Should Pharmacists perform physical exams?

[njac]

hah usually if one of the thermometer alarms is going off in the main pharmacy one of the supervisors gets annoyed and unplugs it...

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[Epic]

hah usually if one of the thermometer alarms is going off in the main pharmacy one of the supervisors gets annoyed and unplugs it...

Oooh..I'm telling.

 

[dr of rx]

Is there a place for services such as this in the future? Only time will tell. But for now, I have waaaay too many headaches and perform waaaay too many other services that I don't get compensated for. I don't need one more.

(edit..tastless joke...sorry)

 

[hyperioncu]

Yearning for professional satisfaction and sacrificing time and money for professional growth will in the end result in a better outcome in the future.

I doubt the cost of airplane is the primary concern for airline industry when hiring a pilot. Lives are.

P.D. I’m sure that airlines concern about people’s lives, I just forgot to put them inside of the plane.

I couldn’t agree with you more, the more you know the more valuable/marketable you are as part of the healthcare team. Education doesn’t finish the day you become a licensed pharmacist, because pharmacy school is just the very base of a lifetime of learning. In a time where the pharmaceutical production brings into scene thousands of new drugs, it comes to pharmacist as drug specialist to control and channel all that knowledge.

Ok, next point to all the whiners. Pharmacist practice scope is different from an MD; we are not taking over their roles, for learning new techniques that will improve the quality of the care that can be given to patients. Just like I wrote before, the more you know the more useful you are. In a few more years when automation reduces the processing time, pharmacist are going to have to show their clinical skills, and believe me, pharmacies are going to tap into that source and manager to pressure you to do some MTM. Taking blood pressure and basic physical examination is going to be your everyday routine, you have to be able to detect when something is wrong and ADVISE to see a physician.

Pharmacy profession will redefine itself sooner than you expect, just like income increases will responsibilities and will the need to be board certified. This process is unstoppable, just like the PharmD became regular. Next step is specialization.
A few years ago very few schools had the PharmD program, nowadays is standard. Nowadays, very few pharmacist are board certified, tomorrow it will be standard. The pill-counter-behind-the-desk-i-wont-touch you is the past, genetics and pharmaceutical industry will bring drugs to a new level, you can either chose to be the vanguard or just the vanishing past.

 

[DHG]

Translation: we PharmDs are feeling unloved and dont get the same respect/importance that the physicians get. Therefore we are unilaterally going to try and squeeze into their turf so we can pretend to be doctors too! That way everybody will think of the pharmacist as their primary care doctor and we'll get to make tons more money!

Translation: I am an angry, paranoid MD that turns every discussion about patient care into a war between myself and anyone not freaking awesome enough to be an MD. And, oh yeah, did I mention that I'm paranoid? Stop looking at me.

Seriously dude, STILL at it? Tone it down, will ya?

 

[Taurus]

Wow. What a difference a few years make. Because of the acute shortage of pharms at that time, there was an imbalance in suppy and demand. Salaries were increasing and posters were gushing with giddiness. And now with $4 generics, free abx, Medicare D, and more pharm schools opening, the future doesn't look as sunny as it did a few years ago.

I'm perplexed as to why some people are surprised by the sudden shift. The market is unpredictable and can shift much faster than most people appreciate. I thought that pharms are especially vulnerable because most of them work for retail pharmacies. The Wal-Mart's, Walgreens, and Rite-Aid's are highly profit-driven companies and have razorthin profit margins. They are fanatical about wringing out costs from their operations. If they think that they can replace you with an automated drug dispenser, they will. They will constantly try to find and develop technologies that will allow them to automate some of what pharms do such as dispensing pills, detecting drug interactions, coming up with alternative drugs, etc. Where you may have needed 3 pharms, you can now do it with just 1 pharm. If pharmacies are practically giving away drugs like $4 generics and free abx, then obviously the retailer is making no money or even losing money from their pharm operations. Then this indicates that there may be a new paradigm. The pharmacies are becoming loss leaders used by the retailers to lure customers into stores so that they buy other items. If the pharmacies themselves are now cost centers, then this puts pharms in an even more precarious position because the retailer has to somehow make up for your salaries and benefits. The best way to have job security and justify raises is to work for the side of the company that makes huge profits, not to work for the cost centers.

