Improving Value Through Pharmacist/Physician Collaboration

The projected shortage of physicians by the year 2025 is estimated to be between 12,500 and 31,100, opening up numerous opportunities for pharmacists in the movement toward a patient-centered medical home (PCMH) collaboration between physicians and pharmacists, explained Hae Mi Choe, PharmD, director, Pharmacy Innovations & Partnerships at the University of Michigan Medical Group, and Laurie A. Wesolowicz, PharmD, director, Pharmacy Services Clinical, at Blue Cross Blue Shield of Michigan. Plans designed to integrate pharmacists into care teams are already being implemented.

Medication-related problems account for an estimated cost of $290 billion annually in drug-related morbidity (13% of total health care expenditures). Adverse drug events occur in 27% of patients in the ambulatory care setting, of which 39% have been deemed preventable. The largest avoidable cost lies in medication nonadherence, at a price tag of $105 billion, and delays in applying evidence-based treatment to patients leads to $40 billion in annual avoidable costs.

Clinical pharmacists can support physicians to free up physician time by providing disease management support, focusing on disease and medication-specific goal attainment and providing comprehensive education on disease states and medications. They can also provide polypharmacy consults/comprehensive medication reviews by evaluating complex medication regimens, identifying and resolving drug discrepancies and drug-related problems, and assessing treatment burden versus needs. 

Support for pharmacists taking on these roles within health care teams is already being seen, the presenters told attendees. 

There are three types of pharmacist collaboration in primary care:

• Coordinated: Collaboration is minimal; pharmacists work in the pharmacy and have limited communication with the primary care physician’s (PCP’s) office. Communication is generally with office staff about prescription orders. 

• Co-located: Consists of basic on-site collaboration where pharmacists work with the primary care office to access patients’ electronic health records to review diagnoses, medication lists, lab results, and notes. The arrangement is typically part-time and pharmacists may provide e-consultations to PCPs without seeing or talking to patients. There may also be close on-site collaboration where pharmacists with direct patient care experience work as team members in the PCP office. 

• Integrated: Collaboration is partial; pharmacists are embedded in PCP offices and meet with patients to manage medications between physician visits, review patient needs, and make medication management recommendations. Collaboration also may be full, in which case the pharmacist’s role is well-defined for medication activities within the PCP office work flow (eg, reconciliation, medication management, and coordination).

Michigan Pharmacists Transforming Care and Quality (MPTCQ) is one such plan designed to integrate pharmacists into care teams in order to improve patient care and outcomes. Among the largest challenges for such collaborations, according to the presenters, are establishing a framework for clinical activities and outcomes, pharmacists maintaining a practice as part of the team-based care model to ensure care coordination, and multiple PCMH practice models. Receiving funding for payment for pharmacist-delivered care is another challenge. Blue Cross Blue Shield of Michigan is funding MPTCQ, they continued, because the program dramatically improves quality and outcomes, decreases costs of care, and allows practitioners to self-optimize: “It is a win for those who seek care, those who provide care, and those who pay for care.”

The University of Michigan Health System (UMHS) is following the MPTCQ lead, Dr Choe continued, with the UMHS pharmacist practice model consisting of 11 embedded pharmacists in primary care clinics. The pharmacist’s time at the clinics varies depending on patient volume (about 1-3 days/week). Pharmacists provide disease management services (specifically, diabetes, hypertension, and hyperlipidemia) and comprehensive medication review (CMR) services. Disease management services involve identifying potential candidates through disease registry and/or the provider clinic schedule. Patients are scheduled for initial 30-minute clinic or phone appointments, after which they are scheduled for 15- to 30-minute follow-up appointments to improve disease control and/or medication management.

The initial appointment associated with CMR services focuses on the patient’s medication concerns, confirming medication use, assessing the patient’s understanding of the disease and treatment plan, and identifying potential barriers to treatment, including drug cost. A follow-up appointment is scheduled for 2 weeks later, where the pharmacist will discuss new treatment plans with the patient with the goal of improving efficacy, safety, and lowering drug costs.

Both initial and follow-up appointments can be conducted over the phone or at the clinic for a total of 75-90 minutes of CMR experience.

As the MPTCQ program expands, Dr Choe told attendees, the short-term goal is to adopt and modify an integrated pharmacist practice model at physician group incentive programs. In the long term, the goal is to improve patient care and outcomes at participating physician organizations through pharmacist integration. Objectives of the MPTCQ program include identifying, training, and supporting at least one pharmacist transformation champion (PTC); adopting and modifying clinical infrastructure and process elements of the integrated pharmacist practice model; and expanding training and support to other clinical pharmacists at their affiliated practice sites. 

The required infrastructure of MPTCQ practice sites must include a proactive patient care referral process, standardized clinic/patient care workflow, a collaborative practice agreement between physicians and pharmacists allowing pharmacists to modify treatment regimens and other clinical functions; efficient patient care documentation; and pharmacist access to patients’ full medical records. Components of MPTCQ education and support include PTC boot camp (a 3-day workshop teaching PTCs how to build, maintain, and expand the pharmacy program within the physician organization), monthly conference calls, quarterly in-person meetings, and patient case discussions. 

MPTCQ patient care expectations include pharmacist services, pharmacist time allocation, and clinic productivity. By the end of year 1 (October 2016), the presenters concluded, pharmacists participating in MPTCQ should be providing direct patient care to at least 8 patients per day, 4 days per week, for a total of 32 patients per week.—M. Mihalovic