adding value to the physician by showing interest in the practice and developing services to improve physicians' care of patients is critical. Equally important is communication and trust, which has been deemed necessary in any healthcare team and may take time to develop. The most important factor was role specification, which will hopefully increase with time and be reimbursed.⁴¹

COGNITIVE SERVICES

The Academy of Managed Care Pharmacy (AMCP) puts cognitive services into three categories: pharmaceutical care, collaborative practice agreements, and pharmacist-directed services.⁴² The paradigm of pharmacists being "product dispensers" has shifted to one of "medication therapy experts." A model of this exists in Quebec in which the prescription is defined as an authorization to dispense, not an order.^43-44 In this model, pharmacists are allowed to bill a fee for service aside from a dispensing fee, for recommendations made to physicians that result in changes and improved healthcare outcomes.^43-44 Such examples provide opportunities for pharmacists to have an integral role on a healthcare team, which can vary from a position in the medical intensive care unit to a community pharmacy in which the pharmacist has established relationships with physicians and other healthcare providers.

Cognitive services by pharmacists have been recognized by the three major payers of healthcare, Medicare, Medicaid, and managed care organizations (MCOs).^{7, 42} Although pharmacists have been given limited compensation through these payers, the role of the pharmacist continues to expand for the benefit of the patient and the provider. These services that pharmacists provide include but are not limited to disease state management, diabetes education, asthma education, smoking cessation counseling, immunizations, and management of anticoagulation.

MEDICARE

NPs receive direct Medicare reimbursement at 85% of physicians' fees because of the Primary Health Practitioner Incentive Act (part of the Budget Reconciliation Act of 1997), in effect as of January 1998.⁸ Additionally, some states, such as Maine, allow NPs to apply for their own primary care provider status to obtain reimbursement from private insurance.⁸

In the current Medicare model, a pharmacist receives reimbursement for services only if meeting the Healthcare Financing Administration (HCFA) criteria for reimbursement even if the pharmacist provided the same services of a physician, NP, or PA. Even after the criteria is met, reimbursement is only given at the lowest rate known as "incident-to." These services are billed under Part B but reimbursement is given to the physician under whom the pharmacist is billed. These services can be performed in a physician's office whether the office is located in a separate building or is an office within an institution or a patient's home. A physician must personally perform the initial service and continue to remain actively involved throughout the course of treatment. The physician does not have to be physically present while the patient's service is being rendered but must be available for assistance and to provide direct supervision. This means that a physician must be present with a pharmacist for a home visit if he/she were to bill under "incident-to".⁴⁵ Four general "incident-to" rules set by Centers for Medicare and Medicaid Services (CMS) must be satisfied in order for a pharmacist to receive reimbursement.^45-46 The service must be 1) an integral part of a physician's diagnosis or treatment; 2) provided under the direct supervision of a physician; 3) performed by an employee of the physician; and 4) something ordinarily done in a physician office or physician-directed clinic.^45-46

In order to receive reimbursement, the pharmacist is faced with the challenge of meeting the rules described above.^45-46 Pharmacists can satisfy the first rule if they have established a good working relationship with a physician or group of physicians. Meeting the direct supervisory rule presents a difficult challenge, because the supervisory physician is required to be present in the same building. This forces the pharmacist to schedule patients only on the days the supervisory physician is available, and if the physician is not available, the services may be rendered but not compensated. An option is to have a collaborative agreement with a group of physicians who rotate the supervisory role. If the physician and pharmacist were employees of the same entity, meeting the third rule is easy; otherwise new contractual relationships must be formed.^45-46 Because HCFA limits its healthcare funds, pharmacists have the most difficult challenge satisfying the fourth rule because pharmaceutical care is not ordinarily conducted in a physician office. This is unfortunate because many aspects of pharmaceutical care which include assessing and educating patients are performed in physician's offices, but until pharmacists are recognized as providers, pharmaceutical care may not be recognized beyond the counter.⁴⁵

A common model in which pharmacists implement this type of reimbursement is in an anticoagulation clinic.^45-46 In this situation, physician X refers a patient to physician Y of the clinic. After physician Y examines the patient, a pharmacist can receive reimbursement of his/her services as long as physician Y continues to follow the patient. This service is billed under the Current Procedural Terminology (CPT) code #99211, where the attending physician receives reimbursement, rather than the pharmacist being directly compensated for his/her services. These factors partially demonstrate the limitation of "incident-to" billing for pharmacists. This is especially detrimental to clinical pharmacists who work collaboratively with physicians daily and cannot receive adequate compensation or reimbursement for their services.^45-46

