Empowering Pharmacist-Physician Collaboration

Cigarette smoking claims more than 480,000 American lives—approximately 1 in 5 of total US deaths—each year, according to the CDC. This makes smoking the leading cause of preventable disease, disability, and death in the United States.¹

Although the number of smokers continues to fall, about 13 of every 100 US adults were smoking cigarettes in 2020 (12.5% vs 20.9% in 2005). This means that approximately 30.8 million American adults smoke cigarettes,² and more than 16 million are living with smoking- related conditions.³

Joe Moose, PharmD, clinical pharmacist, co-owner of Moose Pharmacy in Mount Pleasant, North Carolina

According to Joe Moose, PharmD, a clinical pharmacist, co-owner of Mount Pleasant, North Carolina-based Moose Pharmacy, and director of strategy and luminary development with CPESN USA, smoking-cessation programs are an ideal way for independent pharmacists to collaborate with physician practices.

“What we don’t have in health care are good signals of failure,” said Moose. A primary care physician (PCP) can tell their patient to quit smoking, write prescriptions for nicotine patches and amlodipine to control their blood pressure, and ask the patient to buy a blood pressure cuff for monitoring purposes. But too often, the patient doesn’t act on their physician’s recommendations.

The PCP’s goals include controlling their patient’s blood pressure and starting them on a smoking-cessation program. But without access to the patient’s care plan, the pharmacist doesn’t know that the PCP wants their patient to start the program and monitor their blood pressure in the first place.

At Moose Pharmacy, prescriptions will pop up for smoking-cessation patches and amlodipine, but the patient may tell Moose they are not ready to quit smoking. The conversation could end right there, the patient becoming a statistic who joins the more than 16 million Americans living with smoking-related conditions. Or the pharmacist can seize the opportunity to partner with the PCP and ensure they have access to the patient’s care plan, said Moose. The challenge is getting paid for this work. The solution, according to Moose, is what he calls a neighborhood accountable care organization (ACO).

Embed Pharmacists in the Physician’s Practice

The immediate impact of the pharmacist’s lack of awareness of the patient’s care plan is that the patient may pick up their amlodipine but not start the smoking-cessation program or use the cuff to monitor their blood pressure at home, said Moose.

The remedy is to embed a pharmacist in the PCP’s office for 40 hours a week to learn about patients’ care plans and reinforce and support their efforts to quit smoking, manage their diabetes, or control their blood pressure, he added. This enables the pharmacist to meet with patients directly following their visits to the practice. Immediate benefits include the opportunity for the pharmacist to earn in real time about patients’ care plans, access the practice’s electronic health record, and receive a “warm hand-off” from the clinicians at the practice as an integrated part of the patient experience, Moose explained. These connections are initially made in person at the practice between the embedded pharmacist and the clinical team. And when patients receive a follow-up call from a pharmacy technician at Moose Pharmacy, the whole process feels seamless.

This same collaborative model can be applied in the treatment of other chronic conditions, such as diabetes and hypertension. It can also help the practice successfully achieve quality measures to ensure the practice gets its full value-based care payments, Moose added.

That’s where the neighborhood ACO model comes in, explained Moose. Creating a neighborhood ACO means that accountability for patients doesn’t just rest with the PCP while the pharmacist focuses only on dispensing medications and working with the pharmacy benefit manager. Instead, both physician and pharmacist are accountable for the same measures, which can include reducing blood pressure or getting patients to stop smoking, 2 goals of the value-based model, according to Moose.

What’s missing, though, is assurances that the pharmacist is paid in addition to the PCP’s practice. Moose kickstarts compensation conversations with the practice leader after collaborating on data mining to determine missed annual wellness visits for adult patients, chronic care management opportunities, remote patient monitoring opportunities, and the number of patients with diabetes whose glycated hemoglobin A1C levels are above 9, an indication their condition is being poorly treated.

The simple question Moose poses to practice leaders is this: “If [our pharmacists] complete these things and bring in half a million dollars in payments to the practice, is that worth making a $100,000 payment to Moose Pharmacy?”

But even if Moose is successful with this pitch and delivers on the value promised to the practice, he knows his pharmacists must continue to deliver value or he risks the practice choosing to hire a nurse to take on the same work at 70% of the cost.

Moose’s advice? “You have to be valuable...and help generate income.”

