July 1, 2009 - 10:48am
I have been thinking of developing a program where I take a patient and review their medications, update their profiles with disease information, make recommendations about changing medications for cost savings, eliminate drugs that are unnecessary, offer lifestyle and other therapeutic suggestions, and manage over the counter or supplements. I was considering doing this for $50 an hour, on my days off, to help patients to get the most out of their medications, in both therapeutic effectiveness and cost-benefit as well. This concept, called MTM (Medication Therapy Management) is on the forefront of all major pharmacy groups, trying to offer this service and get reimbursed by insurance companies. In theory, it will greatly impact patients, as they will get the maximum benefit of their medications, and the best outcomes because we can ensure medications are taken appropriately. For example, we can track when Blood pressure, cholestrol, and diabetes medications are refilled, and make sure that they are done on time. We could help patients with diabetes to monitor their blood sugar, record the numbers, and then review these readings to see when the blood sugar is highest, and offer suggestions to achieve greater control. I want to jump the gun, because I feel that their is a great oppurtunity at my store to improve patient outcomes, but we rarely have enough time to offer these services. Just want to get some feedback from you guys, as to whether you think it would be a useful program, would you be willing to participate if this service was offered, any other ideas you think you be beneficial. Thanks for the input.
July 3, 2009 - 1:53am
#2
My pharmacy already pretty
My first thought is that this is the responsibility of my primary care doctor. As it is, my PCP does all of the above mentioned things. In my case, my pharmacy already pretty much does this for free for me and I love it. Once a year at the very least they have me fill out a patient profile thingie that updates all of my information. They store it in their computer. I also change it with them whenever there's a change in my health. I get all of my medications through them (except my morphine cause they only carry Endo, but they know that I take morphine). One of the major reasons I chose my pharmacy is because they have a diabetes care program that is free. They hold classes at least once a month on topics that relate to diabetes. My pharmacist is the one who helped me get my insulin pump and he even will call me from time to time to see how things are going with it. He was the one to make the suggestion of the insulin pump based on my health, other medications, and information I had told him. I even have his cell phone number in case I have any questions about my medications or insulin pump.
What you're proposing is a little different, but I think it's pretty similar. I have to ask for the one-on-one time with my pharmacist, and it doesn't last more than probably 5-10 minutes. Plus my pharmacy is set up to really cater to diabetics. I think they've realized that there is a lot of money in keeping a diabetic as a customer. Anyway, I think what you're proposing is great based on my own personal experiences with having a pharmacist follow me so closely. I'm not sure that I'd personally pay for the service out of pocket because I already get a lot of that for free. Not to meniton, between me and my insurance, I bring in close to 10,000 in business a month. I kind of feel like with that level of purchasing I should be getting this very closely monitored service. I mean, so lose me as a customer would actually have an impact on the pharmacy's bottom line. I think if a patient has the money to spend and doesn't bring in a lot of busines per se, it would be a great service for them. It'd be even better if insurance covered it since they'd probably save money. My only concern would be for your liability. I'm not sure how all of that works for pharmacists, but what would be your liability if you suggested a medication or suggested a patient stop taking a medication and it caused harm? What about the liability of the pharmacy you work for? Would you be doing this as a service through them, or would it be an independent venture? You'd probably have to clear it with your work to make sure they don't feel like you'd be putting them at risk. I guess you'd be able to figure all of that out. Anyway, I really think this is a great idea.
July 3, 2009 - 2:45am
#3
I can see
Where this type of program would be helpful for people to help manage their diabetes, and to make sure blood pressure medicine is refilled when needed. However, my doctor manages my meds, including OTC's and supplements. I wouldn't feel comfortable disclosing my medical history to my pharmacy. In every single pharmacy I've ever been in, I can hear the pharmacy staff discussing patients and their opinions of their meds they take, and speculating what they take them for. This has been in big chains, and mom and pop stores. There are a couple of people at work that I've heard conversations about.
