By: Hayeon Na, Co-Copy Editor and Sang Hyo Kim, Staff Editor
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In Volume 1 Issue1 of the Rho Chi Post, we were honored to have an interview with Sandra Leal, PharmD, MPH, FAPhA, CDE, and Director of Clinical Pharmacy at El Rio Health Center in Tucson, Arizona. She had started a petition to support recognition of pharmacists as healthcare providers (HCPs) under the federal law. The interview was about the importance of pharmacists gaining this status, and we asked a single question: “When you started pharmacy school, did you think you were going to be a healthcare provider? Please explain your answer and the reasoning behind your petition on change.org.” (For those who are unfamiliar with the website, Change.org allows individuals to petition for different causes.) The push for HCP status has definitely gained more momentum since then, and the goal seems nearer than ever. To anticipate the implementation of the new law that many hope for, RCP decided to feature Dr. Leal once more to get an update on her views, with a focus on the future of the pharmacy after these changes are implemented.
Dr. Leal is involved with gathering support to obtain provider status for pharmacists under the law. Pharmacists shouldn’t be content with the traditional role of only being the medication use experts who do not have roles in active disease management. By being proactive, pharmacists can change the stereotype of being “medicine dispensers.” Dr. Leal wants all qualified pharmacists to work directly with patients and other healthcare providers to help optimize therapy before, during, and after the prescription is written. She started the petition on Change.org to recognize and spread awareness of pharmacists as healthcare providers. With over 22,600 signatures, the issue has expanded and has gained interest of different organizations and the media.
Due to the limitations in time and resources, pharmacists cannot properly partake in patient care—in practice setting, pharmacists and interns need to participate in all the areas of pharmacy practice which includes tasks like typing, counting, resolving insurance issues, and managing inventory. As if this were not enough, while the responsibility of pharmacists increases (e.g. immunizations), currently the reimbursement does not follow suit. It is important that pharmacists get compensated for their service and have enough resources to focus on tasks that utilize the six years’ education that they receive. This will inevitably prove to be a worthwhile investment, because pharmacists can aid in disease prevention, bridge the gap between the patients and prescribers though counseling and providing more frequent follow-up, and consequently, save money for insurance companies, the government, tax payers, and patients alike. Pharmacists are deemed the “most approachable health care professionals.” As the group that holds this title, pharmacists can provide information both to and from patients, providing another stage for patient intervention.
For example, Dr. Leal has prescriptive authority under collaborative practice; by having prescriptive authority, she can take immediate action without having to get clearance from the doctor on issues that are routine or that warrant immediate attention. This speeds up the intervention process tremendously, and saves time and money for both the health care professionals and the institution.
However, these kinds of improvements on the current patient care model will place more responsibility and task burden on the pharmacists and thus cannot be implemented without due compensation. According to Dr. Leal, recognition and compensation is essential to spreading this model sustainably. It is about time that pharmacists get the chance to utilize the patient care knowledge that they acquire with due respect and reimbursement. We thank Dr. Sandra Leal for her contribution to the Rho Chi Post, and we hope that this interview can provide insight to others who are following this issue.
Q: You mentioned in your article in 2011 that there are reimbursement issues with not being recognized as a HCP (health care provider). What do you think are some other challenges of not being recognized as a HCP? How would being recognized as HCPs change things for pharmacists? Do you think this change is close to happening?
The biggest challenge of not being recognized as a provider is the lack of a widespread sustainable business model that allows for expansion of care and access to patients as usual care. Recognition would allow for patients to more routinely receive comprehensive interventions by pharmacists. I believe that at this moment there has been a lot of momentum built on pursuing provider status by national and state organizations. This is critical to making this change happen and it is the closest that I have seen to having consensus about getting this done.
Q: We are often faced with patient resistance. While the majority of patients and other HCPs trust pharmacists, some others dismiss them as “prescription fillers.” (In a recent visit to a nurse practitioner, I was asked why I had to go to school for six years “just to fill prescriptions”). In the effort to be recognized as HCPs, what do you think pharmacy students and pharmacists can do to change this atmosphere?
Pharmacists, residents and students need to show the level of clinical expertise they can offer. Often pharmacists are limited in the amount of time they can spend with a patient because they have to fill prescriptions to maintain a sustainable business model. By having provider recognition, that model can shift to clinical care as opposed to product dispensing. I believe that patients would significantly benefit if the profession took that shift. Until that happens, pharmacists need to be vocal and advocate for positions that maximize their education.
Q: What resources are out there for pharmacists/pharmacy students who want to become clinical pharmacists and/or help optimize pharmacotherapy along with MDs and other HCPs? What advice do you have for students who want to get involved?
There are many ways that pharmacists and pharmacy students can enhance their clinical skills. One that comes to mind is residency training if that is an option. If that is not the case, then pursuing trainings in areas of interest are available from multiple organizations. For example, APhA offers immunization training and diabetes certificates.
