Elevated professional status drives patient access
Converging trends in health care, including a rapidly aging baby boomer population, a steady rise in chronic disease and massive policy changes such as those associated with the Affordable Care Act, are creating increased demands for patient care just as the shortage of primary care physicians continues to become ever more pronounced — in five years it is expected that the United States will have about 100,000 fewer primary care physicians than needed — and threatening to further compromise an already overtaxed healthcare system.
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The Pharmacy and Medically Underserved Areas Enhancement Act — now pending in Congress as H.R. 592 and S. 314 — would address that by leveraging the convenience and the clinical expertise of the community pharmacist, helping to expand access to care for millions of underserved Americans, lowering the cost of delivery of critically important frontline health services and fostering new models for collaborative care.
The legislation “would designate pharmacists as healthcare providers in Medicare Part B — empowering them to deliver services to Medicare patients in underserved communities, according to pharmacists’ scope of practice laws in each state,” explained Steve Anderson, president and CEO of the National Association of Chain Drug Stores. He called the growing support for the legislation from Congress and within the U.S. population “just one example of the growing recognition of pharmacy’s value, and the ability of highly trusted, highly educated and highly accessible pharmacists to improve and save lives.”
The “lack of pharmacist recognition as a provider by third-party payers, including Medicare, has limited the number and types of services pharmacists can provide, even though they are fully qualified to do so,” Anderson said. “The adoption of policies and legislation to increase access to much-needed services for underserved Americans, such as … the Pharmacy and Medically Underserved Areas Enhancement Act, would allow Medicare Part B to utilize pharmacists to their full capability by providing those underserved beneficiaries with services not currently reaching them.”
Among the nation’s pharmacy leaders, the bill is perhaps better known simply as provider status legislation. Why? It would confer professional status as healthcare providers on pharmacists who provide health services to seniors in need, putting them on roughly equal footing with other professional caregivers, such as nurse practitioners and physician assistants, as members of the modern, coordinated healthcare team.
“H.R. 592 and S. 314 would build on existing law that allow nurse practitioners and physician assistants to be reimbursed by Medicare by covering services delivered by pharmacists,” noted the Patient Access to Pharmacists’ Care Coalition, an advocacy group whose members include NACDS, the National Community Pharmacists Association, the National Consumers League, the National Rural Health Association and many other groups.
“Similar to the law for NPs and PAs,” added the advocacy group in a report, “the Pharmacy and Medically Underserved Areas Enhancement Act would limit rates to 80% or 85% of what would be paid to physicians, helping limit Medicare spending while improving access.”
Unleashing innovation in cost-effective care
Efforts to expand the pharmacist’s scope of practice have steadily gained traction in Congress. Prior to the end of the last session, H.R. 592 had drawn 264 Democratic and Republican co-sponsors in the House — more than 60% of the total membership — and 41 co-sponsors in the Senate.
Public support for elevated status for pharmacists also is solid. The most recent national opinion research poll from NACDS shows that more than 8-in-10 consumers are in favor of the bill.
Left to right: Alexa Mitchell and Holly Moore, both second-year pharmacy students at Washington State University
College of Pharmacy, work with clinical assistant professor Kimberly McKeirnan, PharmD, to deliver health screenings
at a local Albertsons pharmacy.
Going back at least to the mid-1800s, many community pharmacists have been given the informal title of “doc” or “doctor” by grateful local residents, particularly in smaller towns and rural communities where the local pharmacist might be the only health provider within miles. These days, the title is more than honorary; it’s a requirement.
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Before they even attend their first class, today’s prospective pharmacists have undergone the rigorous selection process required of any student applying to one of the nation’s 135 colleges of pharmacy. Once enrolled, they begin an intensive, six- or seven-year journey toward the doctor of pharmacy degree now required to practice pharmacy in the United States. By the time a student has earned a doctor of pharmacy, they will have completed approximately 140 graduate school-level required course credit hours — about one-third of which are experiential in nature via prescribed types of clinical practice mentoring.
“The doctor of pharmacy degree program requires at least two years of pre-professional (undergraduate) study followed by four academic years of professional study,” noted the American Association of Colleges of Pharmacy. What’s more, said the organization, “a growing number of first-year students enter a pharmacy program with three or four years of college experience.”
Given the fact that pharmacists literally bear responsibility for the health, well-being and in some cases the lives of patients, it’s no surprise that they undergo extensive training and advanced education before donning the white coat. In addition, the field of pharmacy has become increasingly complex as advances in pharmaceutical therapy and genomics have taken hold — and as pharmacists’ patient-care activities have become more integrated with those of doctors and other members of the healthcare team.
