Provider status?

[Mur7ay]

I heard pharmacist may eventually gain a provider status which will give us the opportunity to bill for other services outside the filling fee and also give us the ability to write scripts. Anyone heard anything about this?

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[pharmerjohn]

Deleted eh? Well, I saw you post while I was at work, so I wasn't able to respond... But if you're still interested, according to a prescriber chart that I perused a while back, OH, CA, WA, FL and a few other states allow RPH to prescribe with certain restrictions. RPH also need to have a DEA/NPI number, and depending on the state, a supervising physician must also be present on the script. That's the info I recalled, so don't quote me on any of the things I just said. I hope that slaked your curiosity.

 

[Mur7ay]

Deleted eh? Well, I saw you post while I was at work, so I wasn't able to respond... But if you're still interested, according to a prescriber chart that I perused a while back, OH, CA, WA, FL and a few other states allow RPH to prescribe with certain restrictions. RPH also need to have a DEA/NPI number, and depending on the state, a supervising physician must also be present on the script. That's the info I recalled, so don't quote me on any of the things I just said. I hope that slaked your curiosity.

Ha, yeah I meant to put "provider status". Thanks for the reply!

 

[AlPacino]

Ha, yeah I meant to put "provider status". Thanks for the reply!

I updated the thread name. If you feel you made a mistake, just go to edit, go advanced, and you change the tittle of the thread

 

[Mur7ay]

I updated the thread name. If you feel you made a mistake, just go to edit, go advanced, and you change the tittle of the thread

Ok, thanks!

 

[pharmerjohn]

Ha, yeah I meant to put "provider status". Thanks for the reply!

It's all good, and you're welcome. As far as billing is concerned, I'm not too sure how pharmacists can bill for these types of services. At the moment, there's no way to bill insurance for anything beyond the costs of medications. Hopefully this will change in the future(?)

 

[PearlGirl]

It's all good, and you're welcome. As far as billing is concerned, I'm not too sure how pharmacists can bill for these types of services. At the moment, there's no way to bill insurance for anything beyond the costs of medications. Hopefully this will change in the future(?)

Pharmacists with an NPI number can attempt to bill Medicare for MTM services in 15 minute increments. The problem, however, is that although at least 5 ICD-9 codes exist specifically for pharmacists to bill Medicare for their services, Medicare rarely recognizes pharmacists as "providers." There is a big push from the pharmacy associations for all pharmacists to seek an NPI number so they may gain influence on legislation as more of them become "registered providers." My experience, however, has lead me to believe that many pharmacists are apathetic in regards to the profit potential of MTM services. MTM is a lot of work and takes far longer than 15 minutes to perform properly. The University of Florida is trying to pioneer some MTM programs. I sure a google search of that could lead you deeper into your investigation. One of the last CE's I went to was at UF's Orlando campus specifically on MTM.

Good luck in your search for answers!

 

[needsomehelpnow]

Pharmacists with an NPI number can attempt to bill Medicare for MTM services in 15 minute increments. The problem, however, is that although at least 5 ICD-9 codes exist specifically for pharmacists to bill Medicare for their services, Medicare rarely recognizes pharmacists as "providers." There is a big push from the pharmacy associations for all pharmacists to seek an NPI number so they may gain influence on legislation as more of them become "registered providers." My experience, however, has lead me to believe that many pharmacists are apathetic in regards to the profit potential of MTM services. MTM is a lot of work and takes far longer than 15 minutes to perform properly. The University of Florida is trying to pioneer some MTM programs. I sure a google search of that could lead you deeper into your investigation. One of the last CE's I went to was at UF's Orlando campus specifically on MTM.

Good luck in your search for answers!

Thank you for your comments.

What do you mean by "pharmacists are apathetic"? Do you mean that they don't think MTM will be successful or do you just mean that they are already busy with their work and simply just not so interested in investing their time and efforts to expand it?

 

[pharmerjohn]

Pharmacists with an NPI number can attempt to bill Medicare for MTM services in 15 minute increments. The problem, however, is that although at least 5 ICD-9 codes exist specifically for pharmacists to bill Medicare for their services, Medicare rarely recognizes pharmacists as "providers." There is a big push from the pharmacy associations for all pharmacists to seek an NPI number so they may gain influence on legislation as more of them become "registered providers." My experience, however, has lead me to believe that many pharmacists are apathetic in regards to the profit potential of MTM services. MTM is a lot of work and takes far longer than 15 minutes to perform properly. The University of Florida is trying to pioneer some MTM programs. I sure a google search of that could lead you deeper into your investigation. One of the last CE's I went to was at UF's Orlando campus specifically on MTM.

Good luck in your search for answers!

