Summary
A longstanding physician shortage in the U.S. has given rise to various potential solutions to meet the demand for care. Better incorporating pharmacists into direct patient care could improve the efficacy and safety of medication use, positively impact the patient experience, and increase access to medications and vaccinations. Geisinger’s Medication Therapy Disease Management program is demonstrating the positive impact of pharmacists as healthcare providers. Additional regulatory and system change are necessary to pave the way for pharmacists to meet their full potential as providers; however, programs such as Geisinger’s are proving successful in a primary care setting.
Nationwide Physician Shortage
The physician shortage in our country has been recognized as early the 1960s.1 This initial shortage led to the expanded scope of practice for nurse practitioners and physician assistants. Since then, the shortage has continued to increase with fewer graduating physicians entering into the field of primary care. Many reasons have been postulated to explain this consistent decline, such as a push for specialization and the high cost of medical school.2 This has left a gap in our ability to provide everyone with adequate healthcare services across our country. Numerous solutions have been presented to fill this healthcare gap.3 One solution that has been evolving in parallel consists of the changing role of pharmacists in healthcare.
Changing Role of Pharmacists in Healthcare
The role of a pharmacist has evolved over the past few decades from an auxiliary member of the healthcare team to direct patient care providers. Pharmacists have left traditional roles of “lick, stick and pour” to now providing disease management. The escalating costs of healthcare and powerful medications with narrow therapeutic ranges have made the role of a pharmacist as a care provider more important than ever.
Pharmacists are trained to be care providers and, as such, have proven themselves able to improve efficacy and safety of medication use,4 positively impact the patient experience,5 and increase access to medications and vaccinations. Yet despite these advances, hurdles to the expansion of pharmacy services remain, including the lack of federal recognition as providers, slow adoption of pharmacist scope of practice acts at the state level, limited acceptance of the expanded role of pharmacists among leaders in health systems and other healthcare providers, and minimal ability to receive reimbursements for services. Hence, although evidence supports pharmacists’ expanded role, limitations to implementation, sustainability and scale remain, especially as it relates to providing preventative outpatient care.
Geisinger’s Pharmacist Solution
Geisinger Health System’s extensive Medication Therapy Disease Management (MTDM) program serves as a model of excellence for healthcare systems. Despite many obstacles, including cumbersome state collaborative practice regulations, realignment of provider roles within health systems, and predominant fee for services payment models, Geisinger’s geographic spread has grown exponentially over the past decade.
Geisinger MTDM pharmacists have demonstrated to their stakeholders the ability to improve outcomes (e.g., improved safety and control of disease state), increase efficiencies (e.g., improved physician availability and improved access for patient care), and positively affect the patient experience (e.g., decrease in medication-related side effects, decrease in polypharmacy, and ease of access).
As of 2015, Geisinger employed 54 full-time clinical pharmacists (termed Medication Therapy Disease Management (MTDM) pharmacists) located in nearly all of the 49 Geisinger community-based primary care clinics. This includes services for metabolic disease/diabetes, anticoagulation, heart failure, hyperlipidemia, hypertension, geriatrics, non-malignant chronic pain, oral chemotherapy, multiple sclerosis, medically complex children and anemia. In addition, there are 12 full-time MTDM clinic assistants available to help the pharmacist care for their patients.
Specifically, MTDM pharmacists:
- Perform comprehensive medication therapy reviews and medication reconciliation;
- Identify, modify, resolve and evaluate medication-related problems including adverse drug events;
- Manage the disease state by measuring the safety and effectiveness of the medication regimen;
- Design medication regimens tailored to each patient’s individual needs;
- Optimize polypharmacy regimens;
- Titrate and monitor chronic disease medication regimens; and
- Design cost-effective medication therapy regimens.