MEDICAID

Medicaid is a joint program between individual states and the federal government, in which the states rely heavily on federal dollars; however, the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) allows Medicaid programs to be modified by states with CMS approval.^{7, 47} This allows states to obtain a federal waiver to allow for pharmacist compensation for cognitive services provided to Medicaid patients.^{7, 48} OBRA '90 was significant because pharmacists were recognized as a means to reduce drug costs and improve health outcomes.^{7, 48} To date, 4 states have successfully obtained waivers: Iowa, Mississippi, Washington, and Wisconsin.⁴⁸ The Iowa Medicaid Pharmaceutical Case Management (PCM) Program was the first program in the United States to recognize pharmacists as providers and will pay pharmacist-physician teams who deliver medication management services in the community for high-risk patients.⁴⁸ The program in Iowa allows both the physician and pharmacist to be reimbursed. More importantly, unlike with Medicare, a pharmacist can initiate a medication action plan without the patient having to see a physician prior to this consultation. The purpose of the Iowa plan is to avoid adverse drug events and associated health system costs, and there is sufficient evidence in Iowa and throughout the country in several settings such as ambulatory care and critical care that pharmacists are able to meet that goal.⁴⁸

A prospective cohort completed in 2001 examined patients who received PCM services and those who did not.⁴⁸ To be included, patients had to be taking more than 4 chronic medications from at least one of the following twelve disease states: congestive heart failure, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation, osteoarthritis, gastroesophageal reflux, peptic ulcer disease, and chronic obstructive pulmonary disease. There were 2211 Medicaid eligible patients and 524 received PCM. A 9-month follow-up period evaluating the Iowa program concluded that it improved medication safety without adding additional healthcare costs, and these costs included the costs charged for PCM services.⁴⁸ Despite promising results, Iowa has had difficulty implementing their PCM services throughout the state. In a recent study of Iowa's PCM services, 40%—60% of the evaluated pharmacies provided little or no services within three months of a patient becoming eligible. The problems were attributed to insufficient staffing, which did not allow the pharmacist to maintain and to expand services. Another factor was the it was difficult to maintain which patients remained eligible for Medicaid services. This is disappointing since both patient and physician refusal to participate was uncommon.⁴⁹

Other states, such as Mississippi, have disease management services from credentialed pharmacists, who have passed certifying examinations in one or more disease states, but these require an initial physician consult. Similar to Iowa, a lack of pharmacist participation is hurting promising results in the Mississippi program. Also, pharmacists in Washington and Wisconsin are reimbursed for drugs and drug product dispensing services that are used for the cognitive services provided.^7,50

Other mechanisms that pharmacists have obtained reimbursement through state Medicaid programs include immunizations and disease state management, which requires a pharmacist to obtain a Medicaid provider number. The compensation is limited and varies from state to state. One would have to refer to each board of pharmacy to review its pharmacy practice acts.

MANAGED CARE ORGANIZATIONS (MCOS)

Given the greater emphasis on healthcare outcomes and the advent of MCOs, AMCP recognized that the traditional role of the pharmacist dispensing medications can lead to avoidable drug-related problems contributing to increased healthcare costs and poor patient outcomes.⁴²

Currently there is little evidence to describe payments to either pharmacists or pharmacies from third party payers for cognitive services rendered. In this type of collaboration with MCOs, the pharmacist has the burden of contacting individual companies and assessing contracts typically for selected patients.⁴² Some programs include Outcomes Encounter Program by Outcomes Pharmaceutical Healthcare of Des Moines, Iowa, the collaborative care demonstration project in Tennessee, and services to Heartland HMO Medicaid patients by the University of Oklahoma College of Pharmacy.⁴² An example of a successful venture in which pharmacists contracted with insurance carriers is the Asheville project.

