R.Ph.s can help manage the cost of drugs

One of the best examples, said Jordan, is Tufts-New England Medical Center (T-NEMC), Boston, an independent practice association (IPA) selected as one of five "best practice" organizations in the study. The study identified establishment of the position of clinical pharmacist in 1998 as the intervention most critical to T-NEMC's success in managing its pharmacy costs. As well as finding active cost management critical to financial health, IPA leadership recognized that many new drugs require increasingly sophisticated decision-making on potential safety issues.

T-NEMC's clinical pharmacist, Paul Abourjaily, Pharm.D., said, "Most of our focus is on primary care doctors who practice on site in adult ambulatory medicine, and we have established a medication clinic within that practice. We spend time educating doctors about the most cost-effective therapies, but those doctors also refer patients to us for medication therapy management."

Proximity within a medical center and gaining physician trust are two essentials of successful physician/pharmacist partnerships, said Jordan. In agreement is Richard Wagner, Pharm.D., director of drug use management, who organizes the drug education coordinators at California's Kaiser Foundation Health Plan, another "best practice" organization featured in the study. Noting that hospital pharmacists and physicians have traditionally worked closely together, Wagner said that a consultative component emphasizing quality of care will result in physician trust in a pharmacist's judgment and skills. Abourjaily concurred. "Physicians see that first, then they're much more accepting of recommendations and suggestions. They have to see what you can bring to the improvement of patient care."

Wagner added another requirement for trust. "If the pharmacists don't have credibility as scientific experts with the physicians, they're out of business, basically." The Kaiser drug education coordinators make sure everything they do is vetted and scientifically accurate. While they bring their own pharmaceutical expertise to the medical team and drug use management initiatives, coordinators work with physician specialist "champions" to provide the medical staff with evidence-based information based on current practice standards.

The Kaiser drug education coordinator role began in 1986 and has grown since then. From the beginning, Wagner said, it has had two purposes: "to increase the quality of the prescribing and, where we can, make sure we use our most cost-effective drugs for those conditions." Today, he said, "our efforts are centered around education and trying to make sure the evidence is available to the physicians so they can make the best individual decision for their patients."

How can pharmacists be proactive in developing a pharmacist/physician partnership? "Success is more likely when the medical structure of an organization decides the route it wants to go, provides a role for the pharmacist, then recruits someone for that role," Jordan said. While Abourjaily agreed, that doesn't mean the pharmacist can't provide a nudge or two, he said. "In the beginning we actually did propose ambulatory involvement of pharmacists in our outpatient clinics. Then we took it another step further, saying to our key opinion leaders, 'Look, this risk is on the table; there's probably some way we can help you manage it.' And from there it trickled its way down."