We Are Perilously Close to Giving Up the Gift

OCTOBER 25, 2017
Troy Trygstad, PharmD, PhD, MBA
THE MOVEMENT TO DISASSOCIATE THE PHARMACY FROM THE PROFESSION
For a number of decades now there have been groups of pharmacists blessing, embracing, or in some instances, fully advocating for pharmacists to completely disassociate themselves as professionals from the act of dispensing a medication. The motivation is not without merit—the idea being that we need to move beyond being rote auditors of the required elements of a prescription and stewards of safe and appropriate filling activities to become experts in therapeutics and, ultimately, care delivery.

Machines that support central fill, drones, and the maturation of properly edited electronic prescription order entry have allowed for the industrial engineering of the filling process to a level that the rest of the health care system could only marvel at with our current efficiency. We fill 4 billion prescriptions a year in the United States after all, and fewer and fewer of them require the time and attention that justify a pharmacist’s salary. Tech-check- tech is becoming increasingly difficult to argue against and decision-support tools and drug utilization reviews are moving upstream to the point of prescribing.

COMPETITION FOR MTM CARE DELIVERY
Meanwhile, payment reform on the other side of the wall (medical care) is imposing upon providers value-based contracting and the delivery of outcomes. Thirty day readmission risk to hospitals is now ubiquitous. The majority of shared savings models for physician providers are driven directly or indirectly by optimal use of medications. Other shared risk and reward contracts with more extreme upside and downside risk are leading stakeholders to reconsider the importance of medication management. Amgen just recently agreed to reimburse payers for past fills when a patient has a heart attack while taking Repatha. For Harvard Pilgrim, reimbursement is based on the level of LDL reduction.1 The medical-side system of reimbursement is moving toward an outcomes-based model that will inevitably lead to new models of pharmacy product reimbursement and related services if medications are the primary tool employed to improve medical outcomes.

This means that the opportunity is the threat. Pharmacy has advocated for “provider status” and payment from the medical side of the house for decades now. And now the other side of the house, as a result of payment reform, is coming to recognize the need for optimizing medication use to achieve outcomes. However, that side of the house is much more crowded with mixed company than our side of the house, which is populated alone with pharmacists, technicians and machines. It’s chock full of care management vendors, doctors making house calls, telephonic MTM programs, home health 2.0 providers, carve out programs with social workers, nurses, behavioral health specialists, health home aides, and a slew of other ancillary providers of medication management offerings, sometimes with closed door quasi-mail order pharmacies that require fewer and fewe pharmacists to staff.

OUR SECRET WEAPON: MEDICATION AS A VEHICLE FOR ENGAGEMENT
What is our advantage over these other offerings? The medication as a vehicle for engagement. The No. 1 compliant I get from our hundreds of care managers at Community Care of North Carolina is lack of a carrot or a stick or other means or methods by which to prompt patient engagement and patient activation. It’s no secret that conventional disease management and care management and other like offerings struggle to be effective without patient engagement. But we’ve historically had a strategically important weapon— the act of dispensing the medication. The medication is the vehicle by which we can engage the patient. It is the vehicle by which we engage the rest of the care team. And it is the necessity for the patient with two or more chronic illnesses that make up 70% of our health care spend and 83.1% of our 4 billion prescription fills. Our professors were right, it isn’t about the product. But it isn’t entirely about our knowledge of the product either. It’s about leveraging the provisioning of the product to the patient to enhance the likelihood of a successful patient interaction, and that is our unique advantage.

GIVING UP THE GIFT
Every day that goes by, mail order chips away at this gift to our care delivery model. Telepharmacy vendors grow, pharmacy hours shrink. Drones become more sophisticated. Some pharmacists turn up their noses at other pharmacists they consider to be inferior who don’t regularly engage in the same therapeutic wizardry to which they’ve cornered the market—only to have the patient’s chaotic environment or lack of coaching and support ruin the best laid drug-regimen plans. To have a patient who doesn’t understand what their medications are used for, or how to take them, or how the new prescriptions relate to those other prescriptions they get in the mail every month are real-life problems that go hand in hand with therapeutic knowledge. Billions of prescriptions are dispensed every year without associated support services and due care and attention to patient outcomes that are ostensibly to be achieved through the use of medications.

There is an awakening underway to the gigantic void in our $300 billion investment in outpatient medications, with growing recognition that there is little to nothing invested in services to generate a return on that investment. With this broader awaking comes opportunity to fill that void with funding and resources to optimize medication use, but also competition from cheaper human capital with cheaper modalities of delivery. To fail to leverage a pharmacy’s full capability to engage patients and achieve outcomes, is to squander the gift—and level the playing field to our collective disadvantage.
 
Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.
 


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