Hire a pharmacist?

Having a clinical pharmacist on staff can enhance patient care, prevent medication errors, and make your workday more manageable.

By Gail Garfinkel Weiss
Senior Editor

Western Rockingham Family Medicine, a seven-physician practice in Madison, NC, serves more than 40,000 patients. "We don't have enough physicians to see chronically ill patients on a regular basis," says FP Donald Moore. "So the physicians share patient management with pharmacy professionals. They've become an integral part of our practice. Having clinical pharmacists on site means better quality of care, less morbidity, less mortality, and happier patients."

FP Beth Omundsen is similarly enthusiastic about Sarah Long, the doctor of pharmacy who spends two full and two half days each week at the seven-physician Amherst Family Practice in Winchester, VA. The remainder of the workweek, Long is an assistant professor of pharmacy at Shenandoah University in Winchester, VA.

"Sarah brings label changes to our attention in monthly updates," Omundsen says. "And she's on hand to field questions from patients. For example, when the Women's Health Initiative Estrogen Plus Progestin Study was released in the summer of 2002, Sarah handled the ensuing barrage of phone calls and arranged for follow-up with the physician. With her students, she wrote a patient education pamphlet highlighting the most commonly asked questions, which we distribute to patients who are on hormones."

On-site clinical pharmacists are nowhere as ubiquitous as NPs or PAs in primary care practices, but their ability to handle tasks from Coumadin management to weight-loss counseling has made them valued additions to busy offices. The physicians and pharmacists we interviewed describe this new frontier.

Where to find a clinical pharmacist

Like Sarah Long, most clinical pharmacists who work in medical offices are professors at nearby colleges of pharmacy. "Shenandoah University's School of Pharmacy sends students for the rotations and clinical experience they need to get their doctor of pharmacy degree," Omundsen explains. "Because we're a teaching site for students, SU provides us with one of the instructors. In addition to overseeing the students here, she's available to us for consultation."

Another perk of partnering with a school is that it pays some—or all—of the clinical pharmacist's salary. "Each practice/school arrangement is handled on a case-by-case basis," says Laura Borgelt Hansen, who teaches at the University of Colorado Health Science Center and works as a clinical pharmacist at the AF Williams Family Medicine Center in Denver. "A contract is typically drawn up specifying salary and other details." And because these professionals earn upward of $75,000 a year, plus benefits, sharing the cost with a school allows smaller practices to reap the benefits of an on-site pharmacist.

Not all arrangements are school-sponsored. "We subcontracted with two clinical pharmacists—a husband and wife team—in the late 1990s. They have their own office in our building and a room where they do consultations with patients," says Donald Moore. His practice nonetheless serves as a teaching site for pharmacology students from the University of North Carolina at Chapel Hill, so there are additional hands on deck to help run drug-related programs.

Clinical pharmacists cannot bill on their own, but they can bill "incident to" your services, under your Medicare ID number—provided you're on the premises when the pharmacist sees patients. You don't have to be in the same room, but "incident to" claims won't fly if you're on hospital rounds, in a satellite office, or at another remote location—even if you check in via telephone.

Allen Nichol, a clinical pharmacist and president of the Columbus, OH-based Nichol & Associates Pharmaceutical Care Consultants, which places pharmacists in Ohio primary care practices, says that having a pharmacist on your staff can boost your bottom line by generating direct-bill visits as well as visits for disease management and other programs administered by the pharmacist. "I run a diabetes management program for the Grandview Family Practice in Columbus, and this brings in $450 to $600 a week," he says.

Donald Moore maintains that after paying the pharmacists, "we break even financially," and he thinks that the pharmacists add value to his practice by promoting patient compliance and freeing physicians to see more patients.

What a pharmacist can do for you—and your patients

Physicians set the protocol for the issues that clinical pharmacists address with patients. "We sign off on everything they do," Moore says. "They manage our patients with our supervision."

Unlike cardiology practices, where clinical pharmacists deal almost exclusively with Coumadin and lipid management, pharmacists at a primary care practice typically have an eclectic schedule. "The elderly need to be monitored to prevent problems of polypharmacy," pharmacist Hansen says, "but I work with all age groups—even the little ones when I'm making vaccination recommendations." Among clinical pharmacists' duties:

Patient education."Pharmacists who work in collaboration with physicians can answer patients' questions, explain how medication should be taken, and help prevent medication errors and adverse drug reactions," says Hansen.

Kristen Goliak, a clinical pharmacist who works at the University of Illinois' 12-physician Family Medicine Center in Chicago, does contraception counseling, and she advises students, faculty, and community members who will be spending time abroad. "We'll provide the necessary immunizations and counsel travelers on insect protection, diseases they might be at risk for, and what to eat— and not to eat—while they're abroad," she says.

