In all the time I’ve been writing about population health, I’ve somehow managed not to discuss pharmacists or pharmaceuticals very much. Partly that’s because I associate the two topics closely and, apart from briefly mentioning efforts to make medications more affordable, I haven’t devoted much thought to how medications – or those who distribute them – fit into a population health framework.
Like many people, I’ve always seen the pharmacist as standing somewhat apart from the medical establishment. Yes, many pharmacists work in clinical settings (around 34% according to a 2019 national workforce study), but I’d argue that most people for most of their lives only see pharmacists in the community pharmacy setting, and even then they mainly deal with pharmacy technologists, not the actual pharmacist. If they had a role to play in population health management, went my logic up till now, it would’ve already happened.
But as it turns out, there’s a lot more to the pharmacist profession than simply dispensing medications. After digging into how pharmacists actually interact with clinicians and the general public, how their role evolved basically overnight during the COVID pandemic, and how much potential they have to move the needle on population health, I have come to see pharmacists and pharmacy technologists in an exciting new light.
Location, Location, Location
As it turns out, my own perception that you can’t swing a recently-deceased cat without hitting a pharmacy is actually quite accurate to most people’s experience in the U.S. In fact, a study published last year in the Journal of the American Pharmacists Association (JAPhA) reported that “Across the overall U.S. population, 48.1% lived within 1 mile of any pharmacy, 73.1% within 2 miles, 88.9% within 5 miles, and 96.5% within 10 miles.”
Now that’s what I call patient access! If you’re new to this blog or the concept of population health in general, accessibility of care is of central importance when it comes to improving patient outcomes. If you create too many obstacles for patients to seek care (long waits, exorbitant costs, too little time with their primary care physician), they often won’t comply with preventative care strategies. This in turn often results in patients presenting at the hospital with preventable health issues, and puts further strain on an already overstressed healthcare system.
On the contrary, opening up availability of medical services to the maximum number of patients (or potential patients who are dealing with risk factors) puts healthcare providers in the best position to maintain healthy populations. Although most pharmacists in the U.S. aren’t as highly trained as the average clinician – which, as we’ll soon see, can cause very real challenges to physicians delegating clinical services to pharmacists – they are still generally very knowledgeable about how to deploy medications to improve patient outcomes.
So the upside of there being so many pharmacies is that, unless you live in Alaska, South Dakota, North Dakota, or Montana – where there are fewer pharmacies per capita – you shouldn’t encounter much trouble in speaking either directly to a pharmacist or to a trained pharmacy technologist. The downside is that while you might be able to ask a pharmacist or technician more questions than you might to your PCP due to time constraints placed on the latter, you often won’t have the assurance that A) the medical practitioner is as highly trained as your primary care doctor, and B) unless they work within a healthcare network alongside prescribing providers as coordinated members of a patient’s care team, the pharmacist may not be able to as readily access as much of your medical information through an electronic health record. Limiting access to the EHR, as the linked article notes, “makes ensuring that patients are receiving proper medications and monitoring for efficacy and safety a challenge, if not impossible in some situations.”
These barriers, both regulatory and technological, present tough challenges to creating a fertile environment in which PCPs and pharmacists can become more equal partners in value-based care delivery. That said, I still believe that the framework is in place for pharmacists to begin taking a more active role in population health management. The fact that most Americans can conveniently receive care from a trained pharmacy employee (in both clinical and community settings) positions pharmacists and their staff members to greatly improve the health of the communities they serve.
Your Friendly Neighborhood Pharmacist (and Tech)
Before we delve too far into the specifics around how pharmacy teams can more tightly coordinate care with PCPs to become key value-based care delivery partners, let’s talk about another commonly-held perception: their trustworthiness.
On top of being highly accessible, pharmacists are generally considered honest and ethical by the public. According to a series of Gallup polls run over the course of many years, pharmacists have consistently ranked near the top of the most trusted professions. In parallel with this trend, the rates of pharmacists seeking advanced degrees are increasing; indeed, according to the aforementioned workforce study, “the proportion of licensed pharmacists whose highest degree is a Doctor of Pharmacy (PharmD) degree was 53.5% in 2019 compared to 37.8% in 2014 and 21.6% in 2009.”
Also of note, in 2019 “36.2% of licensed pharmacists held a BS degree as their highest degree compared to 52% in 2014 and 66.3% in 2009,” a clear indication that pharmacists are looking to arm themselves with more knowledge at an ever-increasing rate. I can’t prove that the two data points are correlated, but it certainly does seem that achieving ever-higher levels of education has made a favorable impression on the public. Since a discussion of regulatory barriers could fill a whole separate blog post I won’t go into it much here; suffice it to say, however, that if pharmacists were allowed practice to the top of their license, many could better tailor their care to the patients who live and work in the communities they serve.