My pharmacy knows the meds I take and what I'm allergic to, but not why I'm prescribed them. Except the pain meds, that's obvious. I just don't want to be the subject of a conversation that shouldn't be taking place behind the counter where customer's can hear. Also, I would prefer my diseases and other medical history to remain in my doctor's office and not in my pharmacy's computer. The staff there would have access to it, and just using my pharmacy as an example, they have not proven themselves to be very hip to HIPPA (pardon the pun).
My pharmacy does watch for interactions with any new meds and let's me know about it, even holding scripts until they let my doc know about it.
Kelly, as far as the liability issue, I think NJRx means discussing suggested med changes with your doc, not actually saying you should stop one med, and try another. That would be prescribing, and pharmacists aren't licensed to do that. I think he just means making a recommendation, then your doc would be the judge.
For some people, this would be a good idea, just personally, I would opt out of it.
July 3, 2009 - 4:40am
#4
Tux, that's what I figured,
Tux, that's what I figured, but people aren't always that responsible, ya know? Like my concern would be if he suggested that a medication wasn't really neccessary like he mentioned might be something discussed. A lot of people might assume that since he is a pharmacist what he says should be followed without first speaking with their doctor. Even if he says that they should first speak with their doctor, I think a lot of people are either lazy, want to save money on a doctor's office visit copay, or for whatever reason would just stop taking the med without first speaking with their doctor. I wonder what the liability would be in that case. Even if legally he wasn't responsible, defending himself against an accusation of negligence could be very costly in a lot of ways. I also worry about the liability if he suggested a supplement like he mentioned in his post. I personally ask my pharmacist about OTC medications all the time, but I really don't know what his liability would be if I had a bad reaction or something. I also worry about the issues that might arise out of a disagreement between the pharmacist and the patient's doctor. My doctor probably wouldn't be too happy if she prescribed me something and I went to her telling her that my pharmacist told me it wasn't neccessary.
Like I said, I really think all of the above issues are really the responsibility of a primary care doctor, and as a diabetic my diabetes issues are the responsibility of my endocrinologist. I think an unfortunate side-effect of this service if it weren't handled or set up properly would be that people would replace regular visits with their PCP with your sessions. I'd worry about a pharmacist being the one to track diabetes because in a lot of cases it really needs to be tracked more frequently than the occassional meeting one might have with a pharmacist in a situation like this. That brings up another situation where liability might come into play. What would happen if a pharmacist were tracking a patient's diabetes or blood pressure and they figured this was enough and didn't see a doctor about it and then they had a problem like a heart attack or kidney failure. What would be the liability there? I would assume that if a pharmacist were to take on contract-type work like this they would need some sort of liability coverage, which can be REALLY expensive. I know I had to carry insurance when I worked with children with developmental delays and it wasn't cheap. I don't know that $50 an hour would be very profitable when you deduct all the costs that would be associated with something like this. I really think insurance companies would want a patient to see a PCP for these issues too, so I don't think they'd pay for it, thus leaving the cost up to the customer.
I kind of agree with Tux on the privacy thing. I personally have a great relationship with my pharmacist becuase they themselves up to totally cater to diabetics. However, this is a free service to draw in diabetics to give them business. I should note here that the pharmacist that does all of the diabetes classes, etc. only works part-time in the pharmacy. The rest is doing consults, trainings, etc. I don't know that doing it part-time would be feasible since you'd probably have to devote a certain number of hours to each customer. My pharmacist seems pretty busy. Oh, he does work with my endocrinologist which is a good thing, so if you do take on something like this you probably should try to become a partner with the patient's doctors so you don't step on any toes and so you can provide the best service.
I think if you could figure out the logistics of something like this, like where would you do it? would you do this in tandum with your current employer? would you need to carry some sort of liability insurance? would you work with a patient's doctors? how often would you meet with a customer? Plus I think it'd be important to figure out what services you'd offer that would be different from a customer's primary care doctor. I really think you'd have to make sure that you encourage the customer to maintain their relationship with their PCP and let them know that your advice isn't taking the place of their doctor's orders.
