Making of a medical home: Pharmacists on the inside
Providing MTM as part of health care team.
The concept of the patient-centered medical home is not a new one.
Organizations like the Mayo Clinic, Geisinger Health System and Kaiser
Permanente have been practicing the model for decades – where
accessible, comprehensive, prevention-focused care is proffered by a
coordinated team or group of health professionals.
Although quality care is provided at these sites, the concept is far
from ubiquitous. Much of the nation’s health system is still
fragmented as primary care physicians, specialists, pharmacists, other
health providers, and insurers work in silos on patient care.
But during the current health care reform debate, the Obama
administration and others are making medical homes part of the
discussion. Understanding the role pharmacists will play in the system
is likely to be a core part of the dialogue as policymakers seek ways
all providers can streamline, synchronize, and improve care.
Most pharmacists currently working in medical home settings focus
primarily on collaborative drug therapy. They often work on staff and
have earned their title as an integral part of the clinical team. A
majority of states have enacted legislation since the 1990s allowing
pharmacists to have a broader role in patient care, largely due to the
success of these ventures.
Responsibilities
Bryan Bray, PharmD, has worked in the medical home model for 11 years.
As CEO of Medication Management in Greensboro, NC, he works with other
clinical pharmacists to provide services for four large
physicians’ practices in the area.
Bray said clinical pharmacists are able to keep track of advancements
in the field and are able to understand in detail the role medications
play.
The pharmacists see anywhere from 15 to 30 patients daily. They may
provide drug therapy management, educate patients on self-management
skills, and monitor medication regimens, Bray said.
“Right now physicians are seeing more patients and they have to
see them quicker,” he said. “Many are complex patients on
multiple meds with multiple physicians.”
Chris Green, PharmD with the Ohio State University College of
Pharmacy’s University Health Connection, said drug dispensing
accounts for only about 5% of his days.
Green works on various patient issues, but one of his larger roles is
performing drug research. Primary care physicians are overwhelmed with
the large number of patients and the thousands of drugs available on the
market, he said.
“It’s hard to have a breadth of knowledge of all of these
medications,” he said. “I have been able to get
medicine-related information more quickly and more accurately and
provide good drug informational resources to patients and providers. It
takes away the background research time that they don’t
have.”
Clinical pharmacists also work on disease-specific issues relating to
their patient population like at El Rio Community Health Center in
Tucson, AZ. The group – which provides services to 70,000 patients
at 16 sites – sees predominately Hispanic and American Indian
patients, many of whom have diabetes.
The patients that Sandra Leal, PharmD, CDE, director of clinical
pharmacy, and her colleagues see are typically special needs diabetic
patients: those who are difficult to manage or are not attaining their
physicians’ goals.
“She is able to truly provide patient education that is needed so
the patient can understand what’s going on and be more involved in
self-management,” said Arthur Martinez, MD, MSHA, chief medical
officer at El Rio. “She is an integral part of our team knowing
all of the benefits she provides for our patients.”
Clinical pharmacists are also able to provide a new set of eyes and a
different background than a physician, Leal said. She works with
patients on insurance and accessibility issues, like helping a patient
who has lost insurance transition to less expensive, but therapeutically
equivalent, medication.
Leal said pharmacists are able to add a great deal to a practice –
she helps deal with drug alerts and medication recalls, is more
accessible than physicians, can see patients more frequently and often
wears the hat of social worker and patient advocate as well.
Challenges
Though many of these MTM pharmacists are well
entrenched in their practices, there are challenges to the medical home
model.
Green said some practices experience turf issues between pharmacists
and physicians who are new to a medical home. Bray said finding
pharmacists in his region is a challenge, particularly ones who are
clinically competent and have patient- and practice-management
skills.
Overall, though, a majority of these issues are easily resolved. But
there is one major contention with which almost all practices continue
to struggle: money.