The best response to this new environment is to make yourself so indispensible that a Wal-Mart can't simply replace you with a machine. In response to the discussion regarding monitoring BP, I really doubt that many pharms will encroach on the medical profession turf for liability reasons. Patients will sue you at the drop of the hat. And don't expect that the physician will be there to save your butt after you've failed to properly diagnose and manage a deteriorating condition. If the physician is called in to save the day but is unable to because the pharm has waited too long, then both the physician and pharm will get sued. If the pharm works for a retail giant, then there is even more incentive to sue the pharm and his employer and hence a good reason why the employer probably won't permit it. Many physicians are savvy enough to stay away from this huge red flag. I think pharms would have a very hard time finding physicians who would collaborate with them when monitoring is done mostly by pharms. Physicians are a highly skeptical group and they are very selective of the people that they trust for clinical acumen. I would not enter into a collaboration with a pharm or dentist. If the patient wants to be monitored, they can come to my clinic.

 

[All4MyDaughter]

after you've failed to properly diagnose and manage a deteriorating condition. If the physician is called in to save the day but is unable to because the pharm has waited too long, then both the physician and pharm will get sued. If the pharm works for a retail giant, then there is even more incentive to sue the pharm and his employer and hence a good reason why the employer probably won't permit it. Many physicians are savvy enough to stay away from this huge red flag. I think pharms would have a very hard time finding physicians who would collaborate with them when monitoring is done mostly by pharms. Physicians are a highly skeptical group and they are very selective of the people that they trust for clinical acumen. I would not enter into a collaboration with a pharm or dentist. If the patient wants to be monitored, they can come to my clinic.

I don't think you understand the role of the pharmacist in patient monitoring. Or the scope of practice. Disease state management is very different from diagnosis and treatment of acute conditions.

There are already a lot of pharmacists engaged in disease state management under collaborative care agreements with physicians. The VA is one major place this is common. Others as well.

 

[Taurus]

I don't think you understand the role of the pharmacist in patient monitoring. Or the scope of practice. Disease state management is very different from diagnosis and treatment of acute conditions.

There are already a lot of pharmacists engaged in disease state management under collaborative care agreements with physicians. The VA is one major place this is common. Others as well.

I have read about the pharms' expanded scope at VA centers. I also talked to a pharm about it. The VA centers have a pretty unique ecosystem. I'm not sure that their paradigm can be extended into the private sector. You don't worry about liability in the same way.

Anyhow, any physician would be very cautious about collaborating with another professional, especially one who has not received much clinical training. Sure, pharms, like NP's and PA's, can be trained to listen to the heart and lungs and maybe even do a full H&P. But I highly doubt that most pharms can distinguish between normal and abnormal. Unless you are formally trained with hundreds or thousands of patients under a qualified clinician, it's just not that easy. And this is something you have to practice everyday, not just once in a while. Then once you have that information, you won't know when something is benign or needs an immediate consult. For example, most NP's and PA's do fine with standard, healthy patients, but they may need help with more complicated patients. That's why most work under physicians. If you look at the scope of NP's and PA's at these in-store clinics, it's highly restrictive because the retailers want to minimize their liability exposure.

I would be very wary about collaborating with a pharm or anyone who I did not feel has competent clinical judgment. I don't think that I am alone either. It's not a given that physicians will just agree to these collaborations.

 

[OHMAN0125]

I have read about the pharms' expanded scope at VA centers. I also talked to a pharm about it. The VA centers have a pretty unique ecosystem. I'm not sure that their paradigm can be extended into the private sector. You don't worry about liability in the same way.