You brought up a lot of really good points. I remember reading about MTM for long-term care a while back, but I almost never see pharmacists doing this at the moment (I'm currently working as a tech and I deal with mostly maintenance medications, too!). This is hardly something new either, as it's been around for nearly a decade. And the funny thing is, Medicare is what kind of set this in motion, yet it's quite difficult to get the billing through them as a "provider" as you mentioned. Also, I believe the billing is not like other providers in that pharmacists must bill through a hospital for their services. Hence, this limits the potential for many pharmacists to bill for MTM services. In turns, this somewhat plays into the part you mentioned about pharmacists being apathetic towards the profitability of MTM services. If more pharmacists obtain NPI's, then perhaps we will see a push for pharmacists to also be recognized as providers in the future. This could result in the ease for pharmacists to bill for MTM services among different types of health care coverages and not just through Medicare.

 

[BeLikeBueller]

I heard pharmacist may eventually gain a provider status which will give us the opportunity to bill for other services outside the filling fee and also give us the ability to write scripts. Anyone heard anything about this?

There seems to be a little bit of misinformation with regards to MTM and provider status. The two are not equivalent. "Provider status," in this context, is defined at a federal level by Medicare. MTM does not require you to have "provider status." MTM does require you to have certain provider numbers, but these are not related to Medicare defining pharmacists as healthcare providers. Billing for MTM is very easy (speaking from experience) through either Mirixa or Outcomes, which handles MTM billing for Medicare patients (and possibly private-pay as well, I think?).

The reason that MTM is not catching on is twofold. One: it's being done predominantly in community pharmacies. A first-encounter for MTM can require up to thirty minutes. This means that if you were working a regular shift, you would be thirty minutes behind for each first-encounter visit. So in order to effectively do MTM, you have to do this on your off day, which is a bummer. Two: reimbursements can be good for MTM (upwards of $100/hour, but don't let that fool you...you still have overhead costs, etc.), but if you're working for a big-box store, you won't see a dime of that. Hence, some of the apathy towards implementing it.

MTM is, in my opinion, the springboard for pharmacists doing more than just traditional dispensing. However, it will have to be done outside of the big box pharmacies in order to help us gain professional autonomy and develop more patient-care centered roles. Think doing MTM in a physician's office that sees a lot of older, medicare patients (the population that is most likely to be eligible for/benefit from MTM services).

Provider status, on the other hand, would allow us to bill medicare directly for certain cognitive services (think chronic disease management, diabetic foot exams, anti-coagulation monitoring, etc.). Provider status does NOT necessarily equal the ability to write prescriptions though. In order to write prescriptions (which would vary based on state laws), you would likely have to enter into a collaborative practice agreement with a physician (if you are interested in learning more, search for pharmacy collaborative practice agreement in North Carolina or New Mexico). Under this agreement, you would work within a limited scope of practice - only working with diabetes, HF, and HTN patients, for example.

Here's why you have to have physician oversight...pharmacists are not trained to diagnose. That's not a bad thing though. What we lack in diagnostic training, we more than make up in training on how to treat and manage disease. Pharmacists often get 16+ hours of pharmacotherapy training. Contrast that to the majority of MD programs which have only 4 hours. That's because the focus of an MD is diagnosing. Our focus is treating. So in that sense, there is great potential for a symbiotic relationship between doctors and pharmacists in managing patients who have chronic diseases that require a lot of intensive medication adjustments. Right now, under a collaborative practice agreement, the physician would bill for the service that you provide, and you would be paid out of the money that the physician/practice receives.

The reason that we want provider status is because it allows us to become a more autonomous profession. Right now, we are beholden either to dispensing or collaborative practice agreements that likely have a very limited scope of practice.

Be forewarned though, doing the types of things in collaborative practice will likely require additional residency training (although MTM does not require additional residency training).

Hope this helps!

 

[pharmerjohn]

Thanks for the info, BeLikeBueller!

 

[BeLikeBueller]

Thanks for the info, BeLikeBueller!

My pleasure. There is a lot of potential for pharmacists in the future to do some very cool things, but it's going to require some innovative thinking and some legislative changes. If you're interested in the kinds of things that future pharmacists might be able to do, look into the Indian Health Services. They don't operate under the same set of regulations that most pharmacists do, which allows them to be involved in a lot of innovative practice models.

That being said, these types of opportunities are the exception and not the rule. If you guys are in pre-pharm, please talk to several practicing pharmacists about the future job market, because things are pretty tight right now (although to be fair, things are tight in any career right now, just about). And while there is a lot of potential for growth in the future, we don't know how far off that growth is, if it ever comes. Just be realistic about what you're getting into (massive student loans) and weigh out the pros and the cons before you commit.

 

[pharmerjohn]

My pleasure. There is a lot of potential for pharmacists in the future to do some very cool things, but it's going to require some innovative thinking and some legislative changes. If you're interested in the kinds of things that future pharmacists might be able to do, look into the Indian Health Services. They don't operate under the same set of regulations that most pharmacists do, which allows them to be involved in a lot of innovative practice models.