ASHEVILLE PROJECT

The Asheville Project involves collaboration between the North Carolina Center for Pharmaceutical Care and the City of Asheville.^51-54 The results of this study were published in a series of four articles in the Journal of the American Pharmaceutical Association in 2003. The city of Asheville funds its health insurance for municipal employees, their families, and retirees. Patients were paired with specially trained pharmacists and seen monthly. After documenting pharmaceutical care services, the pharmacists submitted claims for their services.^51-54 This fee-for-service averaged about $40 for every 20-minute visit.^7,55 This is one of the oldest studies showing community-based pharmacist intervention improving healthcare. In summary, the project demonstrated that pharmacist intervention improved glycemic control, primarily in patients with Type 1 diabetes, and decreased medical costs, which include both direct medical costs and costs associated with sick days.⁵⁴ Direct medical costs decreased from $1200 to $1872 per patient year vs baseline, and one employer saved an estimated $18,000 in productivity due to sick days saved.^51,54 Patients and their pharmacist providers also had positive perceptions throughout the study as well.⁵³ Patients were pleased with their relationship with the pharmacist because they were given a sense of control in their care. Providers felt a sense of professional growth and satisfaction that they made a difference.⁵³

PROJECT IMPACT

Although not focusing on reimbursement, Project ImPACT (Improve Persistence and Compliance with Therapy) was a community-based demonstration project involving 26 pharmacies that varied between independent, chain-professional, chain-grocery store, home-health/home-infusion, clinic, and health maintenance/managed care.⁵⁶ The purpose of the study was to: 1) improve patient persistence and compliance with lipid-lowering therapy, 2) increase communication and flow of clinical information among patients, pharmacists and physicians, and 3) improve cholesterol levels. The results showed a 90.1% medication compliance rate, 62.5% of patients achieved their cholesterol lipid goals (based on National Cholesterol Education Program goals) and physicians accepted 265/346 (76.6%) of pharmacists' recommendations. This demonstrated that collaborative practice with physicians, pharmacists, and patients advance the level of care.⁵⁶

LEGISLATION

Legislation began with brave initiatives in states such as California, Washington, North Carolina, Iowa, and Mississippi in the 1970s.⁴⁰ In 1996, 16 states authorized pharmacists to initiate and modify drug therapy. A study to evaluate the extent of these collaborative agreements completed in 2002 found that 32 states had collaborative practice laws (23 states allowed initiation and modification of drug therapy; 9 states were only able to modify drug therapy) and an additional 9 states planned to pursue these laws; currently in 2004, there are now 40 states with and 3 states pending collaborative practice legislation (see Table 2).³⁹

Table 2: States with Collaborative Practice Agreements75
Alabama (pending) Alaska Arizona Arkansas California Connecticut Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maryland Massachusetts (pending) Michigan Minnesota Mississippi Montana	Nebraska New Jersey New Mexico New York (pending) Nevada North Carolina North Dakota Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming

The Indian Health Service began in the early 1970s.⁴⁰ This collaboration began as a training program at Phoenix Indian Medical Center in 1972.² The program was the first time prescriptive authority was given to pharmacists.² A similar national model has existed for several years in Veterans Affairs (VA) hospitals. In 1985, the VA issued guidelines for clinical pharmacy specialists to be "...a pharmacist with a doctor of pharmacy degree preferably including a clinical pharmacy residency or equivalent education...whose primary responsibilities are to promote, assess, and assure quality and cost-effectiveness of drug use and drug therapy..."² These pharmacists continue to prescribe, alter medications, and discontinue unnecessary medications after thorough patient assessment. VA patients are referred to pharmacists by their PCPs for tighter chronic management of their disease states.

Although there appears to be a lack of unity among the various pharmacy organizations, in an attempt to gain provider status for CMS reimbursement, the introduction of H.R. 4724 (better known as the Medicare Clinical Pharmacist Practitioner Services Coverage Act of 2004) has united 7 of the major pharmacy organizations to form an organization known as the Pharmacist Provider Coalition.

Known in pharmacy circles as the Burr Amendment, this legislation aims to amend title XVIII of the Social Security Act to provide for Medicare coverage of authorized clinical pharmacist practitioner (CPP) services involving toxicology, therapeutics, clinical pharmacokinetics, pharmacoeconomics, and other life sciences for the direct care of patients, which would have previously been covered under a physician, or as "incident-to" a physician's professional service. This would also require these services to be performed under state law or regulation in a collaborative practice agreement. The primary concern of the coalition is that the term CPP exists in 2 states, North Carolina, which Burr represents, and New Mexico. This could conceivably cause CMS to narrowly interpret this bill and deny coverage to other clinical pharmacists in other states. A further step that CMS could take is to allow only coverage for a limited amount of pharmacists in North Carolina or New Mexico. Discussions between the PPC and Congressman Burr's staff are ongoing to respond to the American Medical Association (AMA) concerning the financial impact of the legislation on the payment structure for Medicare Part B and the AMA's desire to emphasize "supervisory" rather than "collaborative" terminology.⁵⁷