Anyhow, any physician would be very cautious about collaborating with another professional, especially one who has not received much clinical training. Sure, pharms, like NP's and PA's, can be trained to listen to the heart and lungs and maybe even do a full H&P. But I highly doubt that most pharms can distinguish between normal and abnormal. Unless you are formally trained with hundreds or thousands of patients under a qualified clinician, it's just not that easy. And this is something you have to practice everyday, not just once in a while. Then once you have that information, you won't know when something is benign or needs an immediate consult. For example, most NP's and PA's do fine with standard, healthy patients, but they may need help with more complicated patients. That's why most work under physicians. If you look at the scope of NP's and PA's at these in-store clinics, it's highly restrictive because the retailers want to minimize their liability exposure.

I would be very wary about collaborating with a pharm or anyone who I did not feel has competent clinical judgment. I don't think that I am alone either. It's not a given that physicians will just agree to these collaborations.

As a former pharmacist, I have to agree with Taurus. As a PharmD my clinical diagnostic training was nil. After coming to medical school you realize just how much thinking needs to go into management of patients. I think pharmacists are good for looking at medications and deciding which one is good for a certain patient. But to actually monitor a patient? I don't think most PharmDs know exactly what they're doing, unless they changed this since 3yrs ago when i graduated. NPs and PAs on the otherhand have large amounts of clinical training and yet they still can't compare to a MDs training. So in other words, it's a bad idea unless its just for medication management.

 

[JayRx1981]

As a former pharmacist, I have to agree with Taurus. As a PharmD my clinical diagnostic training was nil. After coming to medical school you realize just how much thinking needs to go into management of patients. I think pharmacists are good for looking at medications and deciding which one is good for a certain patient. But to actually monitor a patient? I don't think most PharmDs know exactly what they're doing, unless they changed this since 3yrs ago when i graduated. NPs and PAs on the otherhand have large amounts of clinical training and yet they still can't compare to a MDs training. So in other words, it's a bad idea unless its just for medication management.

While I agree with the diagnostic training comment, I disagree with the patient management aspect. Currently, I'm on rotation in a collaborative family practice setting doing intensive diabetic, hyperlipidemic, and hypertensive patient management. We do everything from interviewing the patient at each visit, to performing blood pressure and monofilament exams (where warranted), to scheduling appointments, to ordering appropriate labs, to making medication recommendations, and even writing up the prescriptions so that all the collaborating physicians must do is review and sign.

Of course, a retail pharmacist probably couldn't do this, but to say that our training doesn't qualify us to manage patients is an overstatement.

 

[Taurus]

so that all the collaborating physicians must do is review and sign.

This is a myopic view of what the patient encounter is like. During that patient encounter, your physician preceptor is reviewing the vitals and labs, obtaining any new history by asking relevant questions -- probably from both your history taking or asking the patient directly, and examining the patient, even if it is just observing how the patient talks, thinks, or walks. An experienced physician may need just 5 minutes to accomplish all of this if it is a simple visit. On the surface it does appear pretty simple, but knowing what questions to ask and what to look for is why the physician spent so many years in training for. The physician knows when to escalate the level of the visit and when it is routine and normal.

Pharms can take BP, history, etc all they want. If they find something unusual, then they should send the pt to the ER or have the pt schedule a consult with his doctor. What is unlikely to happen is that the information that the pharm collects for each encounter is transmitted to the physician. If a typical PCP has like 3000 patients, they don't want to get 10-20k BP readings per year from pharms and dentists. It creates a nightmare of paperwork for which physicians don't get reimbursed for. Also, if the information is given to the physician, the physician then assumes responsibility and liability because they now "know". No thank you. Any information that pharms or dentists collect they can keep to themselves. I would take responsibility for a pt only when I talk to and examine the pt myself and not based on non-physician clinical judgments. From what I have seen, most physicians feel this way and for good reason.

 

[JayRx1981]

This is a myopic view of what the patient encounter is like.

Your pick of a quote is a bit myopic itself.

I'm not stating that a physician signs off without looking--but they aren't spending even five minutes with the patients and ARE allowing us to manage the conditions previously mentioned.

 

[Taurus]

I would hope my physician doesn't take the same position I'm understanding you to be taking. I want my physician to be willing to take ANY information he can get, if relevant, before he makes a decision regarding my health, not to refuse it because it came from a pharmacist/dentist.