I hope you aren't taking this as being too critical. I think you may be on to something here if you can figure out the logistics of it all.
The biggest question I have for you is what is the difference between what you want to offer and what a primary care doctor's responsibilities are? In other words, what would your sessions offer me that my PCP shouldn't already be taking care of?
July 3, 2009 - 9:25am
#5
Specialist Knowledge
I think this plan sould work because as I said pharmacists tend to know more abot the mode of action of a drugs and any new ones that come to market. An example I have is my father was being prescribed about 9-10 different medications , one was a very potent opioid painkiller another a strong tricylic antidepressant, anther a strong phenotiazine type anti-psychotic, then two benzodiazepines ( xanax and librium ) and a beta blocker ( propanolol ) a sleeping tablet , sometimes dalmane or rohypnol ( the heavy duty ones ) and 2 others I cannot remember offhand, but the point I am trying to make is that he had two doctors , one prescribing about 4 of the meds and the other doctor the other 5. And he usually got the two scipts dispensed in two different pharmacies , or whatever pharmacy he was passing if hed had a srcipt . Anyway beacause of all the cns depressing meds and their tendency to cause drowsiness/ dizziness he zonked off in the car a few times and had two car crashes because of this . He was not seriously hurt ( and no one else ) but if one pharmacist had have seen that he was on all that medication and still driving e.t.c. I'm sure they would have considered it dangerous ( which it proved to be ) . After the second crash I had to contact his doctors and ask them what he was on and I could not believe it, it was a wonder he was concious let alone driving and doing the norm. They ended up radically changing his meds and he they shaved off 5 medications , and my dad seemed much better more lucid e.t.c. But I feel with the service NJ has described he would have found out the meds that he was on and felt that there was a great risk associated and contacted the doctors ( who did not know what the other doc was prescribing ) So that's one benefit I can see from a personal perspective. As well as being able to inform the patient in laymans terms that you are being prescribed such a medication and the reason for this is because...e.t.c. which the doctors really dont seem to have the time to do. So I definetly think it would be worth the consultation for many reasons.
July 3, 2009 - 11:16am
#6
Noble plan
...but M.D.'s , not Pharm. D.'s are in charge of managing patient care in this country. "Eliminate unnecessary medications" you say? That sounds well beyond the realm of your expertise as a pharmacist.
Reminding the patients they are due for refills and watching for drug interactions is you doing your due dilligence. Going above and beyond that is unethical. The way I read your post, it sounds like M.D.'s are only needed for writing the prescriptions you fill, and you'l take over patient care from there.
Milo-you made a great point; NJR surely knows more about the medications his patients are taking than the doctors who prescribe them. But if NJR took on this "role," the term "pharmacist" would take on a whole new meaning. He/ she would need a huge malpractice policy for starters...
As I said, a very respectable idea, but not practical. If you don't mind me asking, how long have you been licensed in the state of NJ? If I had to take a wild guess I'd say less than 5 years.
Have a great weekend! 
