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CHICAGO—Could the addition of a pharmacist to rheumatology care teams improve patient satisfaction, decrease staff burnout or reduce medication-related problems? Three panelists in Integrating Pharmacists into the Workforce, a session at the 2018 ACR/ARHP Annual Meeting, shared positive experiences with this interdisciplinary care model.
Less Burnout, More Satisfaction
Ten years ago, the Arthritis Treatment Center at Tufts Medical Center, Boston, added a clinical pharmacist to its interdisciplinary team two days a week, said William F. Harvey, MD, MSc, the center’s clinical director.
“At that time, there was a rapid increase in the number of complex therapies being administered,” including biologic and biosimilar therapies that required more administrative oversight from his small staff, Dr. Harvey said. “Also, there were changes in insurance requirements. I think we do more paperwork for insurance coverage than we do for anything else in the course of our care.”
Electronic medical records (EMRs) and reimbursement reporting took more staff time away from patient consultations. This contributed to staff burnout and high turnover, increased patient wait times and decreased patient satisfaction, said Dr. Harvey. “We were taking a big hit. It’s easy to feel assaulted by all this technology.”
In the first year, the clinic’s pharmacist focused on point-of-care benefit analyses and prior authorizations for outpatient biologics filled by Tufts’ 340b specialty pharmacy. “Our patients loved our pharmacist. They treated the pharmacist like a member of the team,” said Dr. Harvey, noting patients frequently spoke to the pharmacist more often than to their providers.
The clinic’s model for covering the cost of adding a pharmacist included increasing revenue for its specialty pharmacy, and in just the first year, the clinic found revenue rose slightly. Revenue grew substantially over the next 10 years to make the arrangement cost effective, he said.
‘The pharmacist’s scope of work increased tremendously, & the impact on our practice was profound.’ —Dr. Harvey
Five years into the arrangement, the clinic increased its pharmacist’s responsibilities to include obtaining all prior authorizations, conducting patient education and follow-ups regarding medications, talking with patients about manufacturers’ assistance programs, working rounds in the infusion center, performing medication reconciliations for complex patients and providing injection training.
“The pharmacist’s scope of work increased tremendously, and the impact on our practice was profound,” Dr. Harvey said. The clinic is also able to leverage a pharmacy technician’s time along with other departments at the hospital. “It has completely transformed the operations of our clinic.”
In a typical day in clinic, Dr. Harvey said he may meet with a new patient to review the treatment pathway, then call in the pharmacist to “go over anything the patient will need to know about the medication, and I focus my conversation on their prognosis, the natural history of the disease, what to expect,” he said. “Our pharmacist might teach patients how to do their injections, or if patients are afraid to do their own injections, she arranges for them to come back so we can do this in the office.” The pharmacist consults with patients about the cheapest therapies under their insurance plan and alerts providers when patients have drug side effects, he added.
When Dr. Harvey and his staff analyzed data collected for standardized reporting purposes, “we noticed our provider rating going up,” he said. “Why would our provider rating go up when we started turning over half the conversation about a patient’s medications to the pharmacist? Patients really respond to having an accessible team for their care.” Patient referrals, staff quality measures and provider satisfaction rose after the clinic added a pharmacist. “There were also increases in our scores for culture of safety. We felt like we were taking better care of our patients.”
Did this new concept reduce staff burnout? Although this is hard to measure, Dr. Harvey cited the Quadruple Aim, a model for high-functioning clinics that includes improving patients’ health, experience of care and per capita cost of care, as well as providers taking joy in practice.1 “How many people would love to come home from their day at clinic and say, ‘I had joy at work today?’” he said. With rising administrative burdens and healthcare costs, “It’s becoming increasingly difficult to feel that way. But what if you could do that?”
Adding a pharmacist helped the clinic achieve several Quadruple Aim measures, including adding capacity by sharing care among a team, saving time by re-engineering prescription refill work out of the practice and reducing unnecessary physician work with email management, said Dr. Harvey.2 “We are all a lot happier, have a lot more fun, and one of our providers said that bringing in the pharmacist is the best thing we’ve done in years.”
Careful Patient Follow-Ups
On the other side of the continent, clinical pharmacist Janet Cho, PharmD, typically spends mornings at the Keck Medical Center of the University of Southern California (USC) rheumatology clinic in Los Angeles and afternoons at the Keck Medicine of USC Specialty Pharmacy, which only serves providers in the system.
Her roles and responsibilities include comprehensive medication management; drug safety monitoring; consultations for high-risk medications, such as biologics; prior authorizations; drug transfers between pharmacies; and coverage appeals management. “I want to highlight that patient education is probably the core of what I do. I spend a large portion of my time educating my patients, whether face to face in the clinic or on the telephone,” said Dr. Cho.
Workflow in the rheumatology clinic may begin with a pharmacy consult for a patient’s new therapy. “I always do a screening, making sure the drug is safe for the patient, with no comorbidities or labs that we’d be concerned about. We do all education, which can vary per patient depending on their receptiveness to or hesitation about the therapy. This can take from 10 to 45 minutes or an hour, so I do think that’s a lot of time saved for the team,” Dr. Cho stated. She also trains patients to inject their medications at home.