Let me give you an example to help you understand. Let's say we have a patient who last visited his PCP 1 year ago. The pharm has been monitoring the BP and sends reports to the PCP that it's within normal limits. The PCP is confident that the patient is doing well because the pharm says so. Then the patient has a stroke. Turns out that the pharm was erroneously measuring it and it was actually in the 200's/100's. Who does the patient's family sue? The PCP, pharm, and the pharm's retail company.

If physicians enter into collaborations with pharms, then the physicians essentially take responsibility for any adverse medical outcomes since the physicians are the ones who have the medical training. Similar to how pharms have to take responsibility for the actions of pharm techs, even though the pharm tech is the one who screws up, physicians have to supervise residents, medical students, midlevels, etc. The last thing I want is to also supervise medical monitoring by pharms.

Like most physicians, I will accept a patient and monitor him only if I talk to and examine him myself at each visit. It's too risky and it's bad patient care if you take a non-physician's clinical opinion at face value in a report or over the phone. Then you're depending on their clinical judgment. How much clinical training does a pharm get? About nil.

Furthermore, I honestly don't need a non-physician to monitor my patients. For patients with chronic conditions like DM or HTN, 3 month follow-up visits are typical. That's enough time between visits for me to guage the progress of the treatment. I don't need weekly updates from dentists or pharms.

If pharms want to monitor BP, take history, that's fine. If the patient has an emergent condition, send him to the ER. If his condition worsened, then have the patient schedule an appointment with his physican. By taking on some clinical duties, pharms will also bear the liabilities that go along with it as well. I would not want to get dragged into it.

 

[genesis09]

None of you have been to UIC clinics have you. It's pharmacists which do anti-coagulations, lipid monitoring, diabetic follow-up, etc here. Every hospital clinic from dermatology to oncology has at least one pharmacist associated with it. On the hospital transplant team, there are an equal number of pharmacists as MDs. UICMC has a lot of PharmDs compared to most hospitals. Pharmacists are already taking on major roles in medical care.
Pharmacists get a lot of clinical drug training. What we don't get a lot of is learning how to diagnosis. If a person came in with a BP of 200/100, it's time for them to go to the hospital.
Now, in Illinois, pharmacists outside of hospitals can prescribe within collaborative agreements. You have to send notice of what you did to a doctor within 48 hours. The details of the program still haven't been worked out. The main detail not having been written about is the doctor-patient-pharmacist relationship dynamic. The law just passed less than 1 month ago. The local medical society was against this, but the pharmacy organizations along with the chains managed to keep this provision in the practice act.
The FDA believes pharmacists are intrinsically qualified enough to be the gatekeepers for a proposed BTC class of drugs. In fact, in their own handout about the potential program, they say pharmacists are qualified.

 

[Taurus]

Management of disease is not my main concern. I don't think it's that hard to manage DM or HTN. It's the new conditions that would worry me.

I would throw out there that if a pt is being monitored for his DM or HTN by a pharm then he probably feels that he doesn't need to visit his PCP as frequently. Afterall, you don't need both a physician and pharm to manage them, right? The pharm essentially then assumes the role of provider. At every visit, the pharm does brief, focused H&P and makes an assessment. That assessment is what will come back to haunt you. Pathology can be very subtle and if you don't catch it early the patient may suffer significant m&m. I've had patients who were completely asymptomatic but had the stereotypical aortic stenosis murmur. I've had patients who had grapefruit-size colon cancer tumors who were asymptomatic. If the pharm wants to assume the role of provider, that's fine. Your name and signature will be all over the patient's charts. If you get dragged into court, it won't be because of your management of DM or HTN. I don't want to get dragged down too because you screwed up.

Even if pharms do some of this clinical stuff, I doubt that physicians will change the way they do follow-up with patients. I doubt that a physician will schedule follow-up visits in 6 months instead of 3 months because the patient is seeing a pharm. You can't replace talking to and examining the patient yourself. There's no surrogate unless you have complete faith in the other person's clinical reasoning skills.

