Pharmacists Are Ready and Qualified

The biggest challenge pharmacist's face is obtaining provider status. As a profession, pharmacists are equipped with the knowledge needed to make the change, but other medical professionals are unwilling to let this happen. With the changing of law under Obamacare, the medical professions may have to allow pharmacists to be considered medical providers and capable of billing Medicaid, Medicare, and other insurance companies. Or, Congress may have to step up and mandate that pharmacists be given provider status.

With shortages already occurring in primary care and family medicine, the wait times for doctor appointments are increasing and many are reducing the number of times per year they are seeing patients. With the increasing number of people being diagnosed with diabetes, care for this chronic disease is being strained to the breaking point in some areas of the United States.

These same areas are short on doctors and other professionals capable of helping people with diabetes. This also applies to people capable of providing education for people with diabetes. A shortage of pharmacists does not seem to be happening on the same level. There may not be an abundance, but there is no extreme shortage of pharmacists. Yet the state medical boards stand in the way of pharmacists obtaining provider status.

“As the number of people with diabetes grows, so does the need for health care providers to give optimal care, and so does the amount of money it takes to do so. Diabetes is a complicated disease. It takes a lot of effort on both the patient and physicians part to maintain control. It's tough to see your doctor when you are sick, and it's even tougher to see them on a regular basis. Doctor visits every other month are not enough for most diabetic patients. Things fluctuate and need regular attention. Often, poor people, Medicaid patients, and people without their own transportation have the most trouble with getting care.”

Pharmacists can be more accessible and they can provide optimal care for patients between visits to the doctor. It is possible for pharmacists to monitor insulin pump data, check glucose readings, look over carbs/diets, and make recommendations for therapy adjustments. The benefits of this type of work can help improve care, optimize control, and save money in the end. Yet the state medical boards stand in the way of pharmacists obtaining provider status.

How many times will I have to say the last sentence? State and national medical groups apply pressure to state medical boards who then lobby state legislators to prevent pharmacists from obtaining provider status.

Pharmacists Now Doing More for People With Diabetes

I must admit my feeling about the help that pharmacists are providing to people with diabetes is very positive. Pharmacists are stepping up their public relations (PR), putting their activities into action, and doing a lot more for all people with diabetes than certified diabetes educators (CDEs) have done in a long time.

This action started five years ago in a hunt for the cause of hypoglycemia in the 11 hospitals in the BJC HealthCare system according to Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri. First they realized that adverse drug events were responsible of 20 percent of the preventable harm that occurred in their system. Next they lead a multidisciplinary mission to reduce them.

What they discovered was that 77 percent of the adverse events were caused by severe hypoglycemia. Dr. Milligan described this as a hidden epidemic that was not on anybody's radar. This was discovered by working with each hospitals informatics department to track the origin of drug events. That revelation presented particular challenges. Hypoglycemia has assorted and complex root causes - from prescribing, to drug administration, to patient compliance, to food issues, to equipment variances. Dr. Milligan explained that the population available to study was very large — about a third of the patients in the system had diabetes.

This was not what they had expected, but because clinicians mainly focus on the primary reason the patient is admitted to the hospital, and diabetes is often secondary.  Making the problem even more complex was when pharmacists teamed up with physicians, nurses, dietitians, and diabetes educators to study the problem at 11 hospitals in the BJC system. This team discovered that each hospital had a different primary root cause for the hypoglycemia. At one hospital, the 3 people delivering the food, testing the blood, and delivering the insulin came in at different times, so could not perform their actions simultaneously, which is preferable. At another hospital, admitted patients were getting fewer calories than they did at home, but were receiving the same medication dose, which caused blood sugar to drop.

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Once the root causes were determined, the team developed procedures customized to each hospital. That was one key to BJC's success, because they didn't try to implement one standard list across all the hospitals. We dealt with the biggest problem at each hospital, and sometimes only on the problem floors. You get a big impact and bigger buy-in if staff can see direct results.

“Elizabeth Pratt, DNP, RN, from Barnes-Jewish Hospital, which is part of BJC HealthCare, said some of the problem was a lack of awareness among clinicians about hypoglycemic trends in patients and a lack of automated triggers that would alert clinicians to monitor glucose levels.”

