The big question: Who will provide pharmaceutical care in the future?

The new millennium will belong to patient database managers

Pharmacists concerned about the survival of pharmaceutical care foresee a massive change in their roles, the tools of their trade, and even the quarters where they practice their craft. Those who stay viable will reinvent their jobs and quickly plug into the information systems being built by managed care companies and integrated delivery systems.

In this evolving scenario, information is the currency and the key to success. "If pharmacists can’t provide information to patients and other professionals, we don’t need them," says Carsten Evans, MS, PhD, associate professor in the College of Pharmacy at Nova Southeastern University in North Miami Beach, FL. Emphasizing the extent of the changes afoot, Evans asserts, "There will not be a place for pharmacists who think dispensing is their only role."

"All those people in the dispensing pharmacies will find it harder to maintain their positions than those in the clinical practice site," says Maude Babington, PharmD, vice president of consulting at the Pharmacy Corporation of America in Tampa, FL. This fact was driven home by data recently released by Hoechst Marion Roussel of Kansas City, MO, that indicates 44% of the health maintenance organizations use mail order prescription fulfillment plans.

In this brave new world of pharmaceutical care, those who own the databases will control the information that flows in and out. Insurers and MCOs have made the largest inroads into developing these databases, but future ownership might go several ways, knowledgeable pharmacists say. "At one time I thought the providers would own the patient databases, but now I’m not sure they have the resources," observes Lowell Anderson, RPh, DSc, past president of the American Pharmaceutical Association (APhA) in Washington, DC. Currently a community pharmacist in White Bear Lake, MN, Anderson now thinks managed care organizations are best positioned to own the patient record databases.

In theory, future ownership "is an absolute toss up," says Philip Gerbino, PharmD, president of the Philadelphia College of Pharmacy and Science. Theoretically, there would be an advantage to having more than one set of data reflecting all pharmaceutical care episodes. Gerbino surmises the job could go to the pharmacy benefits management groups. But not all of those companies can ante up the millions to build the databases, he notes. He pegs the costs of database development for large patient populations — including hardware, software, and human resources — at $40 million to $100 million for starters, then maintenance and upgrading at $1 billion every 10 years. Managed care organizations already have invested similar sums in their databases, he says.

But a limited number of databases might not be such a bad idea, Anderson says, explaining that diverse sets of data cripple efforts to integrate care across the continuum. "Our patchwork record-keeping systems break down every time a patient moves from one point to another in the continuum. The reason is that we keep going back to the patient to get it instead of updating it in real time on one database," he asserts. This is not exactly the most effective use of resources, he says, considering that few patients can remember all the drugs they use, particularly under the stress of a hospital or long-term care facility intake interview.

What’s worse, community pharmacists don’t talk to the hospital or consulting pharmacists when patients move from point to point on the continuum. "Continuity of records and flow of information as a patient moves to different points is critical to quality care," Anderson continues. It’s especially important as patients age and move between ambulatory settings and long-term care facilities. At those junctures, they carry more "baggage" of multiple medications and increased vulnerability to adverse drug reactions, he says.

The time is right

Ideally, data integration would evolve through a voluntary alliance among the various players, but that’s unlikely, Babington says. In fact, she projects, the payer will have the clout to require care providers to supply patient care data if they want to take care of certain patient populations. "The federal government wanted Medicare and Medicaid providers to do this a few years ago," she recalls. "It was a good idea that came before its time." But, she adds, the time is prime now. "It’s when not if this will transpire."

Even if the managed care organizations are repositories of the data, "someone has to put it to use," says William M. Ellis, RPh, MS, director of the APhA’s Quality Center in Washington, DC. New roles for pharmacists will come from the ways they use the data. Good pharmaceutical care will involve collaborations across disciplinary lines, Ellis suggests.

For example, he says, an outcomes measure for a cancer patient might involve pain medications. "We would want a patient to be pain-free but still alert enough to feed himself, get to the toilet on his own, and enjoy a walk outside on a warm day. Pharmacists must be able to assess the appropriateness of the drug therapies to produce such outcomes," he says.

Where will each of the different types of pharmacists fit into this new information-driven model? Industry leaders interviewed by Drug Utilization Review offered the following scenarios. In each case, necessary skills will include the ability to conduct patient education, track pharmaceutical care outcomes across the continuum, and manage drug therapy budgets for varying patient populations. Here are their predictions:

Community pharmacists: Anderson sees community pharmacists taking more active roles in drug therapy management. "They might make hospital rounds with the physician when one of their pharmacy’s customers goes into the hospital," he suggests. Perhaps they’ll consult on the implications of a certain drug regimens when the a patient leaves the hospital. Anderson concedes that the hospital pharmacist, if there is one, also might participate in the collaboration.

Perry Cohen, PharmD, senior vice president for Systemed Pharmacy LLP in Glastonbury, CT, predicts community pharmacies will become "general stores" for certain disease entities. For example, one would specialize in diabetes management, offering much more than diabetes pharmaceuticals. "They might have a nutritionist on the staff to handle customer questions and provide diabetes education materials," he says.

Community pharmacists who contract with managed care organizations can expect a management fee of, say, $2 per patient. In return, pharmacists would step up their efforts toward compliance. For example, they would call a patient three days after filling a prescription to see if there are questions and if the patient is taking the medication as prescribed. "Pharmacists in these settings are going to have more work to do," Cohen predicts.