At Amherst Family Practice, Sarah Long teaches patients how to use inhalers, home glucose monitors, and home blood pressure devices. She even fills pillboxes for the elderly, thereby reducing dosage errors.

Chronic illness control. "When we moved into a new building we got a DEXA scanner," says Moore. "The physicians read the DEXA scan, but the pharmacists counsel patients who test positive for osteoporosis or osteopenia. Also, they're doing a study to find out if we can reduce fracture rates by tracking patients and treating them aggressively. After several years, we hope we'll find that we've kept people out of nursing homes and extended their lifespans."

Allen Nichol spends two days a week counseling diabetics at the three-physician Grandview Family Practice. "I'm managing 125 patients for the group by doing ambulatory blood pressure monitoring and other tasks, which help meet HEDIS, American Diabetes Association, and insurance company best practice guidelines for diabetes," he says. "I talk to patients about the complications of the disease. I also teach about medication, foot care, and the importance of exercise and proper nutrition."

Omundsen had a patient with atrial fibrillation who needed to start on Coumadin. "Rather than me taking my clinic time to explain the pros and cons and dos and don'ts," she says, "I handed the patient a prescription and gave him an appointment with Sarah. She went over the particulars, then put him in a Coumadin data bank that helps us monitor protime levels. Sarah makes dosage adjustments as needed, after checking with me."

Pharmacotherapy consults. "Sarah meets with pharmaceutical representatives, gathers information on new products, and educates us in a nonbiased fashion," says Omunsden.

"Before the physician decides what to prescribe, she might come to me for feedback," Laura Hansen notes. "I may have suggestions that are more cost effective or more appropriate for the patient. I also periodically review patients' existing drug regimens and might suggest changes in medication, dosage, or timing."

Hansen also makes what she calls "retrospective suggestions." That is, she may put a note in a chart indicating that a patient who is on medication that requires liver monitoring hasn't had his liver checked in over a year.

Oversee patient assistance programs.Like many pharmacy consultants, Sarah Long helps patients apply for free and reduced-rate prescription medicines. "About 30 percent of our patients are uninsured," Omunsden explains. "A lot of these people couldn't afford medication without the help of a public assistance program. Sarah fills out all the necessary paperwork and gives it to us to sign."

The pharmacists who work at Western Rockingham Family Medicine trained staff members to do the paperwork for indigent medicine programs. "Currently some 165 patients are getting more than 400 medicines that they otherwise might have had to do without," Moore says.

Monitor diet and smoking programs."I do a lot of nonpharmacological counseling," Hansen says. "I'll talk to patients about diet, exercise, and the benefits of an active lifestyle. Someone who is trying to quit smoking might opt for a nicotine patch, but I also support patients when they choose nonpharmacologic methods to wean off their cigarettes."

Community outreach.A clinical pharmacist can be a roving ambassador for your practice. The Western Rockingham pharmacists represent the practice at local health fairs, write newspaper articles, speak at schools and churches, run weight loss and diabetes support groups, and consult with school and industry nurses.

Bringing a pharmacist into the mix

No matter what the pharmacist's duties, adding someone new to your staff requires planning and screening. When internist Robert A. Wheeler was looking for a pharmacist to work with the five-doctor Physicians Inc., in Lima, OH, three years ago, he interviewed several candidates. "We wanted someone very intelligent with a strong personality—someone who's organized and knows their stuff," Wheeler says.

Laura Hansen recommends looking for someone who has a PharmD and is board certified. "Board certification indicates an advanced level of training," she notes, "but ultimately it comes down to a qualified person with the right skills and personality who will fit well in your practice."

Once you've brought a pharmacist on board, be sure to notify your malpractice insurance carrier. "Under the doctrine of respondeat superior, an employer is always at risk for the conduct of employees acting within the scope of his employment," says Lawrence Vernaglia, an attorney with Hinckley, Allen & Snyder in Boston. "It would be unfortunate if a claim arose involving the pharmacist, and the carrier said that your policy only covers physician services."

Vernaglia also advises confirming that the pharmacist has a valid license, and checking the Web site of the HHS Office of Inspector General (oig.hhs.gov/fraud/exclusions.html) to ascertain that the pharmacist isn't sanctioned or somehow excluded from Medicare or Medicaid.

Experts indicate that a solo or two-physician practice would be hard-pressed to afford a clinical pharmacist. Practices with at least three physicians, however, probably have the income and patient load to give this new patient management strategy a try. In Allen Nichol's view, "The best way to control the cost of chronically ill patients is by engaging a clinical pharmacist who can work collaboratively with the physician to bring about desired outcomes."

Internist Robert Wheeler agrees, and adds that he and his partners wouldn't want to be without an on-site pharmacist. "Even if the university withdrew its financial support," he says, "we'd pay to keep this service."

 

Gail Weiss. Hire a pharmacist?. Medical Economics Jun. 20, 2003;80:23.