That being said, these types of opportunities are the exception and not the rule. If you guys are in pre-pharm, please talk to several practicing pharmacists about the future job market, because things are pretty tight right now (although to be fair, things are tight in any career right now, just about). And while there is a lot of potential for growth in the future, we don't know how far off that growth is, if it ever comes. Just be realistic about what you're getting into (massive student loans) and weigh out the pros and the cons before you commit.

Any ideas as to how we can get the ball rolling in terms of making legislative changes and making a push for expanding the role of pharmacists? I imagine it's going to require enormous human power (strength in numbers) and some serious political leveraging. Without a push towards expanding the roles of pharmacists, I see the future of pharmacy being even more heavily dominated by big-box stores and PBM.

Although can't speak for other pre-pharm students, I'm aware of what I'm committing myself to, as I've been a certified tech for several years in a variety of settings. I have a good grasp on the gist of the pharmacy profession and its pros and cons. Therefore, I absolutely agree with you on being realistic about it when committing to pharmacy. I hope other pre-pharm students test the water and weigh their options before diving in as well.

Thanks again for your insight, and leisure rules, indeed!

 

[pharmerjohn]

Based on the "likes," it seems a few pre-pharm students like myself are interested in the potential expansion of the roles of pharmacists. For those who are interested, California passed SB 493 earlier this month allowing pharmacists to attain provider status. To satiate the curiosity of inquisitive pre-pharmers, a summary and explanation of the bill can be found here for your perusing pleasure.

 

[BeLikeBueller]

Any ideas as to how we can get the ball rolling in terms of making legislative changes and making a push for expanding the role of pharmacists? I imagine it's going to require enormous human power (strength in numbers) and some serious political leveraging. Without a push towards expanding the roles of pharmacists, I see the future of pharmacy being even more heavily dominated by big-box stores and PBM.

Although can't speak for other pre-pharm students, I'm aware of what I'm committing myself to, as I've been a certified tech for several years in a variety of settings. I have a good grasp on the gist of the pharmacy profession and its pros and cons. Therefore, I absolutely agree with you on being realistic about it when committing to pharmacy. I hope other pre-pharm students test the water and weigh their options before diving in as well.

Thanks again for your insight, and leisure rules, indeed!

Great question. Unfortunately, this is a little bit above my pay grade at the current moment. Obviously the push for provider status has to occur at a national level. The article you posted about pharmacists in California being recognized as healthcare providers by the state is a huge step forward. What has to happen now, particularly in California, is that pharmacists have to demonstrate a value for "primary care" type services. In other words, we have to show that if we get provider status at a national level, we are going to able to contribute in a positive manner to patient care. Now this doesn't mean that we're going to be doing things that doctors or nurse practitioners are doing, but in the innovative ways that we can help care for patients, we have to demonstrate that we are saving money and improving patient outcomes. That's how we build a strong case for national provider status.

From more of a political advocacy standpoint, there are opportunities to get involved with some of the national pharmacy organizations, particularly the American Pharmacists Association, in helping to lobby for provider status. If this is something that interests you, I recommend checking out their advocacy website here: http://www.pharmacist.com/providerstatusrecognition

Hope that helps! Let me know if you have any more questions. Some of the older pharmacists over on the "pharmacy" board don't seem to think this is such a big deal, but for me, facing down a very uncertain job market in the near future...it's something that can only help increase the opportunities for pharmacists (hopefully creating more jobs), which is something that the profession desperately needs right now.

 

[pharmerjohn]

Thanks again for your insight!

Some of the older pharmacists over in the "Pharmacy" forum are really negative about everything. They wouldn't see an opportunity even if it could talk and wave at them. Oh well, it's their choice. Anything that could potentially increase job opportunities for pharmacists in the future is a definite plus in my opinion, and given the opportunity, I will definitely push for it. Thanks again for all the info. You're awesome!

 

[BMBiology]

You really think old pharmacists post on this forum?

Most of the pharmacists on this forum have only been practicing for 5 years or less including myself. We have heard all of the false promises these pharmacy schools have made and this is just another one.

 

[BeLikeBueller]

You really think old pharmacists post on this forum?

Most of the pharmacists on this forum have only been practicing for 5 years or less including myself. We have heard all of the false promises these pharmacy schools have made and this is just another one.

Not really sure where the above bolded came from, but that is ok. There are a surprising number of "older" pharmacists on the pharmacy board, as denoted by their status as an RPh and not a PharmD. All of these individuals seem to have an overwhelmingly negative opinion of provider status and what it could mean for the future versus some of the newer pharmacists such as yourself.

As you can see above, myself and others have cautioned these pre-pharmacy students that the job market right now sucks and will continue to suck into the future. Retail pharmacy is ill-equipped to handle the influx of new graduates. That is why provider status may be very important. It may present new opportunities that can help absorb the impact of some of these new graduates. Whether or not that will actually play out is anyone's guess...