At the specialty pharmacy, Dr. Cho and her team manage prior authorizations and appeals, document insurance information and ensure that “baseline labs are completed before dispensing the medication. And then when the patient obtains the medication, that’s our favorite part of the process. At that point, we do our call. Initial consultations can last up to an hour, depending on the patient, especially if they have a lot of questions. And periodically, we follow up with them with one call after they start therapy, just to see if they tolerate their medication and to monitor for side effects or injection site reactions,” Dr. Cho explained.
The pharmacy team documents all medication-related notes in EMRs. “We don’t need to ask the care team for any additional information, because we have access to what we need.” Pharmacists have been able to reduce the heavy workload of the clinic’s nurses, she said.
Dr. Cho tracked prior authorization data at her center from July 2017 to September 2018 and found that for rheumatology and gastroenterology autoimmune patients, the clinic posted an 84.6% approval rate, and 21 out of 31 prescription coverage denials were overturned on appeal. The center also exceeded a Medicare standard measure for proportion of days covered by prescription claims for a medication, indicating high levels of patient adherence to therapy.
In another report tracking medication-related problems (MRPs) from August 2017 to August 2018, Dr. Cho found her clinic had 184 total rheumatology-related MRPs, including 110 for specialty pharmacy prescriptions. Safety issues were the most common MRPs, including laboratory or diagnostic tests indicated but not ordered, improper storage of the drug by the patient, and medication overuse or misuse.
The pharmacy staff’s goals include ensuring they address all MRPs among the clinic’s patients and improve patient education and training, said Dr. Cho.
Save Time & Money
How can rheumatology clinics afford to add a pharmacist? It may be feasible only for practices within larger systems, the panelists agreed. However, this model may save costs over time, said Sooyeon Kwon, PharmD, PhD, a clinical pharmacy resident at The Center for Rheumatology (TCFR), a three-clinic network in upstate New York.
“High healthcare costs are not sustainable. It’s been the driving force for every researcher to find a model to really sustain and provide the best care outcomes given the resources,” Dr. Kwon said. In addition to dispensing medications, a pharmacist on an interdisciplinary care team can educate patients to improve adherence and clinical outcomes and, eventually, save direct and indirect costs by preventing future, more costly outcomes, such as hospitalization or emergency visits, she added.
Pharmacists at TCFR, a private practice with 18 providers, are in charge of counseling and teaching patients about new pharmacological therapies, disease state, medication use, self-injection technique and adverse reactions. Based on recent internal patient survey data at TCFR, patients have a high level of anxiety when they start new treatments, especially biologics. After a teaching and counseling visit with a pharmacist, 96% of patients reported they either agree or strongly agree they feel comfortable with the new treatment.
Pharmacists also developed evidence-based justification letters to obtain insurance coverage for off-label drugs. This program streamlined and shortened the approvals process by weeks or months, which is very important patient advocacy, Dr. Kwon said. If this process is delayed, the person who suffers is the patient who needs the medication. To receive an approval from insurance at first submission for off-label use, it is necessary to include the most recent literature to support and justify the use of medication for the patient, which requires time and extensive literature review. From 2009–2014, TCFR found the rate of initial denials for insurance coverage of off-label drugs dropped to near zero.3
Another important aspect of the pharmacy service is saving physician’s time, Dr. Kwon noted. TCFR estimated a pharmacist saved between $1,000 and $4,000 in physician’s billable hours per quarter. Physicians can be more readily available for direct patient care by being freed from time-consuming, insurance-related tasks, such as letter preparation or peer-to-peer process. In a 2016 internal survey, 54% of providers at TCFR estimated pharmacists saved them two or more hours of work per week. In the 2018 updated survey, 70% of providers answered they saved two or more hours per week.
With more pharmacologic agents, such as biologics, available in the market for patients and providers to compare and choose from, the contribution of a pharmacist as a member of a multidisciplinary team to take care of patients becomes more and more important, Dr. Kwon said.
Jessica F. Farrell, PharmD, director of the TCFR pharmacy service, noted in 2017 in Arthritis & Rheumatology that the staff concluded that adding a pharmacist improved the quality of patient care at the clinic, particularly through improved medication safety and prior authorizations.4
Reimbursements also rose after TCFR expanded the pharmacy staff, based on coding data, Dr. Kwon said. Currently, because pharmacists are not recognized as a healthcare provider by the Centers for Medicare & Medicaid Services, revenue generation to compensate pharmacy services may be difficult for a small practice that does not have a specialty or dispensing pharmacy operation, she noted. A quality improvement program linked with insurance companies may open an avenue to generate funds to compensate for pharmacy services. Also, having an on-site pharmacist and the ability to perform medication reconciliations are measures rheumatology practices may report to Medicare to increase reimbursement rates through the Merit-Based Incentive Payment program, Dr. Kwon said.
Susan Bernstein is a freelance medical journalist based in Atlanta.
References
- Bodenheimer T, Sinsky CA. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014 Nov–Dec;12(6):573–576.
- Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: A report of 23 high-functioning primary care practices. Ann Fam Med. 2013 May–Jun;11(3):272–278.
- Farrell JF, Shapiro LS, Kremer JM, et al. Pharmacist-developed letters may enhance success in obtaining insurance approval for off-label use of biologics (abstract 2444). 2014 ACR/ARHP Annual Meeting.
- Farrell JF, Shapiro LS, Miller M. Clinical pharmacist as part of the interprofessional team improves quality of care in patients with rheumatic disease. Arthritis Rheumatol. 2017 Nov;69(suppl 10).
