Directions in Pharmacy: Navigating a New Map

When I entered pharmacy school in 1998, the profession was at a training crossroads manifested by a dramatic shift in program tracks away from the bachelor of pharmacy degree to the doctor of pharmacy degree.

Both the profession itself and the health care system at large had mixed reactions about the re-visioning of pharmacy and its new curricular focus on clinical, patient-focused care delivery versus the product-focused approach.

The nature of this new approach and, more importantly, its new set of professional and implied practice expectations, harkened back to the earlier part of that decade and the beginnings of the “pharmaceutical care” movement. Visionaries lauded this paradigm shift; employers rued their new payroll increases and staff shortages, and pragmatists rolled their eyes. I was myself skeptical, not of the intrinsic merit of the new principles of practice, but rather in my faith that the marketplace could generate demand for these new skill-sets and expectations.

It took me all of 4 weeks upon graduation from pharmacy school to find myself in a graduate program in health economics, assigned to an advisor who had an unflinching belief in the abilities of a pharmacist to provide cognitive services and the unrealized demand in the marketplace for pharmacist services of all types and in all settings. I begrudgingly went along with it. I’ve now had the privilege and experience of more than a decade of work in helping to build a set of programs and initiatives that are exploring and testing real-world, market-driven application of pharmacist services in all settings of care.

Some weeks ago, I saw a job opening posted on our local pharmacist association’s website for a “clinical pharmacist” position embedded in a practice in a very rural part of North Carolina. While I had seen and been involved with pharmacists being embedded in primary care practices in many geographies in North Carolina, I had never seen one in our market that wasn’t associated with (aka subsidized by) either academia or my own employ- er, Community Care of North Carolina (CCNC), particularly in a rural area with its economy of scale challenges. I should note that the North Carolina market does not maintain Kaiser Permanente—like systems, and maintains almost exclusively a fee-for-service payer mix.

Curious, I called my local pharmacist “on the ground” in that area and inquired about the position. “How is this position being funded?” I asked. The response was illuminating: “Our health system is growing its accountable care organization (ACO) presence and the position is being funded by the health system to that end. They have 2 young and progressive physicians who are excited about having a pharmacist in the practice and focusing on patient outcomes and total cost of care.” I grinned from ear to ear. The shift is happening!

Wake-Up Call #2

Not too long ago, CCNC was asked by our state legislature to figure out how to incorporate community pharmacy activities into the CCNC Medical Home model of care. In essence, they were asking us to be thinking more along the lines of “Medical Neighborhood.” We scraped together whatever funding we could find and launched 10 pilot sites of all types and foci in the community, ranging from behavioral health to specialty pharmacy to traditional dispensing pharmacy to a site embedded within a senior center.

Five of the sites were traditional community pharmacies with revenue models nearly completely dependent on reimbursement for product versus services. We were been pleasantly surprised by the reaction to the program within the local communities of care, in particular, the level to which the primary care practices in these communities have been very supportive.

I think it can best be summed up by an e-mail from one of the physician directors: “... (This Pharmacy)... is literally a godsend for too many patients to count ...one of our (other) physicians remarked recently they do so much for our patients that he worried that they could not stay in business...(with continued reimbursement reductions)...”.

Not only were many practices willing to work with their local community pharmacy within this model, we had more than 100 pharmacies that the practices themselves identified as desirable collaborators—and they would be willing to work hand-in-hand with them to optimize medication use for their patients. That e-mail, in combination with the recent Walgreens’ announcement of its 3 ACO endeavors and the ACO job posting, have convinced me that the times truly are a-changin’.

Historical Perspective

Calls for professional sea change have been around for a while, regardless of what your role is in the health care system. Take the example of the “medical home model” in which primary care physicians are meant to be quarterbacks who orchestrate a patient’s care across many provider types and continuums through their practices’ efforts. The model’s principles, according to all of the major primary care associations, include: whole-person orientation (versus a disease-centric approach), coordination of activity across licensure and setting, focusing on quality and safety, all made possible through a payment mechanism (payment reform).

Sound familiar? Here are the principles of “pharmaceutical care,” brought to us by Hepler and Strand in 1990: “The patient is the primary beneficiary... achieving definite therapeutic outcomes.” Refined by the American Society of Health ASHP in 1993 and then best described in the following preamble from the American Pharmacists Association Board of Trustees in 1995 (my emphasis): “Pharmaceutical Care is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient’ s other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of Pharmaceutical Care is to optimize the patient’s health-related quality of life, and achieve positive clinical outcomes, within realistic economic expenditures.”

Yet it has taken 2 decades for pharmaceutical care—or whatever you want to call it—to finally develop a marketplace. If you think ours has been a long journey, just ask medical home proponents. That movement started way back in 1967 with the American Academy of Pediatrics. Ironically, the first known published notion of the principles surrounding pharmaceutical care are found in the excerpts of a speech given by Brodie in 1973, not too long after the notion of the medical home was born. Why has it taken this long for both ideas to take root?

Why Now?