 

[letjin]

Let me give you an example to help you understand. Let's say we have a patient who last visited his PCP 1 year ago. The pharm has been monitoring the BP and sends reports to the PCP that it's within normal limits. The PCP is confident that the patient is doing well because the pharm says so. Then the patient has a stroke. Turns out that the pharm was erroneously measuring it and it was actually in the 200's/100's. Who does the patient's family sue? The PCP, pharm, and the pharm's retail company.

Bad example... when I go to my doctor's office, it is always a medical assistant (not even a nurse) who measures my BP. Never once a MD measured my blood pressure.

 

[Taurus]

Bad example... when I go to my doctor's office, it is always a medical assistant (not even a nurse) who measures my BP. Never once a MD measured my blood pressure.

Ok, not the greatest example in the world. Patient comes in, says that whenever she walks up a flight of stairs now she has to rest for 5 minutes to catch her breath. She also says that her left jaw has been aching.

Don't be doing a medical H&P unless you think you know what questions to ask and what to look for. Your name and signature will be all over the patient's charts. After the patient has a heart attack 1 day after seeing you and dies, the family's lawyers will review your H&P notes and ask, "why didn't you ask her if she had dull pressure on her chest?, how much clinical training have you had for you to know when a heart exam is normal or abnormal?, etc" It was your responsibility to immediately contact her PCP to let him know that she has anginal symptoms or to send her to the ER. If you didn't, then you were negligent.

My point is that if pharms want to take on the role of a provider they will have to accept responsibility and liability that goes along with it. If the patient sees you more frequently than his PCP because he thinks you are interchangeable with his PCP, then the burden on your shoulders will be greater than you think. If pharms are working with older, sicker patients who need their DM, HTN, and lipids managed, there's a good chance that some of these patients will eventually develop an MI, stroke, hypoglycemia, etc. It will be your responsibility to detect and prevent it from happening. So have fun. I know I wouldn't touch this stuff with a 40 foot pole if I were a pharm. This is why I would never enter into any formal collaboration agreements with a pharm. I do not want to take responsibilty for the clinical decision-making of a pharm who has nil clinical training.

 

[njac]

Taurus,

I wasn't able to quote your signature but I'm curious why AAs and PAs are preferable to PharmDs and Nurse Practitioners?

 

[MacGyver]

Contrary to popular opinion, there is no doctor shortage, just a poor distribution.

Which means the pharms trying to cut into our turf will be in direct competition with MDs, PAs, NPs, etc.

PharmDs will lose that battle and it wont even be close.

 

[Old Timer]

I really thought the DR. God complex had died. I see it is alive and well and living in Taurus & MacGyver. Only the GOD all mighty MD or DO can do anything.

I hate to tell you but the battle has already been won. I have tried in vain to convince you that this is the wave of the future. It is called MTM, there are now CPT codes to bill for this service. It is part of Medicare Part D and it's coming to a theater near you.

It is not a replacement for the doctor it works hand in hand with the doctor. When doctors stop feeling threatened and wake up to the fact we are your ally in patient care not your competition, you will see the benefit to your patient.

Your arguments are stupid and condescending. I regularly catch drug interactions and dosage errors by MD's, some of them potentially fatal. Do you want to give up your right to select drugs and leave it to the drug experts? We all have way more experience and training in pharmacology, pharmacokinetics and drug interactions than you do. These arguments are silly. As I explained before, your patient's are monitoring their BP at the supermarket for goodness sakes and you worry that a Pharm D can't be trained to take a BP. You really want to advance such a silly argument?

 

[PharmD2MD]

I don't think pharmacists should get involved in physical exams. I'm gaining a whole new appreciation for the art of diagnosis and it's not something that was taught in pharmacy school at all. Disease state management clinics are fine- that's not what I am talking about. I've worked in these clinics as a pharmacist and taking someone's BP or poking their feet is not a physical exam. It takes years for a physician to really get good at picking up subtle signs. I know pharmacy is kind of in a tough spot right now, and trying to define exactly what it's role is, but getting into physical exams and diagnosis is totally barking up the wrong tree in my opinion. If that's what you want to do, suck it up and go to med school.


