Managing complex patients at two clinics
“Steve” had been out of work—and thus out of health insurance and health care—for 2 years. The pain from his gout had become almost unbearable, keeping him up at night, and causing mild depression, too. His uric acid levels held steady in double digits, though the goal for gout patients is below 6 mg/dL. Since he’d been out of work, his triglycerides and hypertension had gone uncontrolled as well. He shared blood pressure medication with his girlfriend because that’s all they could afford.
Steve went in search of a physician at the outpatient med–peds clinic at Nationwide Children’s Hospital in Columbus, OH, because he heard they’d see him regardless of his ability to pay. But Steve didn’t only get the care of a physician. His case was also reviewed by Cheryl A. Laubacher, PharmD, BCACP, and her pharmacy resident.
In the outpatient med–peds clinic and in an outpatient pediatric practice also at Nationwide Children’s Hospital, Laubacher maintains her own patient panel, in which she manages complex patients with one or more chronic diseases. Like the other pharmacists in this series, Laubacher often feels restricted by pharmacists’ lack of provider status. CMS does not recognize pharmacists as health care providers, though it recognizes most all other health professionals. This means that pharmacists who provide clinical care, as does Laubacher, typically must work under a physician in order to bill for their services.
At the pediatrics practice, where she manages patients with asthma, Laubacher sees patients in scheduled visits and takes a detailed history of their condition and other symptoms such as reflux and allergies. She makes recommendations for the renewal or adjustment of therapies. She also refers patients to outside specialists when she determines their symptoms aren’t asthma at all.
“The only thing I don’t do, obviously, is the physical exam. I do adherence assessment to determine how often they’re refilling their controller medicines or their albuterol, determine how often they’re going to the emergency room, the urgent care, getting oral steroids for asthma flare-ups,” Laubacher said. A particular point of emphasis is to clear up the frequent confusion families have about how to use patients’ inhalers properly.
Since the practice began including pharmacists in asthma management in 2008, patients who’ve seen the pharmacist have had fewer inpatient, emergency department, and urgent care visits, and more well visits in the clinic.
Laubacher manages complex patients at the med–peds clinic as well. When she first met Steve, Laubacher realized it wasn’t just a matter of getting him back on his gout medications. Steve couldn’t take allopurinol, the first-line treatment for gout, because it gave him hives, but second-line medications were all brand name and too expensive for someone without health insurance. In addition to determining Steve’s course of treatment—for gout without allopurinol, and insomnia, depression, and hypertension—Laubacher got Steve on patient assistance programs to help pay for the drugs and recommended third-line gout treatment for him in the meantime.
“This patient, who’s never had uric acid in a single-digit number, dropped from 11 mg/dL down to 5 mg/dL. His gout level is finally within normal limits, and he said to my pharmacy resident, ‘I have not been pain-free for this long in forever,’” Laubacher said.
For 3 months, Laubacher assisted in managing Steve’s gout, monitoring his kidneys to make sure the various medications he’s taking are properly dosed. With his gout under control, Steve returns to clinic less frequently for lab visits and medication adjustments.
“We worked on his insomnia, and he’s losing weight. He’s a motivated patient. It’s a beautiful story. Actually, it’s one of my favorites,” Laubacher said.
Steve is just one among many complex patients with chronic disease whom Laubacher manages. And the physicians in the practice couldn’t do it without her.
At the pediatric practice, physicians refer to Laubacher anyone whose asthma is uncontrolled or who needs education or micro-level management of their condition.
“They’ll forward me the patient’s chart and say, ‘Can you make an appointment for this patient to start seeing you with their asthma?’ So I actually have referrals from the physicians,” she said. And they know Laubacher’s worth.
“You deserve to get reimbursed so much more than you’re able to bill,” one physician told her.
Laubacher feels that CMS is the only one who doesn’t recognize the value that pharmacists bring to health care.
“It’s something we’ve been battling for many years, but hopefully someday we can get there.”