“The biggest challenge is lack of a clear reimbursement
schedule for pharmacists,” Bray said. “Reimbursement has
never been separated from the drug product. This makes it difficult to
gain adequate reimbursement to cover the pharmacist’s salary under
a traditional billing model.”
The practices in which Bray and his colleagues work employ different
types of reimbursement models, including revenue splitting, hourly wages
and contract pay.
Green is employed by the clinic as internal staff; a practice he said
is predominant in his area. He sees a lot of large, self-insured
companies creating on-site clinics work as medical homes, as well as
universities who share pharmacists with outpatient practices.
Though many of these groups have been able to fund programs, it is
often difficult for smaller practices to support an MTM pharmacist, said
C. Edwin Webb, PharmD., MPH, associate executive director for the
American College of Clinical Pharmacy.
“Payment policy is one of major stumbling blocks –
politically and realistically,” he said. “It is hard to make
a viable practice for services that don’t generate
revenue.”
Webb said 80% of practices have four or fewer physicians – and
these are the places where reinventing a fee structure will be a
challenge. But even some of the larger medical homes are having
difficulty meeting all of their patients’ needs because of funding
shortages.
At El Rio, the three pharmacists are paid for mainly through grant
money from the University of Arizona School of Pharmacy, and a local
Indian Tribe who saw the benefits of the services the pharmacists
provide.
The capacity of the El Rio pharmacists is full just by attending to
their high-risk patients with diabetes. Martinez’s goal for the
program is to eventually have funding to provide enough pharmacists so
that all patients with diabetes can receive MTM services.
“I see that as a big challenge,” he said. “If we
could allow every new diabetic to come through and receive services to
understand their disease, participate in self-management and look at
polypharmacy needs … what we could do in regards to helping with
morbidity and mortality and keeping patients out of [emergency
departments] would be phenomenal.”
Building a model
Though a lot of organizations are making medical homes work with
nontraditional funding (i.e., avoiding insurance companies), one group
is trying to create a model that would bring insurance and MTM
pharmacists into the mix and eventually work for all organizations.
“We are seeing a lot of workarounds and what we want to do is
get to root of that and obviate the need for workarounds,” said
Patricia Klatt, PharmD, BCPS.
Klatt, who is a clinical pharmacist at the University of Pittsburgh
School of Pharmacy, is working in collaboration with UPMC St. Margaret
hospital and the UPMC Heath Plan. They are trying to create best
practices for clinical pharmacists in a medical home setting, understand
teaching opportunities, and maybe most importantly, figure out how they
should be paid.
The group has spent the past 2 years with 4 physician’s
practices to understand how to integrate a pharmacist into a traditional
practice to create a medical home.
Stephanie Hackett, project coordinator and employee of UPMC Health
Plan, said the insurer expects three potential payment scenarios to come
from the research.
First, by having a pharmacist take over high-risk patients, it will
enable physicians to see more patients and improve workflow. By having a
larger patient load, they would make more revenue, which they could
split with a pharmacist.
Second, if the health plan sees money savings through measures like
increased usage of generic drugs, or reducing unnecessary medications,
they may allow pharmacists to bill for patient encounters.
Third, and most likely, a combination of revenue sharing and patient
billing will be used. Though they aren’t sure what the model will
be going forward, “The ultimate goal of the research group is to
tell health plans this will really work,” she said.
Making it work
Martinez and Leal are working with the Health Resources and Services
Administration on ways to replicate El Rio’s practices for other
organizations.
Though the model may not be widespread now, she said pharmacists can
learn to create opportunity wherever they may be practicing – from
the Veterans Administration to universities sharing practitioners,
community pharmacies hiring for patient care, to telepharmacy work in
rural or rugged areas.
“There are a lot of models where there is great success even if
they are not qualified for collaborative practice,” she said.
“We truly believe that every site would benefit from having a
clinical pharmacist."
Related resources on www.pharmacist.com:
Related resources on the Web:
Tammy Worth
Freelance Medical Writer
Posted November 3, 2009, 9:00 am EDT
|
