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Pharmacists to play bigger role in clinical care under health care reform
Pharmacists are mentioned in HC reform bill
The 2010 health care reform bill, now called the Affordable Care Act, has the potential of creating many opportunities for pharmacists to become involved in clinical care, experts say.
"Looking specifically at Medicare/Medicaid patients receiving care at the hospital, we can play a larger part in their care," says Ernest R. Anderson, Jr., MS, FASHP, FMSHP, system vice president of pharmacy at Caritas Christi Healthcare System in Brighton, MA.
Pharmacists specifically are mentioned in the Affordable Care Act. Their role is seen as a provider who does counseling and education of patients on multiple drugs.
"In the medical home model, in which a team of providers take care of patients in both inpatient and outpatient settings, pharmacists are a part of that team and model," Anderson explains.
The new health care reform bill sets up accountable care organizations (ACOs), which are a way for providers within a hospital and in the community to develop a partnership when providing care to a specific patient population, says Brian Meyer, director of government affairs for the American Society of Health-System Pharmacists (ASHP) in Bethesda, MD.
"By virtue of doing that partnership, they share in the savings of health care costs," Meyer says. "This is a different sort of payment structure that is related to, but not the same as, a medical home."
The medical home model is centered around primary care providers, but the ACO is a corporate entity that creates and organizes its own health care models, presumably including medical home models, he explains.
Both ACOs and the medical home model will be further defined and explained by the Centers for Medicare and Medicaid Services (CMS), he adds.
"The ACO is a way to try to provide care both regardless of the setting inpatient or outpatient and to create an entity where all providers can come together and be reimbursed," Meyer says.
"The point is that ACOs [initially] will be reimbursed under fee for service or other payment methods, but those that meet certain quality performance standards can receive some shared savings," he adds.
The inclusion of these in the health care reform bill is a signal that the current fee for service hospital care payment model likely will change in the long term.
Also, the way hospitals think of their own role in population-based health care likely will change.
"Hospitals in the future will be held responsible for certain disease states, not only while patients are inpatients, but also for their readmission rates and mortality rates," Anderson predicts. "As I look at this opportunity as a pharmacist, I think we need to play a larger role in discharging planning for patients and in the ongoing maintenance of patients."
Helping patients maintain their health will be particularly important for people with high-profile disease states, including those with diabetes, high cholesterol, and hypertension, he adds.
"Pharmacists have a big role to play in those areas," he says.
Future health systems and ACOs and health care providers serving in a medical home model will have multidisciplinary teams that include pharmacists.
"Pharmacists are the best educated, and the best suited for educating patients on taking their medications properly," Anderson says. "A lot of patient adherence is understanding why they need to take their medications and understanding the consequences of not taking them."
Yet, it remains a challenge to convince hospital leadership to give pharmacy a seat at the table.
"We need to make sure pharmacy is recognized within the c-fleet as having a significant role to play," Anderson says. "Pharmacists are mentioned in the health care reform bill, so that's a great reason why they can go to the hospital administration and say, 'We need to be part of developing a system like the ACO or developing the medical home model.'"
This is the message pharmacy directors need to communicate to hospital administrators, he adds.
"When it comes to medication, pharmacists are the experts, and I think we are the ones who can do the best job of it," he says. "We have to educate the administrators that this is our role."
Meyer and Anderson suggest hospital pharmacy leaders focus on these issues raised by the health care reform bill:
Continue to reduce drug costs and improve quality of care: "Hospital pharmacists have been doing this all along," Anderson says. "They work on cost control related to inpatient services, driving a formulary, and making sure we utilize drugs in a cost effective manner.
For example, there is plenty in the professional literature with regards to antimicrobial stewardship, which can reduce the spread of drug-resistant bacteria as well as reduce antibiotic costs.
The Obama administration has pushed through various initiatives with incentives for hospitals to move to electronic databases and computerized provider order entry (CPOE) systems.
"You can have physician support built into the CPOE, so if a physician orders a drug and there are cultures suggesting it's not the right drug for that type of bacteria, then you could have a smart system with feedback to the physician, saying there are other drugs on the formulary that might be more appropriate for the bug you're trying to treat," Anderson explains.
The pharmacy can build in physician support in electronic systems for high risk drugs, such as heparin with its narrow therapeutic range.
"They can build into the system [safety measures] to make sure the drug is started appropriately and responded to in an appropriate fashion," Anderson says. "They can build in physician alerts that go to physicians and pharmacists and that help to make sure the prescription has been dose-adjusted appropriately."
Smart systems also can alert physicians and pharmacists to adjust a dose if lab values indicate renal function problems, he adds.
"Smart systems like that enable higher quality outcomes based on real time feedback provided to either physicians or pharmacists," Anderson says.
Medication therapy management (MTM) is another model that could be employed to reduce drug costs and improve care quality, and pharmacists often lead MTM programs.
Also, the federal government is promoting the concept of having pharmacists involved in an annual, comprehensive medication review of patients with chronic illnesses, Meyer says.
"There's a newly created innovation center that gives the Centers for Medicare and Medicaid Services (CMS) some pretty wide latitude to look at various potential changes in care," he adds. "And among the areas that are specifically listed in the legislation and law are ones that allow CMS to test different models of care, including the medical home concept and chronic care management and coordinated care."
In all of these medication management are specifically mentioned, and this is an opportunity for pharmacists to be involved, Meyer says.
Improve care transition: Hospital pharmacists increasingly might be involved in care transitions from the hospital to community and the reverse as health care reform regulations unfold.
"Pharmacists will find this is a new term they'll hear about from the c-fleet," Meyer says. "So keep your eyes and ears open as this thing gets further developed because it includes a role for pharmacy."
The focus on care transitions will include a renewed emphasis on quality and cost savings, he adds.
"It includes medication reconciliation to ensure patients are going to follow and adhere to prescription medication regimens they are prescribed at discharge and to make sure providers have accurate medication information," he explains. "And pharmacists can help ensure safe medications are used appropriately while patients are in the hospital."
The health care reform legislation has built-in incentives that will push the industry toward developing electronic medical records and bridging the gap between inpatient and outpatient services, Anderson says.
"Most hospitals and physicians in the outpatient sector tended to act in silos, separate from one another," he says. "What that can do is be very wasteful since you'll have different groups of physicians ordering the same lab test."
This is why pharmacists and other health care providers will need to work on bridging the gap between the hospital stay and the outpatient sector.
"There are incentives built into health care reform that will encourage us to develop these electronic systems," Anderson says.