 

[BMBiology]

Of course provider status would help the profession. An increased in reimbursement would help too. Is it going to happen? No, not any time soon at least.

Pharmacists are not nurses. We don't have the political power. So stop dreaming already.

 

[BeLikeBueller]

Is it going to happen? No, not any time soon at least.

Yeah...I'll second that.

Pharmacists are not nurses. We don't have the political power.

I'll second, third, and fourth that....

So stop dreaming already.

What's happened in California provides hope, which is why I think now is the exact wrong time to give up on this. That being said, is the "hope" of provider status reason for any of these pre-pharmacy students to go to pharmacy school...no, absolutely not. Because, like you said, it's not gonna happen any time soon, if ever. But that doesn't mean those of us who are already here should just give up on it...

 

[BMBiology]

What's happened in California provides hope, which is why I think now is the exact wrong time to give up on this. That being said, is the "hope" of provider status reason for any of these pre-pharmacy students to go to pharmacy school...no, absolutely not. Because, like you said, it's not gonna happen any time soon, if ever. But that doesn't mean those of us who are already here should just give up on it...

I am from California and the bill that just passed is not going to change much because pharmacists here have been doing those things for years now. Order labs? Smoking cessation? Give shots? They started to do those things when I was still a student. The only difference is that pharmacists do not have to work under a physician approved protocol. It cuts out the "middle man". It is still very limited and pharmacists still can't bill for those services. Is it a positive step? Yes of course but even if other states adopt the same bill, it is not going to change how pharmacists practice pharmacy.

 

[BigThing]

Pharmacists often get 16+ hours of pharmacotherapy training. Contrast that to the majority of MD programs which have only 4 hours. That's because the focus of an MD is diagnosing. Our focus is treating.

I see this a lot on this board, and I've also heard pharmacy students say this out loud, and every time it sounds ridiculous. Do pharmacists receive more training in pharmacotherapy than med students? Of course. But how many doctors start practicing the day they leave medical school? Zero. Let's put this another way: I have a question about a cardiovascular drug. Who would be a better resource to ask, the pharmacist who had maybe 8 weeks of classes on the subject many years ago in pharmacy school, or the cardiologist who got 4 weeks of classes on the subject in med school, and then actually learned how to prescribe the drugs for six years of residency plus fellowship? Obviously the cardiologist knows better. For some reason, though, the pharm students on this board want to live in a bubble where doctors don't do residency or fellowship, since the PharmDs generally don't.

Also, Bueller, your focus may be treating, but doctors are still the most highly trained in treatment. Meds are all you see in your world, but as a doctor I have a huge palette of surgery, medication, devices, so on, to choose from in approaching a problem. When I choose something from this palette, I am fully responsible for any and all outcomes that result from it. To suggest you know more about treatment of disease than I do is a massage therapist claiming to know all about addressing disc herniation.

Lastly, to the prepharm students on this board who are interested in provider status: you can try to be a wannabe-doctor all your life, or you can bite the bullet and beef up your application to be competitive for medical school and thus be a real doctor. Your choice.

 

[BeLikeBueller]

I see this a lot on this board, and I've also heard pharmacy students say this out loud, and every time it sounds ridiculous. Do pharmacists receive more training in pharmacotherapy than med students? Of course. But how many doctors start practicing the day they leave medical school? Zero. Let's put this another way: I have a question about a cardiovascular drug. Who would be a better resource to ask, the pharmacist who had maybe 8 weeks of classes on the subject many years ago in pharmacy school, or the cardiologist who got 4 weeks of classes on the subject in med school, and then actually learned how to prescribe the drugs for six years of residency plus fellowship? Obviously the cardiologist knows better. For some reason, though, the pharm students on this board want to live in a bubble where doctors don't do residency or fellowship, since the PharmDs generally don't.

Also, Bueller, your focus may be treating, but doctors are still the most highly trained in treatment. Meds are all you see in your world, but as a doctor I have a huge palette of surgery, medication, devices, so on, to choose from in approaching a problem. When I choose something from this palette, I am fully responsible for any and all outcomes that result from it. To suggest you know more about treatment of disease than I do is a massage therapist claiming to know all about addressing disc herniation.

Lastly, to the prepharm students on this board who are interested in provider status: you can try to be a wannabe-doctor all your life, or you can bite the bullet and beef up your application to be competitive for medical school and thus be a real doctor. Your choice.

I always have to laugh when I see physicians, or in your case, residents (possibly...this is the internet so I really have no clue if you are what you say you are) get their panties in a wad when pharmacists use the term "provider status." Contrary to popular belief, it doesn't mean pharmacists are trying to treat patients in the context to which you refer.