MCO pharmacists: "These pharmacists will be paid by the health maintenance or managed care organization to do drug therapy management," Cohen says. The phone and computer will be their links to patients. For example, he says, "A working mother who takes her sick child to the doctor can better comprehend the dosing instructions if she calls the pharmacist after she gets home. At the dispensing counter, she’s trying to keep an eye on the child and could miss some important tips about signs of adverse reactions."

Hospital pharmacists: "As capitation becomes dominant, hospital pharmacists are going to have to demonstrate that they can play a role in preventing hospital readmissions, because that’s what gets expensive," says John E. Murphy, PhD, professor and head of the Department of Pharmacy Practice and Science at the College of Pharmacy at the University of Arizona in Tucson and current president of the American Society of Health-System Pharmacists in Bethesda, MD.

Nova’s Evans goes further, predicting that hospital pharmacists will prescribe medications. Prescribing pharmacists already are a trend in Veterans Affairs hospitals, he notes.

With the increasing complexity of pharmaceuticals, collaboration among health care providers makes more sense than ever, says Carol Sardinha, director of communications for the Academy of Managed Care Pharmacy in Alexandria, VA. Cases in point, Sardinha says, are drug cocktails for AIDS patients. Many physicians routinely consult with pharmacists in creating combinations according to their predicted outcomes for a patient.

Still, Anderson predicts a steady thinning of hospital pharmacy ranks. "The heyday of large hospital pharmacies is over," he says, "The numbers have been decreasing for some time." Hospital pharmacy functions would include overseeing the total drug distribution and dispensing system and consulting with other care providers in the hospital setting. Of course, there’s nothing to stop the hospital pharmacist from moving into any of these roles, these experts say.

Consulting pharmacists: Long-term care is changing and pharmacy roles will follow suit, Babington says. As rehabilitation and return to community living become more common, she says, pharmaceutical care will have to become proactive. For instance, instead of treating depression after it manifests, Babington predicts consulting pharmacists will use algorithms to predict the onset of depression from clues in patients’ records, such as more time spent in bed.

If MCOs and integrated delivery systems are the two entities best positioned (and bankrolled) to build patient record databases, how will pharmacists access the information housed there? New models are emerging, but a lot of unanswered questions remain. Following are the two most prominent models:

1. The managed care organization ownership model: Cohen describes a system in which a pharmacist fields patient inquiries from a centralized information bank. (See chart, p. 115.) Owned by a managed care organization, the database will have the patient’s entire profile. Calling it drug therapy management, Cohen says it will play a critical role in improving drug compliance.

For example, a 75 year-old patient calls the number on her prescription bottle and tells the pharmacist she still feels terrible after a month on a medicine. Looking at the comprehensive record, he asks questions like, "What time do you take them?" He learns that the label reads, ‘take two a day,’ and the patient thought she would take both in the morning instead of one in the morning and one at night. That kind of care management will improve outcomes for pharmaceutical use.

Eventually, Cohen says, databases will include lab results and chart notes from physicians, nurses, physical therapists, and other providers. This type of data integration will enable pharmacists to meet the new demands of employers who spend the resources to insure their workforces. "First they asked managed care organizations to get them some savings on their insurance premiums," but now the industry is in phase two of the evolution, he explains. "Now they want fewer sick days and hospitalizations for their premium dollar. This is terrifying to health care providers, but it forces us to question who are the competent ones and who should get out of the business."

2. The integrated delivery systems database model: Anderson suggests that pharmacists should not worry over who owns the databases, because in all likelihood database relationships will be "custodial." Competition for custodianship, not ownership, will be between provider networks and MCOs, he predicts. Market pressures probably will force providers and MCOs to share custody of patient information in most cases, he says.

"Employer coalitions are saying, ‘Our costs are going up, we pay top dollar for premiums, and our people are not getting healthier,’" Anderson says. Drug expenses contributed to the cost escalation with an 8% increase between 1994 and 1995, according to studies by Hoechst Marion Roussel. The average per-patient expenditure went from $108.42 to $117.07.

"Managed care hasn’t spent a dime to improve the quality of care," Anderson maintains. "It has never included the provider in establishing the care guidelines," and that has to change. His vision of database custodianship puts "the people who are responsible for patient care in the position of creating the outcome measures," he says. (See chart, above.)

In this model, provider networks would manage patient databases, while ownership would be divided between the network and the managed care organization. Integrated provider groups are the logical designers of such records because they provide the care, he argues. But while employers are moving beyond the fixation on cost savings to outcomes, current data systems are not designed to look at outcomes, he says, because managed care companies have designed payment based systems using physicians’ billing codes.

With any change, there are winners and losers, and pharmacists across the health care industry are scrambling to make sure they are not left standing when the music stops. "This is more a professional association-level concern," Anderson contends. "They’re still trying to protect their members’ interests. But the practitioners already know they are going to have to change their power bases — give up some and take on some new responsibilities. The question is more whether we’re willing to do what we do well."

Changing power bases means making yourself indispensable, Cohen asserts. For instance, he says, take a population of 8,000 diabetics. If 100 of them incur bills of $100,000 each, pharmacists who could identify ways to improve the medication compliance of that group would have a power base.

What new roles pharmacists will play depends upon a recognition of the importance of pharmaceutical care across the continuum, says the APhA’s Ellis. "The role of the pharmacist hasn’t even been tapped yet, but it never will be unless pharmacists show and tell the other players what they can bring to the table."