"With heightened awareness and an alert system, we're able to recognize those people earlier, have a multidisciplinary discussion with the nurses, pharmacists, and physicians," and ask whether the regimen should be adjusted, she said.

Now that the initial problems are under control, Dr. Pratt has taken over maintenance of the program, system-wide. In 2014, the program will be expanded to include the prevention and treatment of hyperglycemia, she reported.

Now, instead of an average 138 such events per month, the system averages in the 30s, said Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri. The team has been credited with preventing more than 2100 hypoglycemic events, which saved 8127 inpatient days and more than $7 million in hospital costs.

Hyperglycemia – No Pain, No Harm Done – Right?

My email inbox had a very interesting question recently. The person said, “If I don't feel sick, how will high blood sugars hurt me?” I have answered the question in several emails, but felt the topic was important for a blog of the experiences this person went through. Too many doctors do not explain high blood glucose and the damage it will cause over time. They most generally just tell people to watch what they eat and leave it at that. This may have been what happened to this person as she was recently diagnosed with type 2 diabetes. Metformin was a good start, but she gave no other information.

A query about blood glucose readings yielded a question mark and her dosage was only 500 mg at the evening meal. I was afraid I had been too blunt about having another visit with her doctor and asking for a blood glucose meter, test strips, and the rest of the equipment, as I did not hear from her for another two weeks. She said the doctor had told her not to be using that and she did not need to know what anything was and that he would tell her everything from her quarterly tests (I assumed A1c from that statement, but I will disclose the actual test later) and would increase her medications if needed. By this time, she was complaining about the problems metformin was causing. She was being sick almost every day.

My immediate email back to her was which type of metformin was she taking and when was she taking it? It was the metformin tablet and not the extended release. The doctor has told her to take it one hour before the evening meal and the pharmacist had said with her evening meal. She had mentioned this to the doctor and he had really chewed her out for not following his instructions. I suggested that she have a talk with the pharmacist and explain what was happening and what the doctor had said.

She had gone to the pharmacy, but passed out on arrival and was rushed to a hospital where she was given tests and a recheck for diabetes. Yes, her reading was over 600 mg/dl and she met with the hospital diabetes educator. The CDE had given her a blood glucose meter and showed her how to use it. She was on insulin while in the hospital and then given a prescription for metformin XR (extended release) and told to find another doctor after discussing what had happened. She also had prescriptions for the test strips and lancets, alcohol pads, and a few other non-diabetes medications.

As soon as she was released from the hospital, she went back to the pharmacy and they were happy to see her. The pharmacist suggested two other doctors and said this was a wise move on her part. The pharmacist was happy to see the prescriptions and said that the metformin XR could be taken most anytime, but the hospital had wisely recommended at meal time. Her dose now was 1500 mg at breakfast, and 1000 mg with dinner.

What her email said then really makes me happy that she has this pharmacist. This pharmacist discussed and explained each medication in terms she could understand and then took a highlighter pen and highlighted the important parts of the instructions. Then when it came to the diabetes supplies, the pharmacist asked if she would afford xxx dollars for the strips. She was told yes and the pharmacist said then she would put five containers in her bag and explained that if the insurance did not cover them, she would be billed. The pharmacist then took time to tell her about testing, approximately when to test pre-meal, post-meal, and before bed time. Then she said it was not a bad idea to have one box of alcohol pads around, but not to use them on the fingers for testing, but instead to wash her hands with warm water and soap and dry thoroughly. Not to handle the test strips with wet hands was her next instruction and then she explained what the alcohol would do to her fingers in the winter time. Bravo pharmacist!!!

She had called the first doctor, but he was not taking new patients at this time, but the second doctor was and she had a next day appointment. She took all her prescriptions and meter with her and the telephone number for the pharmacist. The nurse asked for her meter so that it could be downloaded even if it was only a few results. She was surprised when she was called for a blood draw, but did not say anything. After the nurse had gathered all her information and given her meter back, she said she got a big shock when a woman doctor entered and then she realized that her doctor was a niece that she did not even know was in the area. The last communication was when she was in Denver, Co.