We don't want to treat, we want to manage. Chronic disease state management is what we hope to do, not chronic disease state treatment. The fact of the matter is residency trained pharmacists (which would be required for provider status) have more experience in managing a patients pharmacotherapy. We don't have the training to determine if someone needs surgery vs pharmacotherapy. No one said that and you know it. But we do know how to manage the pharmacotherapy involved in diabetes, or heart failure, or status post stroke or MI, or a whole host of other conditions.

Trust me...the cardiologists that work with the local, pharmacist-run anticoag clinic are more than happy to leave that to pharmacists. Are physician capable of doing anticoag...of course. You know we're not suggesting otherwise. But smart cardiologists know their time is better spent on other tasks.

We're not trying to step on any toes or take over any jobs. We don't want to be physicians (well, some do...but they go on to med school). We are trying to aid in patient care to the level that we have been trained.

And physicians that think provider status is a bad idea aren't particularly bright. A typical visit with a PCP for a diabetic patient last about 30 minutes. The physician will usually only get paid for 12 minutes of that visit (15 if they're lucky). Over half of that visit is spent adjusting pharmacotherapy based on labs and providing patient counseling - something pharmacists are, by your own admission, trained to do.

So if pharmacists had provider status, they could help manage the drug therapy and counsel the patient and get paid for doing so. In some states, pharmacists can and do work contractually with physicians to do these things, but they can't get paid...cutting into the medical practice bottom line.

But if pharmacists could do this as a value-added service, they would cut the time the physician has to spend with that patient in half. So you know what? We can make you more money and give you more time to spend doing the thing that only physicians are adequately trained to do...diagnose.

Does that really sound so bad to you?

 

[BigThing]

I always have to laugh when I see physicians, or in your case, residents (possibly...this is the internet so I really have no clue if you are what you say you are) get their panties in a wad when pharmacists use the term "provider status." Contrary to popular belief, it doesn't mean pharmacists are trying to treat patients in the context to which you refer.

We don't want to treat, we want to manage. Chronic disease state management is what we hope to do, not chronic disease state treatment. The fact of the matter is residency trained pharmacists (which would be required for provider status) have more experience in managing a patients pharmacotherapy. We don't have the training to determine if someone needs surgery vs pharmacotherapy. No one said that and you know it. But we do know how to manage the pharmacotherapy involved in diabetes, or heart failure, or status post stroke or MI, or a whole host of other conditions.

Trust me...the cardiologists that work with the local, pharmacist-run anticoag clinic are more than happy to leave that to pharmacists. Are physician capable of doing anticoag...of course. You know we're not suggesting otherwise. But smart cardiologists know their time is better spent on other tasks.

We're not trying to step on any toes or take over any jobs. We don't want to be physicians (well, some do...but they go on to med school). We are trying to aid in patient care to the level that we have been trained.

And physicians that think provider status is a bad idea aren't particularly bright. A typical visit with a PCP for a diabetic patient last about 30 minutes. The physician will usually only get paid for 12 minutes of that visit (15 if they're lucky). Over half of that visit is spent adjusting pharmacotherapy based on labs and providing patient counseling - something pharmacists are, by your own admission, trained to do.

So if pharmacists had provider status, they could help manage the drug therapy and counsel the patient and get paid for doing so. In some states, pharmacists can and do work contractually with physicians to do these things, but they can't get paid...cutting into the medical practice bottom line.

But if pharmacists could do this as a value-added service, they would cut the time the physician has to spend with that patient in half. So you know what? We can make you more money and give you more time to spend doing the thing that only physicians are adequately trained to do...diagnose.

Does that really sound so bad to you?

Intern in my case. But you're avoiding my point, which is the hubris a lot of pharmacists display in thinking that they know more about medication therapy than specialist physicians who deal with a limited number of drugs every single day for many years. My job is to diagnose AND treat. I'm not going to give any of that up to other people. Your job is to know if my medical treatment is going to cause major side effects or is otherwise inappropriate for dosage reasons. Let's say I was a primary care provider, and I had a lot of diabetic patients, and spent much of each visit with them slightly changing their dose of short-acting and long-acting insulins. Would I be okay with having a pharmacist adjust those doses for me based on the patient's glucometer readings? Of course. Should the pharmacist then have the right to decide if my patient needs an ARB or ACE-inhibitor? Nope, that takes clinical judgment that the pharmacist doesn't have. How about foot and fundal exams? Nope, again that takes experience that pharmacists don't have. I'd much rather have a PA or NP make that kind of evaluation. Even ordering labs should be reserved for the MD, NP, PA - people who can be cost effective in what to order.

And for the record, I have no problem with pharmacists adjusting coumadin doses or vanc doses based on easy lab targets like the INR and serum vanc level, since these are very objective values that even a robot can measure and adjust dosage for accurately.