Strategic partnerships with key stakeholders made expansion and sustainability of the MTDM program possible. Geisinger attributes the MTDM growth to small wins demonstrated to key stakeholders over time. It is not possible nor is it appropriate to convince an entire healthcare system that a new way of providing care is the right way. Hence, each advance had to be carefully targeted and demonstrated to be valuable (e.g., producing the best outcome for the least cost) before acceptance, sustainability and expansion would occur. In these deliberations, key stakeholders such as medical staff leadership, health system administration, health plan partners, healthcare providers (MDs, NPs, PAs, social workers, etc.), the broader pharmacy enterprise, and patients/family caregivers were consulted and engaged. Feedback provided reassurance, or correction, of the planned MTDM role.
Patients played a key role in the success of our program. Their continuous support of our MTDM pharmacists has proven the value to the system.
- “I trust my doctors when they’re making decisions, but I wasn’t getting any better until I saw the MTM Pharmacist – this is a resource all patients should have access to.”
- “I was taking 30 or so medications until I was enrolled in the MTM program; now I take 16, feel better and know why I am taking them.”
Another key player was our provider colleagues who have pleaded their alliance to our pharmacy program.
- “A 20-minute visit is not enough time for me to address all of these patient’s issues; this is what the MTDM clinic is for.”
- “My limitations in medication knowledge and time make this new program a necessity. We along with patients have benefited from a similar pharmacist program.”
In summary, thoroughly and thoughtfully incorporating pharmacists into our primary care platform at Geisinger by way of the MTDM program has demonstrated ample benefit for both patients and providers. With continued focus, and a willingness from our partners to explore new and innovative care delivery mechanisms, this solution to the ongoing physician shortage is poised for further growth and impact.
References
1. Patti Gasdek Manolakis and Jann. B. Skelton, "Pharmacists' Contributions to Primary Care in the United States Collaborating to Address Unmet Patient Care Needs: The Emerging Role for Pharmacists to Address the Shortage of Primary Care Providers," American Journal of Pharmaceutical Education 74, no. 10 (2010): S7.
2. Shaheen E. Lakhan and Cyndi Laird, "Addressing the Primary Care Physician Shortage in an Evolving Medical Workforce," International Archives of Medicine 2 (2009): 14-14. doi: 10.1186/1755-7682-2-14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686687/.
3. Thomas S. Bodenheimer and Mark D. Smith, "Primary Care: Proposed Solutions to the Physician Shortage without Training More Physicians," Health Affairs (Project Hope) 32, no. 11 (2013): 1881-1886. doi: 10.1377/hlthaff.2013.0234.
4. Nancy Greer, Jennifer Bolduc, Eric Geurkink, Thomas Rector, Kimberly Olson, Eva Koeller, Roderick MacDonald, and Timothy J. Wilt, “Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual Care,” Ann Intern Med. 165, no. 1 (2016): 30-40, doi: 10.7326/M15-3058.
5. J.W. Larson, "Patient Satisfaction with Delivery of Products and Information by an Ambulatory Care Pharmacy," American Journal of Health-System Pharmacy 55, no. 10 (1998): 1025-1029.
Author Bio
Michael Evans is the Associate Vice President of Strategy and Innovation at Geisinger Health System and Co-Director of the Center for Pharmacy Innovation and Outcomes. Dr. Evans is responsible for overall strategy development, administrative oversight and leadership for Ambulatory Clinical Pharmacy Programs which includes all Medication Therapy Disease Management clinics in the Community Practice Service Line primary care clinics and hospital based specialty clinics across the health system, managing disease states such as anticoagulation, diabetes, hypertension, non-malignant chronic pain, hyperlipidemia, congestive heart failure, anemia and oral chemotherapies. He and his 61 ambulatory care team members’ success in pharmacist collaborative practice model of chronic disease management have Geisinger on the forefront of multidisciplinary patient care. His is focused on translational outcomes and healthcare redesign, including: Pharmacy Patient Care Models and System Process Redesign, Pharmacoeconomics and Outcomes research, Medication safety, Pharmacogenomics, Health Information Technology and Adherence.