The answer is Arithmetic. Because of a mix of price inflation, technological advances, and the aging baby boomers, the percentage of our gross domestic product (GDP) consumed by health care has risen from 9.8% of GDP in 1985 to 16.8% of GDP in 2010—and it is projected by the Congressional Budget Office (CBO) to be fully 25% of our economic output by 2037. That is an unsustainable trend and we are close to reaching an inflection point.

Reasonable people can argue that we have already reached that point, and that it was this escalating trend that was at least partially responsible for the Affordable Care Act (ACA) coming to pass—despite gargantuan structural and status quo barriers to health reform. But if health reform is viewed in its more generic sense, nobody can argue that it would not have come to pass eventually.

Health Care Versus Butter

A look back in history gives us a view into the future. The economic model and political context around the term “Guns vs Butter” is borne out of the dilemma of warring countries, popularized as a term in World War II. As the layperson’s version goes—you can spend money on guns (meant to imply military spending) or butter (a metaphor for everything unrelated to military spending)—to win the war. If you spend too much on guns, the war machine grinds to a halt because you don’t have the necessary goods and services of daily living and you lose the war on the home front. If you spend too much on butter, you lose the war on the battlefront. Well, it seems that our new battle in a globalized economy is in many ways centered around, or at least largely affected by, the Health Care versus Butter dilemma—if not for reasons of our cost to produce goods and services, then for reasons of consumer choice.

That same CBO report described the likely effect of consumerism on health care purchasing behavior over the next few decades in the following way: “Instead, over time, people will try to limit their spending for health care in order to maintain their consumption of other goods and services.” Why? Because people, when given the choice and being subject to price sensitivity, will choose transportation, telecommunications, food, and housing over health care as health care consumes more and more of our spending on personal consumption. So, regardless of the ACA, change was coming.

Paradigm Shift

Much of that change can best be described as a re-focus from “sick care,” wherein most of our collective spend and effort is in reaction to sickness or a major event such as a heart attack, to “health care” that provides care proactively to avoid sickness and events in the first place. Without this paradigm shift, the only way to contain costs is by reducing reimbursement (cost per unit), a strategy that pharmacy is all too familiar with. The latter focuses on fewer costly units, particularly those of the preventable kind. Indeed, most ACOs or entities engaged in bundling, shared savings, or other pay-for-performance arrangements have keyed in on preventable hospital admissions, readmissions, emergency department (ED) visits, and total cost of care.

This new emphasis represents enormous opportunity for the profession and practice of pharmacy when one considers that our primary defense against kidney failure, amputations, blindness (all emanating from diabetes), heart attacks, strokes, mental health crisis, and even disease related to smoking is well-informed and optimized medication use. Our well-aged, fee-for-service system is under attack—and no sector of the health care industry will go without disruption this time around.

From Silos to Systems

Now that the health care system is gradually tying quality and prevention to reimbursement, we are starting to see the natural evolution away from work flows and output related to producing more units within silos of care and to workflows and output related to preventing units by coordinating the provision of care across licensure and setting.

For pharmacy, this is actually producing a paradoxical effect, wherein the use of more of 1 type of unit (more medication fills) has a preventive effect, on balance, on the use of costly and avoidable units (hospital and ED visits). With respect to CCNC’s Medical Home model, patients who are engaged with their medical home, on average, have 15% to 60% fewer hospitalizations (depending on the complexity of their disease mix and age of the population) than patients not enrolled in a medical home, with 19% to 26% fewer ED visits. Their medication use, however, was 8% to 39% higher, with much of that owed to increased adherence, persistence, and fewer instances of under-treatment.

CCNC’s Medical Home model has placed a strong emphasis on engaging the “medical neighborhood” and its many providers, including community pharmacy, home health, long-term care, behavioral health, and a host of other ancillary service providers including chaplain and other nontraditional, community-based care team members. This strategy and subsequent findings are not unique to CCNC, and similar experiences are popping up all over the country as innovation takes hold. While a great deal of uncertainty remains as to where all of this effort will eventually land, what is certain is that the 5-decades-old pharmacy business model will tested in the very near future.

Troy Trygstad, PharmD, MBA, PhD, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC), a parent organization of 14 regional care management networks. These networks bring together medical practices, county health departments, hospital systems, and mental health providers to integrate care delivery for Medicaid, Medicare, private plans, employers, and the uninsured. CCNC and its networks are responsible for developing and evaluating accountable care systems in North Carolina. Under his direction at CCNC, the Network Pharmacist program has grown to include pharmacists who are involved in a number of diverse activities ranging from patient-level medication reconciliation to practice-level e-prescribing facilitation to network-level management of pharmacy benefits. Dr. Trygstad also plays an integral role in health information technology adoption and proliferation with CCNC practices and across the state, leading electronic prescribing adoption efforts as well as the development and deployment of a statewide medication management platform. He has been involved in novel adherence implementations as well as the development of adherence technologies that use administrative claims data to predict, intervene, and triage adherence interventions and coaching opportunities. Dr. Trygstad received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He is co-editor of the Pharmacy Times series on Directions in Pharmacy.