When reflecting upon the impactful members of a patient’s healthcare team, much consideration is given to the patient’s nurses, primary care physician and specialists. However, with nearly nine in 10 Americans living within five miles of a community pharmacy, and four in five receiving prescription benefits through a pharmacy benefit manager (PBM), the role of the pharmacist in orchestrating a patient’s care on the front lines is often overlooked.1,2
A recent New York Times article by Aaron Carroll highlights the frequently unrecognized role of pharmacists as critical members of the ever-changing healthcare system, and how pharmacists are uniquely positioned to oversee medications, both individually and in combinations, from the numerous prescribers one patient may have. Having the ability to coordinate the complete medication regimen of a patient allows the pharmacist the opportunity to suggest methods for accurately and effectively taking prescribed medications, discuss medication safety, identify and manage side effects, and assist in managing chronic health conditions.
Many patients in the community are unaware that pharmacists have been extensively trained to provide basic healthcare services such as providing blood pressure screenings, educating patients with diabetes on the effective use of glucometers, and ultimately providing an interpretation of these readings and diagnostic tools. Pharmacists can also be a quick-to-reach resource for recommending over-the-counter remedies for common ailments, without the cost and time of getting to a doctor’s office.
On a regular basis, pharmacists in the community, hospital, ambulatory, and managed care settings offer outreach or Mediation Therapy Management (MTM) services to prescribers and patients. If a pharmacist receives a prescription from a prescriber that appears to be unsafe to use with a patient’s other medications, if the dose or duration is inappropriate, or if the cost is overly burdensome, they have the ability to recommend appropriate alternatives by reaching out to the prescriber.
With 66% of adults taking five or more drugs per day and 27% taking 10 or more per day, a pharmacist’s review is critical in identifying when prescriber outreach and consultation should be performed for the safety and well-being of the patient.3 Due to disjointed healthcare systems, many prescribers are unaware of medications a patient may be taking that have been prescribed by another member of the patient’s healthcare team.
Some studies have shown that pharmacist intervention was successful in deprescribing “risky” medications in 43% of enrolled patients within six months, compared to 12% of patients where a pharmacist did not intervene.3
In the managed care setting, pharmacists play a “behind-the-scenes” role in helping manage a patient’s medication regimen. Managed care pharmacists can provide a link between prescribers and patients through MTM services by engaging with patients in discussions regarding proper use of medications, the importance of medication adherence, and identification of high-risk medications. Pharmacists can also provide outreach to patients who are currently utilizing costly medications to provide appropriate alternatives, such as interchangeable generics or a comparable drug within the same class, or advise on elimination of redundant drug therapy.
The provision of MTM services can also assist in identifying gaps in care or dangerous drug combinations that may lead to disease exacerbations, additional medications or costs associated with nonadherence and side effects, or hospitalizations due to suboptimal care.
Aside from patient-specific interventions, managed care pharmacists also play an essential role in promoting cost-effective and clinically-sound drug therapy through the practice of formulary management, routinely utilized by health plans, PBMs, hospitals, and accountable care organizations. In the current landscape of rapidly increasing drug prices, the clinical expertise of pharmacists can assist in mitigating the costs incurred by payors due to growing utilization, innovations in drug therapy (e.g., cell and gene therapy), and lack of manufacturer competition in drug classes for rare disease states. Managed care pharmacists have the ability to assess and compare clinical consensus guidelines and drug-therapy recommendations, review data from clinical trials, and evaluate economic impact to develop appropriate treatment algorithms and frequently used formulary management tools, such as step therapy and prior authorization requirements. With the Food and Drug Administration (FDA) approving record numbers of new drug entities in recent years, the role of the pharmacist in reviewing new and complex drug technologies is critical in ensuring patients are receiving appropriate, cost-effective therapy on both the spectrum of individual and public health.