 

[Mur7ay]

I see this a lot on this board, and I've also heard pharmacy students say this out loud, and every time it sounds ridiculous. Do pharmacists receive more training in pharmacotherapy than med students? Of course. But how many doctors start practicing the day they leave medical school? Zero. Let's put this another way: I have a question about a cardiovascular drug. Who would be a better resource to ask, the pharmacist who had maybe 8 weeks of classes on the subject many years ago in pharmacy school, or the cardiologist who got 4 weeks of classes on the subject in med school, and then actually learned how to prescribe the drugs for six years of residency plus fellowship? Obviously the cardiologist knows better. For some reason, though, the pharm students on this board want to live in a bubble where doctors don't do residency or fellowship, since the PharmDs generally don't.

Also, Bueller, your focus may be treating, but doctors are still the most highly trained in treatment. Meds are all you see in your world, but as a doctor I have a huge palette of surgery, medication, devices, so on, to choose from in approaching a problem. When I choose something from this palette, I am fully responsible for any and all outcomes that result from it. To suggest you know more about treatment of disease than I do is a massage therapist claiming to know all about addressing disc herniation.

Lastly, to the prepharm students on this board who are interested in provider status: you can try to be a wannabe-doctor all your life, or you can bite the bullet and beef up your application to be competitive for medical school and thus be a real doctor. Your choice.

Pharmacist are no longer "registered," pharmacist are now considered doctors of pharmacy

 

[BigThing]

Pharmacist are no longer "registered," pharmacist are now considered doctors of pharmacy

which makes you as much doctors as my friend who has a PhD in creative writing.

 

[BeLikeBueller]

Intern in my case. But you're avoiding my point, which is the hubris a lot of pharmacists display in thinking that they know more about medication therapy than specialist physicians who deal with a limited number of drugs every single day for many years. My job is to diagnose AND treat. I'm not going to give any of that up to other people. Your job is to know if my medical treatment is going to cause major side effects or is otherwise inappropriate for dosage reasons. Let's say I was a primary care provider, and I had a lot of diabetic patients, and spent much of each visit with them slightly changing their dose of short-acting and long-acting insulins. Would I be okay with having a pharmacist adjust those doses for me based on the patient's glucometer readings? Of course. Should the pharmacist then have the right to decide if my patient needs an ARB or ACE-inhibitor? Nope, that takes clinical judgment that the pharmacist doesn't have. How about foot and fundal exams? Nope, again that takes experience that pharmacists don't have. I'd much rather have a PA or NP make that kind of evaluation. Even ordering labs should be reserved for the MD, NP, PA - people who can be cost effective in what to order.

And for the record, I have no problem with pharmacists adjusting coumadin doses or vanc doses based on easy lab targets like the INR and serum vanc level, since these are very objective values that even a robot can measure and adjust dosage for accurately.

I could be off base on this, but I get the feeling that most of your work has been at smaller, community-type hospitals? I've seen clinical pharmacists do all the things that you have issue with, and I've seen physicians thankful to have them do it. In fact, these clinical pharmacists aren't doing anything of their own accord, but rather it's because the physicians specifically ask them to do these types of things. The clinical pharmacists spend all day digging through literature, answering very patient-specific treatment questions. They don't have to keep up with literature on new diagnostic procedures, or surgical techniques, or anything else that is not specifically pharmacotherapy related. Of course seasoned physicians will have the experience that makes clinical pharmacists less useful (but not entirely obsolete). But that's not the point. The point is, pharmacists can help manage the pharmacotherapy of patients. Clinical pharmacists are trained to have the professional judgement to determine if an ACE or an ARB or a thiazide diruetic or a CCB or a beta blocker or an aldosterone antagonist is going to be better for a specific patient. We're trained to stay on top of new and emerging therapies such as sodium-glucose co-transport inhibitors. Is that in the diabetes guidelines yet? No, but clinical pharmacists have already evaluated the literature and identified the roles that it may play in treatment.

The biggest role I foresee pharmacists playing though, isn't working in the hospital with cardiologists or neurologists or the infectious disease consulting services or internal medicine or oncology or .... you get the point (because pharmacists already do all of these things... you can disagree with it all you want, but that's already here and it's here to stay). What I foresee pharmacists doing is in evaluating the cumulative drug regimens that patients are on from all of the various doctors they see. PCPs simply don't have time to do this. It's the acute-nature of our medical system. That's where the biggest issue with pharmacotherapy is...it's not docs making a bad call on which drug to use...it's a patient seeing four and five and six doctors. And pharmacists have the training to come in and say...here are duplicate therapies, these drugs are interacting and the antibiotic you just prescribed is going to be sub-therapeutic because of that, this drug dose is a little too low and it's not going to produce the results you want, etc., etc. That's where pharmacists have the potential to have the greatest impact (in my opinion), and that's something that physicians don't currently do. Like I said, we're not trying to steal your jobs...we want to help patients get better and stay healthy, and we want to use what we've been taught in order to do that. And we'd also like to get paid too which is why provider status is important.