BENEFITS

The benefits of collaborative practice are numerous (see Table 3). Pharmacists working in collaboration with a healthcare team in a variety of settings can improve the appropriateness of prescribing, prevent or minimize adverse drug events, improve therapeutic outcomes in patients, and reduce healthcare costs.^27-30 In addition, collaborative practice brings personal and professional enhancements for the clinician. Five such benefits include: 1) improving the clinician's knowledge and patient care, (insight into the patient's needs), 2) increasing the clinician's biopsychosocial and spiritual awareness, 3) assisting in referrals and consultation, 4) providing personal fulfillment and job satisfaction (examining one's own patterns, responses and pitfalls), and 5) ability to extend beyond personal areas of interest.^9,58

Table 3: Advantages and Disadvantages of Collaborative Practice5
Advantages	Disadvantages
Team exceeds the sum of the parts?	Overlapping responsibilities
Elimination of hierarchies	Disagreement of care
Greater retention of staff	Multiple billing for services
Innovative and creative practices that is a unique marketing tool	Pharmacists viewed as budget holders or cost controllers23
Improved patient outcomes
Distribution of resources and enhanced efficiency
Holistic care emphasized rather than curative
Avoidance of fragmented and individualistic practices
Little to no competition for resources
Incentive to improve practice and knowledge

 

Economic benefits of pharmacy services and improved patient outcomes have been demonstrated in many studies and published by the American Pharmaceutical Association (APhA).^59-60 It is estimated that pharmacists could save up to $46 billion in direct health care costs and up to $3 billion in drug-related morbidity and mortality for nursing facility residents.⁶¹ Clinical pharmacy services have also been associated with impressive benefit-to-cost ratios. These ranged from $2988.57:1 for adverse drug monitoring, and $83.23:1 for drug protocol management.⁶¹

BARRIERS

Barriers to establishing pharmacists as providers are similar to those faced by NPs and PAs in the past. Mainly, these include physician and nursing opposition as well as certain pharmaceutical driven challenges. In a survey to pharmacy state organizations, 41% of responders (n=32) stated medical associations or physicians as the largest barrier.³⁹ Difficulty in educating healthcare professionals about pharmacists' capabilities (16%), pharmaceutical manufacturers (16%), nursing associations (9%), and lack of pharmacist lobbying (9%) were among the other barriers mentioned. These surveys also asked what factors facilitated the advancement of collaborative practice laws in those states and the results were as follows: state boards of pharmacy (31%), state pharmacy associations (25%), having a university of school of pharmacy in the state (16%), and physician advisors/supporters (16%). However, even in states with this legislation, only about 5% of pharmacists perceive they are actually involved in collaborative practice.³⁹

Physician organizations including the AMA and the American College of Physicians continue to fear the advancement of other healthcare professions for several reasons, including potential erosion in the quality of care, perception of resentment, economic competition, and fear of non-physicians working beyond the scope of practice.^14,62 However, it has been suggested that unnecessarily limiting the scope of practice is unethical, given that the non-physician is trained.⁶² Some physicians have recognized that patients enjoy interacting with other members of the healthcare team partly because of the improved access to care that it brings.⁶² This may actually be an attraction to new patients. In addition, using other members of the healthcare team can free up physicians to devote more time on more complex medical problems.¹⁴ Several other factors for both facilitating and preventing collaboration can be found in Table 4.

Table 4: Factors that Facilitate or Impede Collaboration10, 61, 76
Facilitate	Impede
Assignment to patients and authority to document in the medical record	Economics
Access to exam/interview rooms	Time limitations
Office/work space	Confusion or resistance by other health-care professionals
Flexibility of organizational structure/support	Confusion or resistance by patients
Legislation	Unclear roles and expectations
Physician support	Lack of prescriptive authority
Clear job description	Lack of payment for cognitive services
Standardized procedures	Federal reimbursement constraints
Clinical competence	Lack of respect
Professional maturity	Preventative attitudes or behaviors
Feasibility	Hierarchical structure