That being said, I think pharmacists are sadly underutilized when it comes to drug selection. Pushing for more latitude and privileges in this area seems more reasonable to me than getting into something that involves a lot of liability and probably won't reimburse well.

 

[genesis09]

No one in pharmacy is suggesting we get into the diagnosis game. Having a working knowledge on how a disease is diagnosed is expected though. The pharmacist run disease state management clinics work. Most of the studies show an increase in compliance. They have cut costs.
With the MTM CPT codes, we were told the AMA actually played some games to slow down giving pharmacists the codes even though it was required by law.
Sometimes things happen on a level you can't control. Coming January 1, doctors won't be able to get reimbursed at in-network or at all for Medicare Part D vaccines which are currently routine tetanus and shingles. Doctors were allowed for 2007 to bill for those vaccines under Part B. Only pharmacists will be able to be reimbursed at the in-network level. According to the local CMS policy coordinator, many doctors are rather upset over the change.

 

[Taurus]

genesis09, you're missing my point. You won't get sued for your DM or HTN management. You will get sued for missing some subtle sign or symptom that leads to an MI, stroke, DKA, diabetic coma, etc. If a patient has an MI or stroke 1 day after seeing you and during the visit had complained of some classical symptoms that you didn't pick up on, what do you think they will do? They're paralyzed now, no job, and a heap of bills. The lawyer tells them that he won't charge anything unless he wins. This is not a far-fetched scenario.

If you listen to someone's heart, you better know what the ramification of that is. It assumes that you know what is normal vs. abnormal. If you start to ask history questions, it assumes that you're following some logical line of questioning based on the signs and symptoms. It's not just some random questioning. Since you'll most likely be monitoring older, sicker patients, there's a better chance that one of your patients will develop one of these conditions and you better know what questions to ask and what to look for on examination. Document it clearly in the charts and send them to the to ER or have them see their PCP immediately. What no physician wants is to be held responsible for patients' conditions who he did not talk to or examine except for the assessment by the pharm. I see a lot of downside to having formal collaboration agreements with pharms and little to no upside.

Two pharms who went on to med school have given you their views. Take it for what it is.

 

[MacGyver]

Sometimes things happen on a level you can't control. Coming January 1, doctors won't be able to get reimbursed at in-network or at all for Medicare Part D vaccines which are currently routine tetanus and shingles. Doctors were allowed for 2007 to bill for those vaccines under Part B. Only pharmacists will be able to be reimbursed at the in-network level. According to the local CMS policy coordinator, many doctors are rather upset over the change.

What goes around comes around. If they can dumb down vax from docs to pharmDs, they can also dumb it down again to RNs. You too, will get cut out of the loop becasue it makes ZERO financial sense for a doctoral degree person to give a stupid vax.

So have fun giving those vax and watch as the reimbursements plummet as CMS figures out that RNs can give those simple shots out just as easily and for half the cost.

In the end, you'll get some paltry 50 cents for each vax you give. And when that happens, all the pharmDs will get out of the vax business, proving that their propaganda about wanting to expand healthcare "access" was nothing but smoke and mirrors bull****.

Nobody buys the pharm industry lies about wanting expanded scope so they can "alleviate the healthcare shortage." Its all about the $$ for you guys and everybody knows that.

 

[parabolic]

You won't get sued for your DM or HTN management. You will get sued for missing some subtle sign or symptom that leads to an MI, stroke, DKA, diabetic coma, etc.

So far as this goes, the gray area seems to be when the patient begins listing symptoms to the pharmacist-- those 'subtle' or 'classic' signs that you have mentioned. The point that hasn't been made yet, though, is that this already happens all the time. I hear our pharmacist say, time and time again, "You should really see your doctor" when patients start talking about their symptoms at the consultation window. I mean, patients would never think to approach a butcher/photographer/cashier and start spouting off their symptoms, but they do it to pharmacists because pharmacists are visible, accessible health professionals.

