What’s the Point?

The role of most healthcare practitioners, viewed by both the public and the professionals themselves, is to make patients well.  We go see physicians for a variety of reasons.  Hopefully we’re going in for annual check-ups to make sure were are staying healthy, but oftentimes we see them because something ails us and we want to get better.  In a pinch, we’ll go to a walk-in clinic to seek relief for an infection or a sprained joint.  When the need is dire, we’ll get whisked-away to the hospital and only get discharged when we are either well or on our way to being so.  Ultimately, in all of these cases, there is one common goal: return to wellness.  The one area of healthcare where this doesn’t seem to be the case is in community pharmacy.  Think about what most of us do on a daily basis: we fill prescriptions and then provide enough care to ensure the patient knows how to take their medications correctly and with as few issues as possible.  While this job is extremely important, the job is only half-completed if we don’t take the next step to make sure the patient actually achieves outcomes with those medications.  This involves looking at the patient’s health conditions, seeing which medications are the most appropriate for achieving either nationally-recognized outcomes standards or physician-derived outcomes, and then following the patient to ensure those outcomes are met.

There are some programs emerging in community pharmacies that do focus on reaching outcomes.  Many pharmacies, including Barney’s Pharmacy in Augusta, have diabetes and blood pressure programs that focus on helping patients make lifestyle and healthcare changes to achieve outcomes.  These programs involve pharmacists who spend a large part of their time in clinical settings—much like seeing a physician in the office—working one-on-one with patients to devise and implement individualized care plans.  Some of these pharmacies have even attained recognition by the American Diabetes Association and can therefore receive reimbursement for their services by Medicare.  Another example of outcomes-based pharmacy patient care is Coumadin Clinics, where patients can have their warfarin doses adjusted immediately after a finger-stick INR test, providing a much more efficient way of maintaining therapeutic drug levels.  A few pharmacies combine compounding and outcomes into bioidentical hormone replacement therapy programs and pain-management programs.  However, even if every community had enough pharmacy clinics to saturate their respective markets, there would still be a large majority of pharmacists left staffing their front counters and a vast majority of patients not achieving their medication-related goals.  The solution is to move the practice of pharmacy forward by taking each aspect of pharmaceutical care to the next logical stage of evolution.  Just a few examples are in how we fill prescriptions and counsel patients.

Prescription Filling

Professional services sometimes get all the spotlight when it comes to advancing our profession, when in fact one of the most crucial and underrated functions of being a pharmacist is filling prescriptions.  While we do need to put more emphasis on our services, the dispensing of medications should not be separated out as a worthless act.  Our current community practice model depends on it to keep our doors open.  However, we must take the oftentimes monthly task of dispensing and use that time to our advantage to work with our patients to achieve outcomes.  As opposed to making additional trips to the pharmacy to take part in MTM sessions or to see a diabetes educator, the occasions when patients do return to the pharmacy for refills—a time patients have already budgeted into their schedules—are great times for pharmacists to assess their patients’ medication regimens and their progress towards achieving their medication-related goals.  While this would require pharmacists to spend a grand majority of their time working directly with patients as opposed to merely running the pharmacy, I would argue that we should be doing this in the first place, leaving all operational tasks to our technicians.  Instead of merely checking prescriptions, answering non-clinical phone calls, and helping solve inventory/insurance/filling problems, the pharmacist should be talking to patients about their prescriptions, checking to make sure they are being taken correctly and are appropriate for their indications, and that the patients are actually achieving some sort of goals.  If one of these is not occurring, the pharmacist should then assess how to help the patient make adjustments, or should suggest adjustments in the regimen to best suit the needs of the patient.  Quality of the prescription filling process will then come not in the speed in which it occurs but in the quality of the visit during which it occurs.  Any progress will then be tracked, and that quality will then be measured in actual clinical outcomes met.  It sounds very altruistic, but if any given pharmacist can prove to one of their patients that the pharmacist’s attention he or she receives leads directly to better outcomes and therefore a better quality of life, the value of the service becomes much more than the cost of the medication received.

Patient Counseling

We all learned the IHS Three Prime Questions in patient counseling: “What did the prescriber tell you this medication is for?”, “How did the prescriber tell you take this medcation?”, and “What did the prescriber tell you to expect?”.  These questions help facilitate the declarative statement, “I take metformin twice daily for my diabetes, and I can expect that I should see a drop in my blood sugar readings and perhaps even a drop in my weight.”  Even if all of our patients were to become so knowledgeable about their medications, such knowledge does little beyond getting the patient on the right regimen.  Ultimately, we want to empower the patient with defined endpoints to which we can create goals to achieve.  Without goals, patients are disenfranchised from their own healthcare, powerless to do anything besides take their medications as directed.  If you give patients goals for each of their medications, however, you provide them with defined, specific, and detailed endpoints towards which we can help coach them towards achieving with each encounter.  Because patients see us so often, and because we are so trusted, I don’t believe there is another profession best suited to be that medication goal coach.  Therefore, I believe there should be a fourth, outcomes-driven question added to the IHS patient counseling method: “What did the prescriber say to you is the goal for taking this medication?”  We have now transformed a repetitive exercise into a goal-centered, meaningful regimen.  What was simply a money pit to the patient becomes an investment in good health.  Once the patient has achieved his or her goals, the point of coming to the pharmacy and working with you, the doctor of pharmacy, becomes brilliantly clear and worth every penny.

Again, all of these changes occur when the goals of pharmacy become aligned with those of every other healthcare practice: achieving patient outcomes.  We must move beyond simply ensuring patients take their mediations correctly and focus instead on ensuring that they are getting the most benefit from those medications.  As we hear about more and more these days, physician reimbursement will soon be based on how well their care helps achieve patient outcomes, which means prescribers will more than welcome our help if they believe we have the ability to help them make their patients better and therefore help them get paid.  But coaching patients into achieving outcomes is just the first step: we must then track every move we make from the start so that can prove our value to everyone, including those paying for healthcare.  This will be how we justify getting paid for our services, and how we will justify telling our communities that trading with our particular outcomes-driven pharmacies is worth every penny.  Bottom line: when we decide that helping patients get better is more important than simply providing a product quickly and in some cleaver package, we will finally justify why we earned the title of doctor.  This is not about taking pharmacists away from the community practice everyone is used to seeing us in; it is about making that practice work better by making patients well.  Ultimately, when the point of filling prescriptions moves beyond maintenance and into to outcomes, we will prove to the world the point of having a pharmacist in the first place.