Jessica Gustin, PharmD, pharmacy manager at Gwinnett Drugs in Lawrenceville, Georgia

Jessica Gustin, PharmD, pharmacy manager at Gwinnett Drugs in Lawrenceville, Georgia, agreed it’s important for pharmacists to show their worth to physicians. Consultations with patients experiencing chronic pain is one area in which she has achieved success. Providing this service is important because many people pass judgment on individuals taking opioids for pain management when they may actually need them, said Gustin. She is also cofounder and chief operating officer of SynerGrx, based in Chamblee, Georgia, which facilitates collaboration between pharmacists and physicians.

After asking patients about their pain management challenges, Gustin can discuss the adverse effects of opioids, provide access to naloxone HCl (Narcan), and suggest patients participate in physical therapy.

Collaborate With Physicians on Diabetes Management

Eklavya Lalwani, PharmD, pharmacist-in-charge at Olden Pharmacy in Hamilton, New Jersey, said that pharmacists—with their 6 to 8 years of education in a pharmacy school program in addition to clinical knowledge and skills—are uniquely prepared to provide clinical services. Despite this education and experience, though, pharmacists are “extremely underutilized,” he said.

Eklavya Lalwani, PharmD, pharmacist-in-charge at Olden Pharmacy in Hamilton, New Jersey

Lalwani, who is also a preceptor for Fairleigh Dickinson University School of Pharmacy and Health Sciences, said a good way to start collaborating with physician practices is to focus more closely on patients with diabetes. For example, when a patient says their insulin is too expensive, the pharmacist can call the physician and suggest the patient switch to a less expensive biosimilar with a lower co-pay. Most of the time, the pharmacist is talking to the receptionist, a medical assistant, or a nurse in these conversations. Over time, these team members start to remember the pharmacist and look to them as an expert. Lalwani also steals a page from the pharmaceutical sales rep’s book by occasionally showing up for quick in-person meetings at practices.

The ever-present challenge, though, is getting paid for chronic condition management, Lalwani noted. The American Society of Health-System Pharmacists (ASHP) provides guidance to pharmacies on billing Medicare for diabetes self-management. First, the pharmacy needs to set up a diabetes self-management training/education program that has been accredited or recognized by the American Diabetes Association or Association of Diabetes Care & Education Specialists. The program can be run and managed by a registered dietician, nurse, or pharmacist.⁴

For billing, the pharmacy must use the practice’s or pharmacy’s National Provider Identifier (NPI) rather than the pharmacist’s NPI. Payment can range from $15 per patient for a group-based diabetes self-management training education session to $51 for a 30-minute session for an individual patient, according to ASHP.

Clinical Outcomes

“Ultimately...the primary role of the pharmacist is ensuring that medications are utilized in the safest, most effective, most efficient manner,” said Tom Kalista, PharmD, a lecturer at the University of Rhode Island College of Pharmacy. “Facilitating communication is only going to enhance that.”

Tom Kalista, PharmD, lecturer at the University of Rhode Island College of Pharmacy

Frequently, the biggest pitfalls are difficulties that occur between prescribing and dispensing, he said. Reviewing drug use and insurance coverage and addressing questions about cost and dosing concerns can take weeks, which introduces delays in patients’ receiving therapy, Kalista explained. “Any delays have an impact in terms of long-term outcomes.”

Kalista recalled a time over the Christmas holidays when a family of 5 came to the pharmacy unsure if they all had COVID-19 or strep throat. As a result of the pharmacy’s collaboration with a local physician, the family was able to access a diagnosis and treatment within 25 minutes. In addition, they were advised against going to a New Year’s Eve party to avoid spreading the strep infection.

“Picking up the phone or walking into the physician’s office is probably the biggest hurdle to [collaboration] because all the parties have the same intention, [which is caring for patients],” Kalista said.

References

1. Current cigarette smoking among adults in the United States. CDC. Updated March 17, 2022. Accessed May 16, 2022. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

2. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco product use among adults – United States, 2020. MMWR Morb Mortal Wkly Rep. 2022;71(11):397-405. doi:10.15585/mmwr. mm7111a1

3. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress. CDC; 2014. Accessed May 16, 2022. https://www.ncbi.nlm.nih.gov/books/NBK179276/

4. FAQ: alternatives to “incident-to” billing for revenue generation in non-facility (physician-based) ambulatory clinics for pharmacists. American Society of Health-System Pharmacists. March 2019. Accessed May 16, 2022. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/alternatives-to-incident-to-billing-2019.pdf