July 3, 2009 - 12:31pm
#7
I am a doctor
I have a doctorate of Pharmacy, been licensed for 3 and a half years. I am trained in all aspects of healthcare, from giving a physical exam to differential diagnoses to pathophysiology. I have the same training a docotr does, with a better emphasis on medication. Most of my friends who went to medical school had 4 classes related specifically to medication and pharmacology. Most other information was secondhand in other classes, i.e. Infectious disease class (and which antibiotics to use) or cardiology classes. In the continuem of training, I pharmacists now have seven years of school, with over 2000 hours of practical experience (at hospitals, pharmacies, etc.). Some people I know in medical school (they went to pharmacy school first, then chose to go to medical school after 3-4 years) have told me the level of study is the same. Therefore, I have to say I am more than qualified to give this kind of care. However, that being said, I have no intention of ever taking the care of a patient out of the doctors hands. It doesn't work that way. I always end any counseling session with "before changing any drug regimen, ask your doctor" or something along those lines. The reason I asked this question was because a regular physician who prescribes to a good percentage of my patients spoke to me the other day, asking if I was interested in have a form of collaborative practice arrangment with his office. CP is basically where a doctor and another health care entity enter into an arrangment where the other entitiy (pharmacist, nurse, physicians assistant) has authorization to perform certain duties, ranging from refilling prescriptions, to changing medications, to order lab tests, among other things. He was more interested in arranging to have his patients use us for medication review. The problem is that some patients, through accident or design, go to multiple doctors and get prescribed many different things, sometimes duplicate medications. While we often spot and correct these things, sometimes they slip by because the patients are unsure due to their cognitive ability. Therefore, offering this service would help to fix some of these oversights. A few examples include:
1) A patient was getting both Ambien and Lunesta, two sleeping pills, and their insurance was paying for it. The patient said the doctor told them to take both. When we called the doctor, he said that was not true, and told us to D/C the ambien.
2) A patient called the other day complaining of leg pain. She thought she had low potassium and magnesium. After she came in to buy supplements, I got her to agree to a leg exam. After examing her leg, I told her I thought she had a Deep Vein Thrombosis and told her to go to the ER. She did, and her husband called to say that they had caught it before it went to her lung and caused a Pulmonary Embolism (which is usually fatal)
3) Another patient came in complaining of leg pain. After some research, I saw they were taking Lipitor for cholesterol. Upon further questioning, I came to find they were getting simvastation from a different doctor at a Wal Mart pharmacy for 4 dollars. Both of these, taken together, probably caused the muscle pain, and upon stopping the simvastatin, the leg pain resolved. When I asked why they were taking both, the patient replied that nobody told them the drugs were the same.
Just a few of the many examples we see on a daily basis.
July 3, 2009 - 9:45pm
#8
Another recent example
was my aunty two days ago collected her prescription for blood pressure, she would normally take one 5mg tab once a day, the script indicated 20 mg twice a day , which the pharmacist printed on the bottle , after taking the two 20 mg pills later on in the evening she felt really weak ( her blood preesure plummeted down ), like she was going to faint, she stood up and collpapsed injuring her back and knees, she could not get up of the ground and was found by her daughter about 40 mins later, who rang an ambulance. Turned out the doctor made a mistake with the script ( he freely admitted it ans was mortified and extremely upset annd apologetic ) but I could not help thinking that the pharmacist would have had ample oppurtunity to notice the discrepancy and ring the doc. But there are so many locum pharmacists working over here that I really dont think they are familiar with the meds. And a lot of the doctors write the market name of a drug, instead of writing the generic drug name ( which should be recognised by any pharmacist , no matter where they are from ) So I think they should write the generic drug name first and market name second, it may have helped the locum pharmacist recognise that the script was wrong. Anyway she is fine now, but just another example. May not be the same in the U.S.
July 4, 2009 - 1:09am
#9
When I signed up for my new
When I signed up for my new medicare prescription plan, I was offered a medicine review. I didn't have some number she wanted to schedule it. But she told me to call my pharmacy and set up an appointment. I never did because I do not take alot of meds. There is no treatment for my disease. But it sounds like a good idea. I like my pharmacist but, others should stride to be more like you.Take care, htmom
July 4, 2009 - 5:03pm
#10
My best friend is a
...Dr. too, as in Ph.D. HE's a doctor of Marine Engineering. Semantics is fun.
I like you NJR, and I know your heart is in the right place. Too bad the majority of pharmacists are not interested in taking a hands on approach to patient care.
Best of luck to you.
Enjoy your holdiay!