There are currently many barriers for pharmacists to provide cognitive services and the primary reason is the lack of adequate reimbursement and compensation. In the community, pharmaceutical care and associated cognitive services are typically included in the dispensing fee.⁴³ Pharmacists are not typically reimbursed for the time spent with a patient beyond the
dispensing of the medication.⁶³ In one survey, pharmacists were less likely to spend more time with patients because there was not enough time to do so.⁶³ However, the survey results also indicated that if pharmacists were reimbursed for their time spent, it would be more likely that they would take more time with patients. Another factor is that pharmacists had no incentive/reward from their employers, making these services less likely to exist.⁶³

There is also a lack of consistency in obtaining reimbursements.^63-64 Evidence to support this from the state of Washington was published in 2000.^63-64 Christensen and colleagues studied pharmacies that were reimbursed $40 per month (control) versus pharmacies that, in addition to $40 per month, received $4 per intervention up to 6 minutes and $6 for interventions greater than 6 minutes.⁶⁴ Approximately 75% of 20,240 cognitive service interventions were from intervention pharmacies, which reported 1.3—2.4 interventions per 100 prescriptions dispensed. The control pharmacies reported 0.7—1.0 cognitive intervention per 100 prescriptions dispensed.⁶⁴ Without cognitive service, pharmacists will remain unrecognized and patients will not know how the pharmacist is contributing to their care in both the inpatient and community settings.²⁶

Difficulties to collaborative practice are largely based on attitudes and behaviors learned. A case study for 3 months evaluating the collaboration of 6 teams (none involving a pharmacist) identified 3 types of groups: the directive, integrative and elective.⁶⁵ In the directive group model, a person leads by status or power and directs the actions of others. This was very common in groups with physicians. The integrative team held team-work as the standard and learned from each other's disciplines. These teams were usually comprised of both physical and occupational therapy, social work, and nursing. The elective model, composed of mostly mental health professionals, preferred working independently but referred to others when they needed them. Groups that modeled integrative behaviors excelled professionally and personally.⁶⁵

Additional barriers reported by healthcare professionals are low/little proximity between providers, being in a team with too many collaborators or collaborators that do not share the same work ethics, collaborating with professionals that do not understand their limits, or the perception that multiple disciplines will actually create a larger workload.^9,58,66 Despite these barriers, 70% of physicians and NPs believed collaborative practices, particularly in rural, urban, and suburban areas, would increase.¹⁶

MECHANISMS FOR FUTURE OPPORTUNITIES

Creating future opportunities begins with declaring competency. Clinical competence is probably the most important variable in successful collaborative relationships and can secure a mutual respect between all participants.⁸ The pharmacist must demonstrate their expertise by the means of advanced training or certifications.⁷ This includes certifications in diabetes (CDE or ACDM), asthma education (AE-C), smoking cessation counseling, immunizations, and geriatrics. The National Association of Board of Pharmacy currently offers disease state management certifications in areas such as diabetes and asthma. Other pharmacy organizations such APhA offers a certification in diabetes education, and the Board of Pharmaceutical Specialties (BPS) offers 5 specialty certifications including oncology, nutrition, psychiatry, nuclear and the most common, pharmacotherapy.

Other key concepts in creating and maintaining successful collaborations include self-recognition of not being the expert, exercising inclusion instead of exclusion of other disciplines, and avoiding taking matters personally.⁵⁸ Richard Waldman, a physician advocate of collaborative practice said, "similar but distinct professions working together can create a synergism that results in a product that is greater than could have been produced by the professionals alone."⁶² Other variables for successful collaborative relationships are in Table 5.

Table 5: Elements for a Successful Collaborative Agreement10, 11, 76

Voluntary agreement to work with one or more physicians under a written and signed agreement to perform certain patient care functions under certain specified conditions Shared vision/goals Effective communication skills Clinical competence Shared problem-solving or conflict resolution and leadership Mutual trust and respect Understanding and value to everyone's roles Collegiality Willingness to change and negotiate Accountability for the same quality measures Equal exchange of information and knowledge