Harry Leider, chief medical officer for Walgreens, said, “The level of education and training pharmacists receive has increased significantly in recent years. Pharmacy students are now required to earn a doctor of pharmacy degree (PharmD), which typically takes seven to eight years to complete — including undergraduate and pharmacy school education. Many pharmacists go on to receive additional specialized training in areas of growing need like immunizations, diabetes or HIV/AIDs.”
Learning to collaborate
“The role of the pharmacist is rapidly changing,” agreed the University of Pittsburgh School of Pharmacy in a mission statement. “Pharmacists are able to contribute to the healthcare team by utilizing tools and skills that facilitate patient care. With significant national support for pharmacists’ ability to impact the healthcare of patients, there is an imperative need to address the significant gaps in access to patient care services.”
“Pharmacists are patient-care providers who focus on the appropriate, safe and effective use of medications while collaborating with members of a healthcare team,” added Pitt Pharmacy School dean Patricia Kroboth. “Changes in the U.S. healthcare system are driving an exciting evolution of responsibilities and roles for pharmacists. Our graduates practice in a variety of environments on the continuum of keeping healthy communities healthy to caring for the sickest of the sick.”
At the University of North Carolina’s Eshelman School of Pharmacy, the education of prospective pharmacists now features “more patient-care experience, expanded research … and a flipped classroom that shifts the lecture[s] outside of class and replaces them with more interactive, team-oriented and critical-thinking activities.” In this “new curriculum,” said Russ Mumper, Eshelman’s vice dean and professor, “the role of patient care … will begin much earlier in the student’s educational process.”
According to Evan Robinson, founding dean of Western New England College School of Pharmacy, new educational guidelines from the American Association of Colleges of Pharmacy reflect the dramatic evolution of pharmacy practice. This expansion of pharmacists’ expertise and engagement comes as pharmacists fill a broader and more clinical role as frontline patient care providers, working in partnership with physicians and health systems as part of an integrated care team focused on improving patient outcomes and long-term wellness.
“Pharmacists have been very effective communicators, and now the question is, ‘How do we grow in our role as educators?” Robinson said. “The goal now is to enhance our therapeutic knowledge to make us far more valuable as a member of the interprofessional team in collaborative services for patient care and outcomes management, whether it’s in a patient-centered medical home, in care-based activities, etc.”
The nation’s schools of pharmacy have significantly expanded their curricula and community outreach, said the pharmacy educator, to give newly minted doctors of pharmacy the fully rounded, advanced-degree education in pharmacotherapy and health sciences they’ll need for today’s more complex and clinically oriented model of pharmacy practice. But today’s pharmacy students also are gaining a deeper understanding of patient relationships, empathetic long-term care, counseling on healthier lifestyle choices for patients, the management of chronic diseases and the team-based approach to patient care that increasingly defines today’s healthcare system.
“Our curricula have evolved in a very solid, stepwise, evidence-based manner to try and find ways to capitalize collaboratively for patient outcomes,” Robinson said.
‘Redefining pharmacy’s role’
Today’s pharmacy curricula is preparing new generations of community pharmacists for work as behavior management experts spending less time dispensing and more time on patient management activities.
“Communication skills are critical,” said pharmacy educator Kimberly McKeirnan. “As pharmacists, we regularly interact with people who are faced with difficult situations like health concerns of their own, health concerns of a family member or financial difficulties.”
As a result, “PharmD education includes training and opportunity to practice communicating — interviewing and counseling patients, effective communication with other healthcare providers,” said McKeirnan, clinical assistant professor in the College of Pharmacy at Washington State University Health Sciences.
Pharmacy schools are aligning with the changes in pharmacy practice in order to better prepare students for a more clinical and holistic approach to patient care by pharmacists. At the University of Iowa’s College of Pharmacy, for instance, “classes are now organized by disease state and will be team-taught.”
“PharmD students in small groups will learn about the scientific process, develop a scientific project and present findings,” the school reported recently. “An essential piece of the [new] ‘Learning and Living’ curriculum is having pharmacy students and other health sciences students collaborate. There will be more flexibility for students seeking dual degrees and additional specialization.”
According to Donald Letendre, dean of Iowa’s pharmacy school, the college is “redefining the role pharmacy will play in tomorrow’s healthcare system one outcome at a time, … from the discovery of new drug therapies to groundbreaking delivery models for patient care … advancing the world of pharmacy by achieving outcomes that matter.”
“Our students are rubbing elbows with nurses and physicians every day,” Letendre said. “We are always at the forefront of innovation.”
Connecting the new healthcare team
The future of American health care could be summed up in one word — “connection.” To thrive in a fast-reforming healthcare system that demands better patient outcomes at a lower cost, pharmacies, physicians, hospitals, health systems, outpatient clinicians and diagnosticians are going to have to connect much more effectively, both with one another and with the patients they serve.