Stepping Up in Challenging Times
Remember that part above about clinicians delegating authority to pharmacists, and how important it may be to the future of population health? Well, this theory was put to the test during the COVID-19 pandemic, which proved to be a watershed moment for the pharmacy profession. The fact that pharmacists became an integral partner not just in dispensing COVID-19 vaccines, but also in testing people for the illness, was lost on neither physicians nor patients.
Up until then, many people viewed their local pharmacist as someone who stood behind a counter dispensing medications ordered by their doctors; but when COVID hit, these benign figures snapped to action, becoming indispensable foot soldiers in a life-and-death battle, administering needed vaccines directly to members of their community when the need exceeded the capacity of primary care physicians to do so.
This dramatic shift in course is borne out in the numbers. In a report published last year that surveyed more than 3,000 patients, 1,000 pharmacists, and 500 providers, the latter of which included physicians and nurse practitioners, with the purpose of understanding the expanding role of pharmacists, the following results begin to tell a compelling story:
- A majority of pharmacists anticipate transitioning from transactional care to taking on more direct patient care responsibilities.
- More than half (53.3%) of pharmacists agreed their current training and education are sufficient to manage patients. However, pharmacists did identify opportunities for additional training in chronic disease education, diagnosing, and prescribing.
- Nearly half of patients would find it helpful to have routine testing and medical visits done from home. Many pharmacists are equipped to interface with patients using telepharmacy technology, and of the pharmacists who use this technology, more than a third told the report authors that “it gives them more time to interact with patients, allowing them to provide crucial information and support when – and where – patients need it most.”
So if pharmacists could step up during a public health emergency to ensure patient backlogs didn’t build up in clinical settings, might they not also be able to play a more active role in preventative healthcare more generally?
Pharmacists and Population Health
I was reading an article by the American Society of Health-System Pharmacists (ASHP) on how pharmacists can influence population health, and I happened across my new favorite definition of population health management:
“While population health refers to the outcomes of a defined group of individuals and the…drivers and determinants of health, population health management refers to the infrastructure that enables programs to target defined populations and employ a variety of interventions aimed at slowing disease progression, improving health-related outcomes, and decreasing total cost of care.”
There is a growing consensus within the pharmacy field that participation in population health should be a priority for pharmacists. In fact, as part of their 2030 Patient Advancement Initiative, the ASHP puts forth several recommendations pertaining to population health:
- Pharmacists in all care settings should be included as integral members of the healthcare team and share accountability for patient outcomes and population health.
- Pharmacists should use health information technologies to advance their role in patient care and population health.
- Pharmacy should establish standards for the application of artificial intelligence (AI) in the various steps of the medication-use process, including prescribing, reviewing medication orders, and assessing medication-use patterns in populations.
- Pharmacists should be leaders in federal and state legislative and regulatory policy development related to improving individual and population health outcomes.
These statements are, of course, only aspirational and don’t necessarily signal progress in any of the specified areas. Still, the ambitiousness of these goals speaks volumes about where ASHP sees the future of pharmacy with respect to population health.
In the document “FAQ: Getting started with population health management” I quoted earlier in the post, the ASHP elaborates on the above goals, stating that, “Identification of barriers, both clinical and non-clinical, that prevent patients from achieving better therapeutic outcomes is a key to successful and sustained care” and providing the following examples of ways pharmacists can participate in population health management: “performing comprehensive medication management, transitions of care services, wellness promotion classes, monitoring for high-risk or specialty medications, and employee health assessments.”
All of the above functions are important, and most share a common feature: they involve collaborating closely with other members of a patient’s care team, particularly the patient’s primary care provider.
Partnering with Clinicians
The term “comprehensive medication management” (CMM) or, as it’s also called, “medication optimization” or, more broadly, “medication management services,” can mean many things to many people. But in this context, a definition that appeared in a 2021 article in the journal American Health & Drug Benefits, seems to fit best: “when a patient’s medication has been optimized by the healthcare team and the patient uses the regimen in the ideal manner to improve health outcomes.”
It’s also important to note that CMM is often delivered in clinical settings, as noted in this definition offered by the American Association of Colleges of Pharmacy (AACP):
“CMM is a patient-centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers.”