The problem is that many patients don't realize that pharmacists are not equipped to diagnose, and that some problems require more than an OTC recommendation. Of course, some are just looking to avoid their doctor's office (and related copay). "You should see a doctor" is not going to disappear anytime soon, and that's a good thing. I don't think there is anyone in pharmacy who would advocate putting an exam table between the registers and the tabloids.

 

[genesis09]

What goes around comes around. If they can dumb down vax from docs to pharmDs, they can also dumb it down again to RNs. You too, will get cut out of the loop becasue it makes ZERO financial sense for a doctoral degree person to give a stupid vax.

That can't happen currently because of the way the Part D law is written. The Part D law says only pharmacists and pharmacies can be in network. That's why for 2007 doctors are getting reimbursed for shingles through Part B. It uses a community pharmacy model. Part A uses a hospital model and Part B uses a doctor's office model.

 

[Taurus]

The problem is that many patients don't realize that pharmacists are not equipped to diagnose

I agree with that. However, if pharms start to do H&P and even prescribe, you can't avoid being labeled as a provider and its implications. Don't lay your hands on a patient or listen to their hearts if you don't want the responsibility and liability.

 

[genesis09]

Pharmacist as provider, that's something being discussed. Don't know where it will lead but some in the pharmacist community want to get recognized as providers by CMS. They are planning to raise this issue when MTM gets reviewed by CMS in another year or two. They believe if CMS recognizes pharmacists as provider than everyone else, other insurance companies, will follow. This will be an issue in the coming few years.

 

[Taurus]

I regularly catch drug interactions and dosage errors by MD's, some of them potentially fatal.

Ok, I'll respond to this. Physicians make mistakes in drug dosing and interactions. One of the roles of pharms is gatekeeper to drugs and in this role pharms are supposed to catch these mistakes. You are a safety net when it comes to drug safety.

If a pharm does an H&P on a patient with no physician oversight, where is the safety net? Any report you send of that patient encounter to the physician assumes that you know how to do an accurate H&P, something which takes years for physicians to master. Without seeing the patient myself, how do I know for sure that your description of "heart exam was normal" is accurate? Plus, physicians have tight schedules and therefore may not be able to read your report for a few days. Unless a physician is in the office with you, you have to be able to make clinical judgments independently.

If the patient walks out of your office and you didn't know that the patient was exhibiting signs of a life-threatening condition, then there may not be a safety net to prevent that patient from having an MI or stroke. You were it.

That is why your analogy fails.

 

[Old Timer]

Ok, I'll respond to this. Physicians make mistakes in drug dosing and interactions. One of the roles of pharms is gatekeeper to drugs and in this role pharms are supposed to catch these mistakes. You are a safety net when it comes to drug safety.

If a pharm does an H&P on a patient with no physician oversight, where is the safety net? Any report you send of that patient encounter to the physician assumes that you know how to do an accurate H&P, something which takes years for physicians to master. Without seeing the patient myself, how do I know for sure that your description of "heart exam was normal" is accurate? Plus, physicians have tight schedules and therefore may not be able to read your report for a few days. Unless a physician is in the office with you, you have to be able to make clinical judgments independently.

If the patient walks out of your office and you didn't know that the patient was exhibiting signs of a life-threatening condition, then there may not be a safety net to prevent that patient from having an MI or stroke. You were it.

That is why your analogy fails.

First, you must not have had read the entire thread.

First: I make clinical judgments every day. I may not touch the patient, but I use the clinical skills I was taught in school and honed over the last 25 years of practice. I have sent people to their doctor, I have sent people to the ER and I have treated people with OTC medications for mild self limiting conditions. When people come in with a complaint, I must determine what the problem really is and whether the condition is treatable with OTC medication.

Second: MTM is in collaboration with a physician under a defined protocol. If there is a problem, then you pick up the phone or have the patient pick up the phone and contact the physician. It would depend on the protocol of MTM program.