July 4, 2009 - 5:29pm
#11
Hi Feliks, In certain
Hi Feliks, In certain countries a pharmacists knowledge is held as so akin to a doctors knowledge that they have prescribing powers, a few months ago a friend of mine went to a doctor to ask him to start a detox from diazepam , the doctor was about 67 so you would expect he would be quite knowledgable about medication, not so , he rang up to his daughter ( also a doctor ) upstairs in their practice and asked her what would she recommend for a diazepam detox ( he was taking about 10 -15 mgs of diazepam a day ) . anyway she said to her dad prescribe him xanax 1mg three times a day , repeat the script for 3 months and tell him to come back then. So he went from a weaker long acting benzo to a very potent short acting benzo and developed a tolerance to xanax . Despite me telling him that this was a stupid decision now he has to try detox from 3 mgs of xanax a day , which will most likely require at least 40 mg of diazepam or more to titrate him down from the xanax. I told him to go back to the doc befoe he got his next refill and try to explain the difference in potency and duration of action between xanax and diazepam, and the doctor saw red and started berating him with " who's the doctor here you or me, and I have been practicing medicie for blah blah blah. Now obviously the suggestion is not that pharmacists take on the role of doctors, but again , and I know I am repeating myself do you think a well informed pharmacist would have given this counter productive advice to that same request ? Maybe you think it's just a way for some pharmacists to increase their income but if a once every 3 -6 month consultation could prevent scenarios like the ones I described for $50. And as I mentioned the cirriculum and modules for doctors are very similar and just as intensive. It's not like your going for a consultation with somebody with a Ph.D in shariah law in post revolutionary Iran. Well I hope not anyway.
July 5, 2009 - 4:27am
#12
NJRx242- I am a little
NJRx242- I am a little confused...the scenarios that you gave...aren't those tasks already the duty of my pharmacist? I mean, why would I pay a pharmacist $50 an hour for tracking my meds when a core job of a pharmacist is to track the medications a patient is on and to not fill medications with negative interactions (unless my doctor were then to clear it)? I know that whenever my doctor prescribes something that has even a moderate interaction with another medication I am on my pharmacist won't fill it until she speaks with my doctor to make sure it is okay. They also track my health conditions to make sure what I'm on doesn't have any interactions with my health conditions as well. I thought the whole purpose in going to 1 pharmacy was to make sure that your pharmacist could do their job and track a patient's meds. I know with competitive pricing that doesn't always happen. Even in my case, I get all of my scripts except for my pain medications filled at the same pharmacy. However, they don't carry the brand I like of my pain meds, so I get them filled elsewhere as of late. However, I keep them updated on what I am taking every time there is a change.
My pharmacy even goes as far as to offer me free diabetes classes. I know they also offer free and low cost shot clinics, they take and record blood pressure on the spot, my pharmacist always gives me help when I need an OTC medication (she will even leave behind the counter and come out into the store with me to go over what she suggests), they offer some other classes that I don't attend, and many, many other things. Maybe my pharmacy is way ahead of the times and does more than they should, but when I think about it, all of the pharmacies I have gone to in the past have done most of these things. A big part of it of course is putting into the relationship what you expect to get back. I always make sure my pharmacist knows me and make sure I keep them up-to-date on all of my meds and my health. Of course they couldn't follow me very closely if I didn't put in the effort myself. Then again if someone is going to pay for that type of service they'd be putting in the time I'd assume so they could get their money's worth.
I guess now my question is what specific services would you be offering me for $50 that isn't already a part of your job? I'm not sure if you've read my other posts either, but I had some questions in there that I'm curious about as well. I hope you take my posts as constructive feedback since you came here to bounce an idea off of us. I'm just trying to figure out what exactly you're offering and the logistics of it.