 

[BeLikeBueller]

which makes you as much doctors as my friend who has a PhD in creative writing.

awww come on, that's just a troll comment. Science PhDs operate on a level higher than you and me. And you can't tell me they don't, because I know you've sat through a pathology lecture taught by some research PhD and said, "what the heck is he talking about?" Now I'm sure you'll never admit that, but I have enough friends in med school to know that this is universally the case...

You want to know the people who really deserve some respect? MD/PhDs...Personally I think they're kind of wasting a degree (which one depends on what they ultimately do), but that's some serious knowledge acquisition right there.

 

[BigThing]

awww come on, that's just a troll comment. Science PhDs operate on a level higher than you and me. And you can't tell me they don't, because I know you've sat through a pathology lecture taught by some research PhD and said, "what the heck is he talking about?" Now I'm sure you'll never admit that, but I have enough friends in med school to know that this is universally the case...

You want to know the people who really deserve some respect? MD/PhDs...Personally I think they're kind of wasting a degree (which one depends on what they ultimately do), but that's some serious knowledge acquisition right there.

My friend with the PhD in creative writing has forgotten more about James Joyce than I know about diabetes, I have a lot of respect for all PhDs. I don't consider science PhDs to be operating above a higher level than me though - by the time I'm finished with my training, I'll know far more about heart disease as a whole than, say, a PhD who studies the role of M2 macrophages in switching fibroblasts into cardiomyocytes post-MI. I also don't think MD/PhDs deserve more respect than people who are just MDs or just PhDs, since in my (albeit limited) interactions with them, their clinical judgment is generally not as good as someone who does clinical medicine full-time, and I know they definitely attain PI status at a later age than their colleagues who are only PhDs.

Regarding your post about drug reconciliation being a key service that only pharmacists can do - yes and no. First, you're assuming that patients get all of their meds from one pharmacist (or more accurately, one chain store). I don't think this is generally the case, although I've mostly been in academic centers where the patients get a lot of their meds from the hospital pharmacy, so maybe I'm biased. Second, every specialist I know will always contact the referring PCP to tell them which drugs they're adding and why. I'm sure there are cases of patients being on a CCB from their cardiologist without their PCP knowing, but the solution for that is probably a centralized EMR or portable health card, the way European countries do it, rather than making it the pharmacist's job to coordinate all of these meds and add an extra level of people to be notified each time there's a drug change. That being said, as a med student on inpatient teams, part of my job was calling up each and every doctor the patients we received saw to figure out which drugs they were getting from which, and often I called the pharmacies for that info as well. It's a huge pain to sort through all of the drugs they're on and why and how long it's been that way, and I'm not sure it's something a pharmacist can do in 15 minutes and be well-compensated for it.

 

[BeLikeBueller]

Regarding your post about drug reconciliation being a key service that only pharmacists can do - yes and no. First, you're assuming that patients get all of their meds from one pharmacist (or more accurately, one chain store). I don't think this is generally the case, although I've mostly been in academic centers where the patients get a lot of their meds from the hospital pharmacy, so maybe I'm biased.

Nah, I'm not making that assumption. If you look at some of my other posts, I think pharmacists should be doing med rec and chronic disease management in large PCP practices. It's the most logical place. Again, you've got to remember that when we're posting on here, we're usually thinking of innovative ways to care for patients. And you also keep operating under the assumption that we're talking about retail pharmacists doing all of these things. We're almost always talking about residency-trained, clinical pharmacists. Unless we're talking about MTM or immunizations or some other stuff like that.

Second, every specialist I know will always contact the referring PCP to tell them which drugs they're adding and why.

Man if you knew the number of times I saw duplicate therapy. A lot of it, I'll admit comes from inpatient settings were someone is switched to a formulary drug and it's not discontinued at discharge. Still, a good ammount does come from both specialist and PCP in an outpatient setting.

I'm sure there are cases of patients being on a CCB from their cardiologist without their PCP knowing, but the solution for that is probably a centralized EMR or portable health card, the way European countries do it, rather than making it the pharmacist's job to coordinate all of these meds and add an extra level of people to be notified each time there's a drug change.

Yeah, a centralized EMR or portable health card is a must, for a variety of different reasons. Still, even while a centralized patient record would help cut down on medication errors, it will also better help pharmacists who are involved in chronic disease state management, anticoag, etc., etc. (which I also think should be done in large PCP offices).

That being said, as a med student on inpatient teams, part of my job was calling up each and every doctor the patients we received saw to figure out which drugs they were getting from which, and often I called the pharmacies for that info as well. It's a huge pain to sort through all of the drugs they're on and why and how long it's been that way, and I'm not sure it's something a pharmacist can do in 15 minutes and be well-compensated for it.