The email said that the doctor spent about an hour with her discussing testing and nutrition, and what foods she should avoid and lots of good information. Her A1c was still high as the doctor had expected. Turns out the previous doctor only used the oral glucose tolerance test for everything. I think he is behind the times. She is to bring her meter in for downloading every fourth Monday of the month so the doctor could review it. She is to have another appointment on the next time she brings in her meter. Future appointments will depend on what the meter readings show for diabetes management. She even said the new doctor had discussed hypoglycemia and hyperglycemia and given her a few sheets of facts so she did not need my answer any longer. She said she was happy that I asked so many questions as this had given her the confidence when she was talking to the CDE and to understand how important the information was that she was receiving.

After this, she said the communication from the previous doctor was very unpleasant and between the new doctor and her, they asked the local sheriff if he would pick up her records. For a small fee, he would, but even the deputy reported he was happy that both had provided letters of authorization for the transfer. Her new doctor even had to take time to unseal the box and confirm to the deputy that they were her records and that the box had been received unopened. She would not say that the records were complete, just that she had received what was in the package. She then stated the doctor had sent her a bill for the time and packaging, which she talked over with her new doctor. Both felt it was unethical, but agreed that it should be paid since charges were being filed by other patients for malpractice and this could be added to the charges. She concluded by saying that her new doctor had found several areas of problems and she is to go in tomorrow to review whether these would be added to the complaints since queries had been sent to all doctors receiving patients of his.  She is very happy with her niece as her doctor. 

The Under-appreciated Professions

The four occupations included in this blog are among the most under appreciated professions. They still can have people within the profession that are bad apples for the profession. Most are a credit to the profession and do their jobs effectively and efficiently. Physician's assistants, nurse practitioners, nurses, and pharmacists are the occupations for this discussion. All have national organizations for support and advocacy. With the looming shortage of physicians, these professionals will serve a vital role in medicine and seeing patients on a more active basis. Links to professional organizations will be the profession below.

Nurses, whether they are registered nurses or any of the 68 different types of nurses, they have a role to fill and in general do excellent in their profession. The list of 68 may not be inclusive, but shows many of the areas that nurses may become specialized for their profession. Under the physician shortages, they will need to step forward and learn how to handle an ever-increasing load. Those that can obtain some additional education quickly will be in line for promotions and work in this expanded need.

Nurse practitioners (NP) and physician assistants (PA) will find more physicians that are more willing to work with them and expand their roles under the physician shortage. They will need to be cautious, as there will still be some physicians that will not accept their role or even work with them. These physicians will do more to damage the medical reputation of themselves and those round them. Physician shortage will not be easy for those still practicing.

If some of the hurdles can be removed, nurses, nurse practitioners, and physician assistants will in some of the more rural areas, be spending more time visiting elderly patients in their homes and using video conferencing (telemedicine) or telephone if necessary. Except in the states that have passed laws requiring physicians to physically see the patients before they can issue a prescription, physicians in the rest of the states should be able to issue prescriptions with the assistance of nurses, nurse practitioners, and physician assistants. In a small number of states already experiencing physician shortage, there is some talk about amending the law to allow these medical exceptions when driving distance is an impediment to physically seeing a physician.

The position of pharmacist is still being discussed, but physician resistance for allowing any pharmacist to issue prescriptions is still strong. One state is considering situations where a pharmacist would be able to renew prescriptions especially for certain chronic diseases like diabetes. Another largely rural state is considering allowing pharmacists with certain qualifications to be able to work with physicians in a capacity like nurses. Pharmacists in hospitals, assisted living facilities, and nursing homes may be given more responsibilities and with continuing education expand their roles even further.

Some pharmacists are already expanding their own roles in some of the larger chain pharmacies and this should also be considered and supported. Too many patients do not utilize their pharmacists to prevent polypharmacy conflicts. I think that there needs to be restrictions placed on patients using one pharmacy for one medication and another pharmacy for a different medication. If nothing more, pharmacists need a technology system to be able to access by name and social security number all pharmacies within a certain parameter to search for medications being taken by a patient to prevent medications conflicts. It is not unreasonable to find patients using three or more pharmacies for prescriptions and I have a few acquaintances that use this to keep (supposedly) others from knowing what other doctors are prescribing. I suspect prescription abuse to be honest.