July 5, 2009 - 2:14pm
#13
Medication Review
Kelly: most of that is part of the job, but with the amount of prescriptions that are filled, there is a limited amount of time to spend with the patients. I try to get in the most out of when I talk to them, but it is difficult to do this in a limited time. Simple things can be overlooked or not said. And some patients aren't comfortable talking at the counter, about side effects, asking questions, etc. A set aside period, where you can review medications, and get all a patients health conditions written down, would be extremely helpful. A great deal of pharmacists, myself included, only know of a few medical conditions a patient has, mostly second hand through the drugs they are prescribed. Therefore, we hardly ever enter these in a profile. Its mostly through inference that we catch drug-disease interactions. Being able to enter these conditions into the computer to catch any interactions would be useful. For example, we may enter osteoporosis into a computer when a patient gets Boniva, but what about Toprol XL for blood pressure? There are a great number of conditions that this drug is prescribed for. Having a review of this, along with medications, herbals, OTC's, etc. would help to provide a better health care plan. The recent outcry with APAP illustrates this point. Some people accidentally take their percocet with tylenol because they don't know any better. I tell everyone getting these drugs to limit tylenol intake, but some people don't listen. Driving the point home may help. Eventually, pharmacy organizations want this to be covered by insurance, because I guess pilot programs show better disease outcomes when MTM is done on a monthly basis.
July 5, 2009 - 9:04pm
#14
Thanks for answering my
Thanks for answering my question. After reading your answer, I think this sounds great for patients like my hubby, who only sees his PCP once a year. I think it'd be even better if you could try to get health insurance companies on board, kind of as a cost-saving effort on their part. I don't really have a choice other than to stay on top of my health conditions and to make everyone who is a part of treating them as involved as I can get them. However, someone like my hubby could benefit from something like this because he could avoid a costly trip to the doctors when he just needs something like ibuprofen, or a blood pressure workup. Perhaps a way that you could advertise it would be towards people who don't necessarily have severe health problems. I think that's probably a good chunk of people.
I also want to say, I'm VERY fond of my pharmacists. Every pharmacist I've ever had has gone above and beyond with my care. I have had numerous occassions where my pharmacist has prevented me from taking something that has a dangerous interaction with another medication I'm on. As I mentioned before, I used to babysit for one of my pharmacist's children so I got to learn a lot about him and his job. I couldn't believe how stressful it was. I mean, you literally have people's lives in your hands every time you fill a script for them! I saw a study once of 10 most stressful jobs and pharmacist ranked #1. I wasn't surprised by that. Pharmacists do far more than just count pills.
July 6, 2009 - 12:00am
#15
Thanks for the kind words
Its tough, we only tend to remember the people who complain, but 95 percent of my customers are great, and I would go out of my way to help them. We do little things sometimes, like deliver to homebound patients (we don't deliver regularly) or go out of our way to help with people who have trouble paying. As I said, most of our customers are great, and its that bond that makes the job great. I always get that tinge of pride when someone thanks me for doing something, even though it is doing what I'm supposed to. I usually believe that the customers who show me respect will get nothing but that from me. We don't ask for people to be rays of sunshine when they come in, because honestly, people are coming into the pharmacy because they are sick in some way. I try to remember that when dealing with, what I would term, difficult customers. But thankfully, we do have our share of wonderful customers. It amazed me when Christmas came around, we got about 30-40 cards from various customers, a cookie basket, and some other gifts. I was almost moved to tears, as I had not expected such an outpouring of gratitude. It nice to see such a bond, essentially among strangers, in the society we live in. I hold that relationship as sacred, and that is why I do what I can to help my patients.
And thanks to everyone for all the kind words on here. I hope that I can help everyone out on here in some way with whatever useful info I can provide.
I think it is an excellent plan NJ , certainly very practical , and a lot of pharmacists are so clued in to the latest meds , their mode of action e.t.c. It would be great if the general public where able to utilise the skills and knowledge of the pharmacists, which I think are underated ( in my country anyway ) The pharmacists study and cirriculum over here is about as intensive as a doctors and a lot of modules the student doctors take the student pharmacist takes also. Although I do think the doctors would get very nervous about plans like that over here. But I think the public should change their perception ( should it exist ) that the pharmacist is just the guy or girl who fills your scripts. Anyway I think it is a great plan, gives people more choice and oppurtunity to discuss their medication. Hope you have good response and success . All the best . M