Other options include obtaining board certification or other types of certification like a CDE (certified diabetes education) from organizations like ASHP. Another way would be to volunteer with organizations such as community health centers or colleges of pharmacy to train students or create journal clubs to develop clinical opportunities to practice.
Q: Considering the current pharm D program, what additional service can we offer when we are recognized as HCPs? Legislation to give pharmacists HCP status AND limited prescribing authority has been introduced in California. Do you think other states should follow suit?
I strongly believe all states should pursue provider status while still advocating for federal change. The more states that get involved the more information we will be able to pull from to show outcomes data, improve patient care with integration of clinical pharmacy services. I believe that pharmacists have an opportunity to improve public health and be a primary care provider for people that are already having access to care issues. There is a shortage of primary care providers now that will only worsen with time.
Q: What does it mean to work as a pharmacist with prescriptive authority? What do you do differently on a daily basis? What are some anecdotes you can share about the challenges and rewards of your position? As discussed in the previous question, what do you see as the limit to your practice, and how do you negotiate this?
The benefits of having prescriptive authority under collaborative practice is that I can take action immediately as I am seeing a patient versus having to call a provider to recommend what we should do. This is very gratifying because the actions that I am taking are resulting in improved health outcomes of the patients that I serve. My area of specialty is diabetes, and I find that patients need a lot of help with this very complicate condition with multiple co-morbidities and medications. Having the pharmacy background lets me make interventions through a different skill set than a nurse or physicians; this contributes significantly to improving a patient’s health. The greatest limitation that I am experiencing is difficulty in spreading the model that we have because there is a limit in direct revenue stream to fund the clinical pharmacist in this type of role.
Q: What advantage does collaborative practice have over the traditional setting?
Historically, pharmacists have had to call and make recommendations on a patient’s medication regimen. By having collaborative practice, the changes can be implemented immediately as opposed to waiting for authorization of things that are routine and correct or are urgent.
Q: As you mentioned in your 2011 article, the “reality is that you are liable no matter what.” But of course, there are bound to be pharmacists do not agree and are reluctant to gain the “added responsibility.” If some pharmacists want to “opt out,” what would they do when pharmacists are finally recognized as HCPs?
Not all practice sites will require the same levels of clinical pharmacy intervention. I am sure that those pharmacists do not want added responsibility can continue to practice as they do now as those positions will not fully go away.
Q: Where do you think the pharmacists who are currently practicing fit in? How? Would we have a division of “regular pharmacists” and “HCP pharmacists?” Would the pharm D program change? Would further education be required for pharmacists who are currently practicing?
I believe that like other providers, pharmacists who want to practice in more advanced areas would have to be credentialed by health plans with privileges associated with the site they practice, much like a primary doctor cannot perform surgery; a surgeon has privileges and is credentialed based on their additional training. Additional training will be determined based on the site, scope of practice and other similar but important factors.
Q: How has your Director-At-Large position at ASHP helped this cause? In what ways has your perspective on pharmacists’ ability to integrate with other professionals? If pharmacists were recognized everywhere as HCPs, how do you think the services should be divided between other health care providers and pharmacists? How can the inevitable “power struggle” between pharmacists and other HCPs be delicately negotiated? (For example, nurses and nurse practitioners have definite roles. Where would pharmacists stand? Can we become patient educators as well as “prescription fillers”?) Affordable Care Act (ACA) is going into effect next year; considering the shortage of primary care doctors in America, what role can pharmacists play to improve the situation?
There are numerous examples of how pharmacists are working in teams with other providers where there is not a power struggle but a realization that each profession is contributing based on their expertise. I believe that when other providers and patients understand the training that we have and what our contributions result in; they will understand the value of clinical pharmacy services. That has been my so far.
Q: What can we do to facilitate this understanding?
Communicate with patients every opportunity we have. A lot of times we are behind a counter, which limits us from being able to directly communicate with patients. In an ideal world, pharmacists would talk to every single patient whether a medication is new or just being refilled, just to touch base about simple things like adherence. This is a good time to also have a conversation about things such as the education pharmacists must go through, the years of experience, the role that pharmacists can play as advocates for good patient care. These are just a few examples of what the possibilities are for a pharmacist to be very proactive in getting the message out. The same would be true in communicating with providers. It is key to always make them aware of how team based approach can and will result in better care for the patient.
Q: What “goal” should community pharmacists have in caring for the patients? What is your ideal neighborhood pharmacy? Your ideal hospital pharmacy and clinical pharmacists? The pharmacists’ tasks?
I believe pharmacists should be advocates for their patients, so that the patient has the best outcome possible. A pharmacist in any setting should make sure that they are contributing before, during and after the prescription is written to improve the health of the patient.
Q: If we are recognized as HCPs, how would everyday tasks change? Should there be more or less technicians in pharmacies? How would the roles of technicians, interns, and other members of the pharmacy?
