Lindsey Elmore, PharmD, BCPS
“Ted” walked into FMS Pharmacy in Bessemer, AL, with a paper sack of some 50 prescription bottles. Dropping them on the counter in front of the pharmacist, he said, “I don’t know what to do with these. Which ones do I take? Which ones do I not take?”
Among the bottles, Lindsey Elmore, PharmD, found expired medications, multiple antidepressants, multiple atypical antipsychotics, five or more antihypertensives, antihyperglycemic agents, and a litany of other drugs.
Ted couldn’t pay for pharmacists’ patient care services such as medication therapy management (MTM), and his insurance didn’t cover it. But if Elmore were to provide him with a service too closely resembling MTM, she could be charged with fraud for billing payers who do cover MTM for a service she had given Ted for free.
“It’s a challenging situation. From a patient safety perspective, I can’t let that guy walk back out of our pharmacy,” she said. Elmore is an Assistant Professor in the Pharmacy Practice Department at Samford University’s McWhorter School of Pharmacy and Director of the school’s community pharmacy residency program.
In a predominantly African American town where more than one-quarter of residents live below the poverty line, conditions are ripe in Bessemer for high rates of diabetes and other chronic diseases that a pharmacist could help manage. But without provider status and collaborative practice agreements in her state, Elmore often struggles to do what’s best for her patients while still following the rules. The Alabama native wouldn’t practice anywhere else, though. She is an advocate for patients and the profession in her state, and she teaches her student pharmacists and pharmacy residents to be as well.
“Managing medications. This is what pharmacists do. And we do it well,” Elmore said. “So there are situations when pharmacists are torn between, ‘Do I send the patient home with something that’s potentially dangerous, or do I overstep my bounds and risk potentially committing fraud?’”
A month before wandering into FMS Pharmacy, Ted had been discharged from a 16-day stay in a psychiatric ward. He’d landed there after he’d told his primary care physician that he wasn’t taking his medications. The physician strongly encouraged him to take “all” of his medications. And, taking the advice literally, Ted went home and took one of every prescription he had. Drug interactions and exacerbations of psychiatric symptoms ensued, and a family member took Ted to the hospital. After he was discharged, he was afraid to take his medicine, which included large doses of insulin, so he took nothing. Now he was seeking the advice of a pharmacist.
“Had he had MTM, had we been able to bill for MTM services for all patients equally, we potentially could have prevented him from going to the hospital in the first place,” Elmore said. “He went from taking absolutely no medication to taking 40 or 50 drugs at one time. We could have prevented that extended stay in the hospital if we had provider status.”
But Elmore only met Ted after his hospital stay—when he was dangerously close to going down the same path again. And without provider status, Elmore had to walk the fine line between the counseling that pharmacists have been required to give away for years and the comprehensive MTM that Medicare Part D and private payers cover for some patients, but not all.
“Technically I wasn’t doing all the complete steps of MTM, like giving him a medication action plan and a complete medication review, but I could at least clean up [his medication list] a little bit and make sure that he knew what these medicines even were and what the risks are,” she said.
Pharmacists in any state can relate to Elmore’s ethical dilemma—the tightrope walk between bureaucratic restrictions and patient well-being. Pharmacists in Alabama are particularly confined, however, as Alabama is one of very few states that don’t have provisions for collaborative practice.
“Given the restrictions, I’m powerless to take care of patients in the best possible way that I can,” she said.
Elmore returned to Alabama after she completed postgraduate year 2 training in the ambulatory care residency at New Hanover Regional Medical Center in Wilmington, NC. There she worked with pharmacists who could prescribe under collaborative practice agreements.
“We saw patients with [a variety of chronic diseases], patients with complicated drug therapy, and patients requiring anticoagulation,” Elmore recalled. “This set-up was so conducive to patient care because our physician colleagues would diagnose patients and then send them to the pharmacist for medication initiation, titration, and evaluation.”
Collaborative practice allowed pharmacists to immediately resolve medication issues without the middle step of consulting the physician to make a necessary change.
“I’m not implying that a pharmacist can practice without a physician. We need a lot of collaboration in diagnosing, solving acute problems, and referring complex patients,” she said. “But in the case of managing chronic disease and solving drug-related problems, pharmacists can greatly assist physicians in achieving disease state goals and raising Medicare star ratings.”
Back home in Alabama, Elmore can’t assist physicians in this way. “In Alabama, I have to call for even the most minute of problems,” she said.
For example, when insurers request that Elmore put a patient on a 90-day rather than a 30-day supply of medication, she has to get permission from the physician.
“This is such a simple adjustment, yet without collaborative practice or prescribing authority, the call must be made. This not only slows me down, but it also [must] be very annoying to a physician to receive such calls,” she said.
The decision to return to her state wasn’t easy, but for Elmore it was the right thing to do.
“I knew that I was coming back to a place that wasn’t as progressive as North Carolina, but there’s something about coming back to where you grew up and trying to make a difference in those patients,” Elmore said.
Not only did Elmore feel she could support patients in her home state, but she also felt she could better support her profession by returning to Alabama.
“I’m not saying that states like North Carolina that have more progressive pharmacy practice acts are exactly where we want to be,” she said. “But there are places that are in need of really strong pharmacy advocates. So I wanted to be somewhere that change might be more difficult to implement.”
Elmore has become that strong pharmacy advocate for her state. This February, in an event organized by the Alabama Pharmacy Association, Elmore joined some 400 pharmacists, technicians, and pharmacy students in front of the state capitol in Montgomery for a legislative day. The event allows lawmakers to meet pharmacy professionals in their constituency and hear from them about issues that affect their practice and the patients they serve.
Elmore models advocacy for her residents, requiring that they attend the annual legislative day as part of their community pharmacy residency. This year, resident Candice Mercadel, PharmD, and preceptor Patrick Devereux, PharmD, Pharmacist-in-Charge at FMS Pharmacy, joined Elmore for the event.
“It’s so critically important for pharmacists to be active with many pharmacy organizations, including APhA,” Elmore said. “We’ve got to have the lobbying out there to go head to head against the medical association. When they say pharmacists shouldn’t do that, we need to say, ‘Yes, we should, and here are the reasons why.’”
FMS Pharmacy offers the only American Academy of Diabetes Educators (AADE)–accredited diabetes education program in the state. The program offers group classes and individual follow-ups that address nutrition, exercise, and medication with eligible patients. While the AADE accreditation helps FMS bill Medicaid and Medicare for providing beneficiaries with diabetes education, it doesn’t solve any problems for patients whose insurance doesn’t cover diabetes education.
“As with everything else, there’s that tightrope that we walk of providing good services to everyone while not committing Medicare fraud,” she said.
To strike that balance, FMS offers an abbreviated 1-hour workshop that covers the “quick and dirty,” as Elmore puts it, from the three sessions that Medicaid and Medicare patients get.
Elmore believes that her student pharmacists and pharmacy residents must learn to walk the tightrope, too. She tells them, “Every pharmacist has these decisions to make, but when it comes down to it, you’ve got to take care of that patient standing in front of you. I’m toeing the line between not providing MTM and still ensuring that the patient is safe while taking their medicines.”