This is a big push for pharmacists to do...particularly on the outpatient side since, like I said above, that's where we see a lot of duplicate therapies occurring. Sadly, we don't get compensated for this though.



As much as you and I and others on this board have had disagreements, I kind of like the way you're thinking. Kind of. I really hope you get the chance to do your residency at a large medical center (preferably academic), because I think you will get to see clinical pharmacists operating at the height of their training. And it will probably surprise you how harmoniously pharmacists and physicians work together in those environments. The physicians love that pharmacists are taking care of some of the more mundane, routine, or time-intensive things because it frees them up to do the things that only physicians can do and hopefully the things that they love doing.

The other thing is...you've got to stop approaching all these posts with the idea of your local chain-store pharmacist. I think pretty much everyone on here (maybe not the pre-pharms, but they'll learn) believes that residency training has to be a requirement in order for pharmacists to be doing these clinical roles. That's additional, intensive training, just like you guys. Less stressful with regards to the fact that we don't typically have a patient's life in our hands (although the ID guys would beg to differ on this one), but equally as exhaustive. We don't think that a four year degree prepares you for that...just like medical school doesn't....just like nursing doesn't. When you say things like, "Who would be a better resource to ask, the pharmacist who had maybe 8 weeks of classes on the subject many years ago in pharmacy school, or the cardiologist who got 4 weeks of classes on the subject in med school, and then actually learned how to prescribe the drugs for six years of residency plus fellowship," that shows me you're still thinking retail pharmacy. This is the stuff that clinical pharmacists do, day-in and day-out. That's why I really hope you get the chance to work with a good clinical program (not all are created equal), because I think you might be pleasantly surprised.

 

[BigThing]

Nah, I'm not making that assumption. If you look at some of my other posts, I think pharmacists should be doing med rec and chronic disease management in large PCP practices. It's the most logical place. Again, you've got to remember that when we're posting on here, we're usually thinking of innovative ways to care for patients. And you also keep operating under the assumption that we're talking about retail pharmacists doing all of these things. We're almost always talking about residency-trained, clinical pharmacists. Unless we're talking about MTM or immunizations or some other stuff like that.



Man if you knew the number of times I saw duplicate therapy. A lot of it, I'll admit comes from inpatient settings were someone is switched to a formulary drug and it's not discontinued at discharge. Still, a good ammount does come from both specialist and PCP in an outpatient setting.



Yeah, a centralized EMR or portable health card is a must, for a variety of different reasons. Still, even while a centralized patient record would help cut down on medication errors, it will also better help pharmacists who are involved in chronic disease state management, anticoag, etc., etc. (which I also think should be done in large PCP offices).



This is a big push for pharmacists to do...particularly on the outpatient side since, like I said above, that's where we see a lot of duplicate therapies occurring. Sadly, we don't get compensated for this though.



As much as you and I and others on this board have had disagreements, I kind of like the way you're thinking. Kind of. I really hope you get the chance to do your residency at a large medical center (preferably academic), because I think you will get to see clinical pharmacists operating at the height of their training. And it will probably surprise you how harmoniously pharmacists and physicians work together in those environments. The physicians love that pharmacists are taking care of some of the more mundane, routine, or time-intensive things because it frees them up to do the things that only physicians can do and hopefully the things that they love doing.

The other thing is...you've got to stop approaching all these posts with the idea of your local chain-store pharmacist. I think pretty much everyone on here (maybe not the pre-pharms, but they'll learn) believes that residency training has to be a requirement in order for pharmacists to be doing these clinical roles. That's additional, intensive training, just like you guys. Less stressful with regards to the fact that we don't typically have a patient's life in our hands (although the ID guys would beg to differ on this one), but equally as exhaustive. We don't think that a four year degree prepares you for that...just like medical school doesn't....just like nursing doesn't. When you say things like, "Who would be a better resource to ask, the pharmacist who had maybe 8 weeks of classes on the subject many years ago in pharmacy school, or the cardiologist who got 4 weeks of classes on the subject in med school, and then actually learned how to prescribe the drugs for six years of residency plus fellowship," that shows me you're still thinking retail pharmacy. This is the stuff that clinical pharmacists do, day-in and day-out. That's why I really hope you get the chance to work with a good clinical program (not all are created equal), because I think you might be pleasantly surprised.

Noted. Good luck with your studies as well.

 

[PharmtoCS]

*flop* goes provider status

Remember how back in the day provider status was supposed to save our profession? It looks it hasn't, after all.

 

[DagS132]

*flop* goes provider status

Remember how back in the day provider status was supposed to save our profession? It looks it hasn't, after all.

was provider status achieved?

 

[PharmtoCS]

was provider status achieved?

Not to the extent we had hoped for, and we certainly didn’t get the massive job growth that many said would happen.