Key here is the term “clinical pharmacist”; I couldn’t find many examples of CMM happening widely in community or retail pharmacy practice, at least not without the supervision of a more highly-trained physician (a point I’ll elaborate on in a minute). One of the case studies highlighted in the AACP article illustrates the potential effectiveness of a CMM approach in improving the health outcomes of defined patient populations, a key feature of population health. As described in the article, a center called the Monroe Clinic that serves rural Southern Wisconsin sought to solve a problem: chronic disease patients there were waiting up to six weeks to see their PCPs and, as a result, many ended up in the emergency department.
To solve this issue, the pharmacy team at the Monroe Clinic approached their PCP colleagues about allowing the pharmacists to meet with patients for chronic disease management. As part of this effort, the pharmacists provided their clinical colleagues with a CMM framework that would relieve the primary care doctors’ caseload and allow the latter to see patients who had more acute issues. The approach is paying dividends and, according to the article, one of the pharmacists has been offered a full-time role managing the CMM process.
As in the example of the Monroe Clinic, CMM is an important step forward when it comes to pharmacists becoming key players in population health management. But in my research, I didn’t turn up many ways – aside from being part of an integrated specialty pharmacy within an accountable care organization (ACO) – that pharmacists are directly being reimbursed for implementing CMM or other sorts of value-based care.
Chronic Care Management
One potential exception to pharmacists not being reimbursement for value-based care exists in the form of something called “medication management.” For those pharmacists working in community practice and who deal with Medicare beneficiaries with two or more chronic health conditions, medication management offers an avenue for reimbursement through a program formalized in 2015 by the Centers for Medicare & Medicaid Services (CMS) called Chronic Care Management, or CCM.
Not to be confused with CMM, CCM is defined by CMS in the following way:
“CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services are typically not face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.”
As I mentioned above, medication management is an integral component of a comprehensive care plan for chronic care management and, according to the ASHP, pharmacists can engage in CCM services in the following ways (and please note, “QHP” here stands for “qualified healthcare provider”):
“Under CMS guidelines, pharmacists are recognized as “clinical staff” who can provide CCM services within their scope of practice under general supervision of a QHP. The pharmacist can be directly employed, or under contract (independent contractor) or leased employment of the qualified billing healthcare professional that is providing CCM services. The QHP must be able to provide general supervision of CCM services provided by a pharmacist but is not required to be physically present or colocated (must be available by phone). Under CCM guidelines, a pharmacist cannot consent a patient, develop a comprehensive care plan, or bill for CCM services.”
As key as pharmacists are to a successful CCM program, most are not considered billing providers and, as stated above, must work under the supervision of a physician or other qualified provider. ASHP lists the following as QHPs who can bill for CCM services: physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives, with only one practitioner per patient being eligible to receive payments for CCM services per calendar month. The document goes on to say the following:
“CCM services may also be furnished by clinical staff that meet Medicare’s “incident to” rules. Licensed clinical staff include the following: clinical pharmacists, RN, LSCSW, LPN, MAs or CMAs. The time spent by clinical staff members furnishing CCM services directed by a QHP counts towards the time thresholds. Non-clinical staff time cannot be counted.”
Since most pharmacists aren’t as highly trained as physicians, their avenues for participation in CCM are limited to collecting data, maintaining and informing updates for the care plan, providing 24/7 access to care, and documenting CCM services, and, again, their work for the most part is subject to the supervision of a physician.
CCM in Practice
A real-world example of pharmacists acting as highly effective practitioners of so-called medication therapy disease management (MTDM) appeared in a 2018 article in the journal ClinicoEconomics and Outcomes Research. The authors noted that the approach “has shown improvement in clinical outcomes in patients with certain chronic diseases.” One of these diseases, diabetes mellitus (DM), affects over 30 million people in the U.S. and represents an enormous cost burden for those who suffer from the disease; indeed, states the article, “the cost burden for an individual with DM is more than twice as high as it is for an individual without DM, while the total direct and indirect cost burden of DM in 2012 was estimated to be $245 billion.”
Additionally, studies suggest that when healthcare teams treat diabetes patients and include a pharmacist instead of other healthcare professionals like nurses, doing so is associated with “greater reductions in patients’ blood glucose levels.” Incredibly, despite this clear advantage, at least one study noted that fewer than 10% of U.S. adults with DM have had the factors contributing to their illness adequately controlled. This is primarily because of a lack of data on the impact of this approach on both health care utilization and overall cost of care.
There are any number of other ways that pharmacists can enhance their role in population health, from becoming members of transitions of care teams to working with patient-centered medical homes. But since reimbursement pathways haven’t kept pace with innovation, population health management care approaches have been unevenly adopted throughout the pharmacy industry. It will be interesting to see how areas like medication management and CCM evolve, and if other payers adopt these proven ways for pharmacists to positively influence patient outcomes.