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This move to coordinated care is critically important to the nation’s overburdened and overly costly health system. “A growing body of evidence suggests that when physicians, nurses, pharmacists and other healthcare professionals work collaboratively, better health outcomes are achieved,” said Steve Anderson, president and CEO of the National Association of Chain Drug Stores. To that end, he said pharmacists are “partnering with healthcare providers work ing in nearby health systems and hospitals, serving as part of care teams to help improve patient health and outcomes.”
The nation’s pharmacy providers are helping to drive the change. Wielding advanced automation and data systems, they’re working hard to align their pharmacists’ patient-care and disease-prevention activities with the overall clinical efforts of hospital systems, physician groups and other health providers. In the process, they’re helping to build a new team-based, patient-focused model of coordinated community care.
“Integrated delivery models and team care are the wave of the future, and the way to ultimately control healthcare costs and deliver better care,” said Robert Thompson, recently retired EVP of pharmacy for Rite Aid. “We’re trying to have a broad range of capabilities to participate in that environment.”
In a growing number of stores and regions, “Rite Aid pharmacists and specially trained care coaches, located in Rite Aid pharmacies, work with the physician and patient on an ongoing basis to improve the patient’s overall health and self-management abilities. The care team members collaborate with the patient to establish health goals, eliminate barriers and create a personalized healthcare action plan in coordination with the patient’s physician,” noted a company spokesperson.
Through the company’s Health Alliance program, local and regional health systems are beginning to embrace the idea by enlisting Rite Aid stores in a network of extended care for post-discharge patients with chronic conditions, Thompson said.
“It takes a village,” added Jocelyn Konrad, Rite Aid’s current EVP of pharmacy. “We want to collaborate, whether it’s with other health professionals, employees, health plans — whatever that may be. We want to be part of that solution.”
Linking ‘the healthcare ecosystem’
This new health delivery paradigm is about being “a more integrated part of the healthcare ecosystem,” noted Brad Fluegel, SVP and chief strategy and business development officer for Walgreens Boots Alliance. “Across the spectrum, we’re trying to figure out how to help stitch together various parts of the healthcare system to deliver a better experience for the patients.”
“A lot of what we’ve been doing as we talk with health systems, health plans and others is making sure that we can connect our process and our data with theirs, so that we can help improve adherence rates, close gaps in care that patients might be experiencing and use our digital health tools to create incentives for patients and consumers to take better care of themselves and remain adherent,” Fluegel added.
Richard Ashworth, president of Walgreens pharmacy and retail operations, said the goal “is to leverage the assets that Walgreens brings — including our locational advantage and our core pharmacy capabilities — and to put those together with our other adjunct healthcare services … in partnerships with local health systems.”
Ashworth called those partnerships “one of the strategic pillars for our healthcare strategy.” And hospital-based health systems, he added, are “the crux of where care is really delivered, which is in the community, by hospitals and health systems and physicians.”
To that end, Walgreens and other pharmacy providers are positioning themselves as the community-based health resource for patients after their discharge from the hospital. It’s about extending and completing the web of patient care beyond the hospital or physician practice setting in a new “collaborative services model,” Ashworth said. “This means we take the assets we have and the infrastructure we have, and work together with the local health system to better coordinate care.”
Connecting the dots in health care can involve every aspect of a pharmacy organization. CVS Health, for instance, joined with the Department of Health and Human Services last year in a partnership involving both its pharmacies and its more than 1,100 MinuteClinic in-store clinics. The goal: To promote an online information resource for Americans that “provides recommendations from government-recognized clinical experts for the personalized preventive services patients should receive based on their age and gender,” according to the company.
“Many of these recommended preventive services are conveniently delivered at MinuteClinic, where we can coordinate with a patient’s primary care physician,” said Andrew Sussman, associate chief medical officer for CVS Health and MinuteClinic president and EVP.
This team-based, coordinated network of care will require advanced automation to capture and share patient data and electronic health records in systems that protect patients’ privacy, while still allowing all the members of their healthcare team — doctors, hospitals, clinicians and pharmacists — to share the information needed to make the best informed decisions on their behalf.
Pharmacies have been ahead of the automation and data-capture curve for decades. Their leadership in automated health information began with integrated pharmacy dispensing systems that link all stores within a pharmacy chain on a common information and record-keeping platform. And the rollout of electronic prescribing over the past 15 years strengthened those data connections, forging new links between pharmacies, prescribing physicians, health systems, health plan care coordinators and pharmacy benefit managers in a continuum of care.
All these connections are forging “a more connected and collaborative healthcare system with a technology-neutral platform that exchanges vast amounts of data across a disparate range of health technology systems,” said Tom Skelton, CEO of e-prescribing platform provider Surescripts.
“There is no question that healthcare is going digital,” said Skelton. “Providers … are sharing critical information to coordinate patient care. Just as we’ve witnessed continued growth in e-prescribing, so too have we seen the complexity of the healthcare system multiply, while patients and providers demand easier access to health information.”