I think that there should be enough technicians, interns and residents to free up the pharmacists to be able to have time to thoroughly review the medication regimen with the patient. With the improving technology, accesses to EHR as well as access to lab values with Smartphones are becoming more realistic. We have to be prepared to utilize this information in a way that improves the patient’s experience and results in optimization of a regimen to improve health. There are also many opportunities for patient education, counseling and adherence interventions that could be achieved if the pharmacist had time to do that. Again, the limit in time is primarily due to the lack of reimbursement for those types of intervention.
Q: What kind of interventions should pharmacists and pharmacy interns make in community setting? Students are sometimes exposed to more updated/ current news because of faculty who try to provide information that will be of help in the future. How can pharmacy students and interns “step up” to help both patients and pharmacists?
In a community setting pharmacists can make numerous interventions such as teaching a patient how to test their blood glucose and helping them understand goals. Pharmacists could perform point of care test for routine chronic care conditions such as diabetes, dyslipidemia and hypertension. Pharmacists can set up vaccination clinics, smoking cessation clinics, or weight education clinics. The possibilities are endless! Pharmacy students provide a workforce that is engaged and eager to learn. Students that have rotated at our site, for example, go to other sites and describe what we do and often times they try to implement some of the interventions they learned.
Q: We are often limited by the access we have to demonstrative tools. In community practice, it is often frowned upon to show that with a real glucometer. Do you think this concern is valid? Would pushing for more educational tools from manufacturers and pharmaceutical companies be practical and helpful?
If an employer frowns upon using a real glucometer the problem is with the employer. This is where I would petition for that to change so that you can do your job better. I think that educational tools are also great, but a lot of times those tools do not necessarily provide information for those with low health literacy and does not use language that is appropriate for the patient.
Q: All of these questions are based on the new legislation that pharmacists hope will be implemented. This will be an arduous process that may take years. How do you think the pharmacy profession has changed over the years? What do you foresee in the future?
I think that the training for pharmacists has become more focused on case discussion and clinical interventions. Also, I have seen more emphasis on residency training and board certification for practice in clinical settings. Again, I believe technology will offer even more opportunities for interventions.
Q: Pharmacists’ responsibility as health care providers is increasing without reimbursement or increase in salary. Pharmacists administer flu and pneumonia vaccines without being paid extra. This increases the liability of pharmacists without equal increase in reward. What changes like these are seen right now? Do you think this will help your cause or hurt it?
I think that increased workload without compensation will aggravate pharmacists and their employers. I hope this will push pharmacists and many chain pharmacies to demand payment for these types of services. Otherwise we will continue to give our services away for free while other providers get paid to do the same thing. Why do we allow this?
Q: In the past few years, Medicare has been hiring pharmacists and pharmacy interns to provide remote patient MTM (over the phone) in accordance with the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Many interns partake in this, and community pharmacists are curious about this opportunity. Currently, the counseling points and services are limited, but further changes may come along.
Because pharmacists and interns are paid “per case” for MTM, ensuring high quality of care is difficult. Do you think monitoring will be necessary later if we earn HCP status?
Health care reform is targeting outcomes measures improvement for reimbursement. I believe that health care is getting scrutinized more and more to justify interventions that work. The key is to compensate those interventions that work, like clinical pharmacy services, and not those that have been compensated for years without accountability.
Q: So would this mean that we should measure the methods for their effectiveness in improving outcome, then put a value accordingly?
Yes. This can be done in numerous ways. With health care reform accountable, quality care is the new objective. Pharmacists and other providers will be measured on being able to meet those objectives. I do not doubt that we can achieve that, but we have to petition to get credit for what we do; this way, we can create and spread sustainable models.
There may be challenges to putting value according to effectiveness, because it will take a long time to gather proof that pharmacist intervention improves patient outcomes. However, if and when the criteria and rewards are determined, there will be a logical evolution.
On the other hand, trying to see if providers are “actually doing their jobs” would probably be impossible. Even though we have systems to check whether any HCP is doing his or her job, there are always those who are not recognized for the good he/she does, and those who do not put enough effort into their trade as they should.
Q: Do you think there are system of checks and balances that are not in practice yet? What improvements can be made, if any?
I think that a lot of opportunities still await. Medication reconciliation outcomes and documenting and preventing adverse drug events are just two of many areas in which much work needs to be done. There is no better opportunity for pharmacists to step in and own those areas. Other areas include pharmacist integration into primary care, where pharmacists can continue to be the most accessible health care provider.
Q: How are you pushing provider status in Arizona?
We are working with a state representative and our state pharmacy association to look at the language in our state and other states that have receive or are in the process of receiving provider status to introduce our own legislation.
Q: Being a pharmacist is a full-time profession that leaves little time for other commitments such as family. As someone who is actively involved in so many aspects of the profession, how do you balance your responsibilities as a practitioner, board member, director, and an individual apart from all this?
My family is my first priority and I allocate my time to that first. The rest of my responsibilities are integrated with my areas of interest so it makes it easy to be active in efforts that I feel very passionate about.