Depending on how critical the physician shortage becomes will determine much of the expanded role for nurses, nurse practitioners, physician assistants, and pharmacists. Those that are willing to seek additional education now will be able to capitalize later. I know of two nurses presently studying to become nurse practitioners. I have written about the role of pharmacists here and need to say that some of the questions have been answered, but not all have been explained to anyone’s satisfaction. Walgreens has even gotten even more secretive while other pharmacies have become more open and transparent in what they want for their patients. Some of this is good while some actions do raise more questions.

It will be interesting to see what happens during the upcoming physician shortage. How long will we need to wait to get an appointment, how long will it be between appointments, will emergency departments continue to exist in some rural areas, and how many minutes will we have available with the doctor during appointments? These and many more questions are clogging my brain. I can only hope that I am fortunate enough to avoid many of these problems.

Pharmacists Could Be Health Care Providers

This is a great article and everyone should read this. Will it work? This will depend on many factors and largest problem is the patients themselves. Why, you ask? Because many patients fill one prescription at one pharmacy and then go to another pharmacy to fill a second prescription. This is so common it is scary. I see it all the time. I asked a couple not too long ago, why they would do this. I was not surprised by the answer as I have heard it before.

They said it was not the business of the pharmacist to know all their medications. The husband goes to several doctors and goes to the three pharmacies in town to fill prescriptions from different doctors. The wife sees four different doctors and does the same. Each takes more than five different medications. I asked if they had time to talk, but they were in a hurry to get the next pharmacy.

As they walked away, I could not help but think that they are living very dangerously. They are the ones putting their health and lives in jeopardy. I wonder if they had the same attitude about keeping the supplements they take from their doctors. They were both older than me, and the wife was using a walker, but they were as unconcerned about my question and more concerned about keep information away from the pharmacist.

I am concerned about my privacy as much as the next person, but when it comes to my health, I want to make sure my doctors know and that my pharmacist knows. Granted I do business with two pharmacies, one a military pharmacy and the other a local pharmacy. You bet I make sure the local pharmacy has a list of all medications I am taking plus any supplements. I try to update the list at least quarterly with the local pharmacy.

Only once has the local pharmacy asked me to stop taking a supplement and one prescription when the two would have conflicted with the new medication I needed for ten days. I was asked several questions and the reason for the new prescription and then she told me which supplement and prescription to stop and for how long. This was most reassuring to me and let me know that I was doing the right thing by having my list of medications and supplements on file with the pharmacy.

This interview with Rear Admiral Scott F. Giberson, RPh, PhC, MPH, US Assistant Surgeon General and chief professional officer of pharmacy at the US Public Health Service in Rockville, Maryland is very interesting about moving pharmacists into the healthcare profession legislatively.

The model Dr. Giberson is proposing would compensate pharmacists (as healthcare providers) based on the level of service they provide. Much like other health professionals, as the complexity of care increases, so too would the compensation. It may include both Medicaid Part D and Medicare Part B. Currently, pharmacists receive compensation within Medicare Part D for services provided through Medication Therapy Management (MTM). However, this is limited by considerable restrictions, including the number of medications (at least seven) the patient takes and the number of chronic conditions (two or three).

This subject I am sure will continue to be put before professionals and congress.
There are even greater ramifications not mentioned here. First, most doctors are being required to submit prescriptions electronically which should help eliminate some of the pharmacy hopping done by many people. As they get closer to issuing all prescriptions electronically, it will become evident to the doctors what patients are doing and may help the doctors to avoid conflicts in medications and even supplements.

This country still has a long way to go in this arena, but progress is being made. More doctors as beginning to ask the right questions about prescriptions and supplements and some are beginning to insist on a complete list from their patients. Some even are requiring that patients bring the actual medications with them to the appointments. A few doctors are even asking to see the supplement bottles as well. Patient medication safety is on the move and will be slowly implemented. Now is the time and next the clinics in many communities will be brought into this.