The role of the pharmacist in public health has been transforming and expanding in recent years. For example, in many states, including Massachusetts, pharmacists can become certified to provide injections such vaccinations and long-acting antipsychotics without the appointment and trip to the doctor’s office. In 2012, the number of vaccines administered by pharmacists was expanded from just the flu shot, to include a total of 10 adult vaccines for prevention of illnesses such as shingles, hepatitis A and B, meningitis, and more.4 In many cases, vaccines are available through prescription insurance without a copay or the cost of an office visit. In many states, pharmacists have the authority to recommend and prescribe routine medications such as smoking cessation agents and oral contraceptives, as well as interpret common diagnostic tools such as for influenza and strep throat. 5,6 The trend continues to expand in many other states as the need for accessible and affordable healthcare continues to grow and an untapped resource of providers is being recognized.7,8
Aside from the ability to independently prescribe basic medications in a community pharmacy setting, for many years pharmacists have been able to work in tandem with physicians through what’s known as collaborative practice agreements (CPAs), where pharmacists are involved in the provision of expanded direct patient care through comprehensive disease management.9 Examples of pharmacist responsibilities in these settings include performing patient assessment activities, ordering and interpreting laboratory tests, developing therapeutic plans, and ultimately utilizing prescriptive authorities to initiate, adjust, or discontinue drug treatment.
As of 2011, CPAs between physicians and pharmacists were authorized by 44 state pharmacy boards, including Massachusetts.9 In a 2008 survey of prescribers who had worked collaboratively with pharmacists through these types of agreements, 96% of physicians who responded reported numerous benefits, including improved disease management outcomes and the allowance of the physician to shift their workload to more critical patients.9 Arrangements such as CPA’s take the pharmacist-prescriber consultative structure to a level of a healthcare partnership which integrates pharmacists as primary care providers, rather than responders to a predetermined decision.
As the healthcare industry shifts from a reimbursement structure based on volume towards a reimbursement structure based on value, the unsung role of the pharmacist as an integral healthcare team member will come to realization. As practitioners trained to assess the whole-patient picture, pharmacists connect the dots between prescribers and impact the clinical and economic effects of drug therapy in an ever-changing healthcare system. Professional medical and pharmacy organizations remain instrumental in advocating for the underutilized resource of pharmacists in any healthcare setting.
1Centers for Disease Control and Prevention. Get to Know Your Pharmacist [webpage on the internet]. Centers for Disease Control and Prevention. 2018 Oct 18 [cited 2019 Feb 20]. Available from: https://www.cdc.gov/features/pharmacist-month/index.html
2Werble C. Pharmacy Benefit Managers. Health Affairs Health Policy Brief. 2017 Sep 14 [cited 2019 Mar 4]. DOI: 10.1377/hpb20171409.000178
3Carroll AE. The Unsung Role of the Pharmacist in Patient Health [webpage on the internet]. The New York Times. 2019 Jan 28 [cited 2019 Feb 20]. Available from: https://www.nytimes.com/2019/01/28/upshot/pharmacists-drugs-health-unsun...
4Lazar K. State allows pharmacies to offer more vaccines [webpage on the internet]. The Boston Globe. 2012 May 21 [cited 2019 Feb 20]. Available from: https://www.bostonglobe.com/metro/2012/05/20/massachusetts-pharmacies-po...
5Macdonald-Evoy J. House panel approve bill to let pharmacists write prescriptions, over doctors’ objections [webpage on the internet]. AZ Mirror. 2019 Feb 07 [cited 2019 Feb 20]. https://www.azmirror.com/2019/02/07/house-panel-approve-bill-to-let-phar...
6Lu S, Rafie S, Hamper J, Strauss R, Kroon L. Characterizing pharmacist-prescribed hormonal contraception services and users in California and Oregon pharmacies. Contraception. 2018 Dec 16. pii: S0010-7824(18)30525-0. doi: 10.1016/j.contraception.2018.12.002. [Epub ahead of print]
7Davis A. Bills aim to allow Arkansas pharmacists to dispense birth-control pills, administer some vaccines [press release on the internet]. Arkansas Democrat Gazette. 2019 Mar 1 [cited 2019 Mar 4]. Available from: https://www.arkansasonline.com/news/2019/mar/01/bills-aim-to-add-to-drug....
8Cummings C. Gov. Reynolds proposal would increase access to birth control in Iowa [press release on the internet]. KHQA. 2019 Feb 13 [cited 2019 Mar 4]. https://khqa.com/news/local/gov-reynolds-proposal-would-increase-access-...
9Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.