Another important mechanism for successful collaboration involves designing effective teams. The collective goal of the health team should be to "promote and maintain the patient's health or well-being."⁶⁷ It requires good leadership and a willingness to be flexible,⁶⁶ as well as a high level of maturity and motivation and an ability to communicate, educate, give feedback, and resolve conflicts.⁶⁶ One suggestion for a good team is for it to consist of 6—10 members with adequate resources and processes to guide their development.⁶⁶ Another element of having a good team is being able to have each team player add services to the rest of the team. For pharmacists, this can mean finding ways that physicians may benefit from your service (ie, anticoagulation management).³⁸ How this is approached is important, though. Experts in the art of collaborative practice suggest using phrases such as, "How can I be helpful" instead of, "This is what I can do to help you improve your patient care."⁵⁸ Trying to be overly ambitious could ruin relationships before they can be built. In addition, written agreements to define roles and provide legal protection are recommended.¹⁴ These agreements should include every party's name and title, professional training and experience, certifications, specialized areas of practice, standards of practice, and professional responsibility.¹⁴ In addition, the volume of patients and billing expectations may be relevant to include.¹⁴

For pharmacists to be an effective member of the team, one suggestion is to implement target drug programs that assess inappropriate drug use and drug use which will improve the correct use of drugs, subsequently improving patient care.⁵⁹ These programs should be based on literature, focus on cost minimization, assess generic or therapeutic interchange, and lead to clear information usable in future studies. More advanced programs can be prospective in nature and try to quantify health outcomes while capitalizing on the role and value of the pharmacist in various patient groups.⁵⁹

Another mechanism begins at the level of pharmacy school education. One such modality includes interprofessional programs/activities. In advanced cardiac life support, multiple disciplines create for a more effective approach. Understanding each person's profession, role, and capability leads to a more unified team and better outcomes.⁶⁸ Education of multidisciplinary teams and practice abilities (as emphasized on rotations or projects such as immunization drives) throughout a pharmacy student's curriculum including both didactic and clinical experiences can increase awareness and effectiveness across disciplines and provide opportunities to perfect collaboration.⁶⁹ One effective model to teach and learn collaborative practice was first presented by Biggs (1993) which is called the 3P model; presage, process, and product (see Figure 1).¹¹ Presage factors are things that influence the planning and outcomes of a learning experience. The process involves trying multiple different strategies to teach collaboration during different stages of the student's education.^11,65 The ultimate product is a collaborative system that will impact patient outcomes. This is a dynamic complex system with a continuous feedback mechanism that can affect multiple levels (ie, presage factors influencing the product directly, which can return to influence the process).¹¹

Figure 1. 3P model of learning to collaborate11

In addition, students should be able to see collaboration and the increased responsibilities of pharmacists being modeled by their faculty and various educators by having courses taught by an interdisciplinary faculty.^58,70 Bellack et al in 1997 said, "discipline-specific knowledge, while necessary, is not sufficient for practice in today's world." He concluded that professional programs do a very good job of stressing interdisciplinary culture and identity to prepare students for their role in that profession, especially on clinical rotations. He added that although students are exposed to interdisciplinary practice, they are not specifically taught to "blur the professional boundaries across disciplinary lines," which should be done in the classroom as well.⁷⁰ This was attempted at East Carolina University but faced many challenges including students' fear of being singled out in front of other disciplines, disciplines taking "supremacy" with the belief that they were more knowledgeable, initial weak relationships among the faculty, and schedule conflicts. Despite these obstacles, the course had significant support from upper administration that facilitated its success. Evaluations measured attitudes, beliefs and knowledge about the system and students' opinions about it. Course instruction showed students had improved perceptions of collaboration in healthcare. There was a demonstrated increased sophistication and depth in their descriptions of collaborative practice at the end of the course. Evaluation of the course included questionnaire tools such as the University's Survey of Student Opinion of Instruction as well as personal journaling. This university is now involved with the Public Academic Liaison (PAL) network in North Carolina, which supports teleconferences to discuss interdisciplinary course development between several schools.⁷⁰

Three final mechanisms for pharmacists include: 1) continued involvement in research efforts to prove the clinical effectiveness of the collaborative model, 2) consistent lobbying efforts to push for legislative action and 3) continued research with other disciplines.⁷⁰ Collaboration can increase the organization's capacity and productivity of research which can eventually be implemented into practice and decision-making.⁷¹ Finally, the understanding that collaboration takes time to develop, but requires commitment to succeed is critical.¹⁰

As Zellmer emphasizes in Searching for the Soul of Pharmacy, "Pharmacy is an occupation physically bound to the act of providing medications to patients but which knows that it must find a new reason for being."²⁶ As the role as healthcare providers is changing, pharmacists have the opportunity to be recognized for their contributions to patient care.⁶⁸

 REFERENCES