Third: As I said in a previous post patient's with Asthma, Hypertension, Diabetes are already monitoring their conditions by themselves. Adding a pharmacist to the mix improves compliance, reduces cost and improves outcomes. It is still better to get your BP checked by a pharmacist than a machine in the supermarket or shopping mall.

Consider the pharmacist your eyes and ears when you are not there. When Mrs X came in to renew her NTG after a long period of time, but within legal limits, I did not let it go. I questioned her in detail and two days later she had angioplasty. I could have shut up and filled her RX, however I used my clinical skills to diagnose a worsening of her CAD that required physician intervention. I was her safety net. I did not pull out my stethoscope and EKG machine. I'm not a physician. This happens every day. You are taking the word PE out of context. We will not be doing a complete PE. What we will do is use our clinical skills to evaluate our patients under a defined protocol.

 

[pharmacogenomic]

First, you must not have had read the entire thread.

First: I make clinical judgments every day. I may not touch the patient, but I use the clinical skills I was taught in school and honed over the last 25 years of practice. I have sent people to their doctor, I have sent people to the ER and I have treated people with OTC medications for mild self limiting conditions. When people come in with a complaint, I must determine what the problem really is and whether the condition is treatable with OTC medication.

Second: MTM is in collaboration with a physician under a defined protocol. If there is a problem, then you pick up the phone or have the patient pick up the phone and contact the physician. It would depend on the protocol of MTM program.

Third: As I said in a previous post patient's with Asthma, Hypertension, Diabetes are already monitoring their conditions by themselves. Adding a pharmacist to the mix improves compliance, reduces cost and improves outcomes. It is still better to get your BP checked by a pharmacist than a machine in the supermarket or shopping mall.

Consider the pharmacist your eyes and ears when you are not there. When Mrs X came in to renew her NTG after a long period of time, but within legal limits, I did not let it go. I questioned her in detail and two days later she had angioplasty. I could have shut up and filled her RX, however I used my clinical skills to diagnose a worsening of her CAD that required physician intervention. I was her safety net. I did not pull out my stethoscope and EKG machine. I'm not a physician. This happens every day. You are taking the word PE out of context. We will not be doing a complete PE. What we will do is use our clinical skills to evaluate our patients under a defined protocol.

Old Timer - for one I agree with you whole-heartedly!

Taurus is a medical student/resident......not completely versed in actually the kinds of issues which come up with patients who are in the medical "system" - how hard it is for them to deal with the "system". Access to medical care is difficult in many areas of the country - mine is one & I live in a very upscale & well-to-do area with few physicians. Why? Its expensive for new physicians to move here! I'm going to guess Taurus is in a medical university environment which we all know, since we've been there, does not reflect the actual real world of private practice.

All the time, we are faced with exactly your scenario of the ntg - or could be the persistent cough that doesn't go away with otc medications (the pt is on an ace inhibitor), the pt who complains of aching muscles they thought was due to the weeding they did in July, but...guess what - they were put on a statin in July & no follow-up. The receptionist took the call from the pt, but the dr advised ibuprofen - via the medical receptionist, because the pt complained of paid due to weeding. The hx was obtained by the receptionist - not the physician. No correlation with lfts - which I later requested via communication. Funny - the rx was changed after the pt went in for labwork after my request. Then...there is always the pt who wants something "more" than the otc heartburn medications - on acquiring hx...we find the pt has run the gamut of otc - from h2 blockers to proton pump inhibitors - no relief. When they're advised by use to seek medical care - we find they have gastric CA. Well - we could have just kept "selling" them otc stuff,but no - our responsibility is to get the pt the best care possible. Sometimes thats an otc product with very little outlay of money. Sometimes, its a physicia visit.

Oh - the very best one yet - my own family member who had an obvious atopic dermatitis with a very complete hx documenting it (names withheld to keep anynomity)......the family practice resident & attending both said it was excema & to use 1% hc cream. I told her over the phone they were nuts & to see a derm. The derm attending saw her the next day & confirmed she had a rip-roaring atopic dermatitis & it wasn't anything close to excema & 1% hc wouldn't even come close to treating it. He treated her with oral steroid taper & rx topicals - which I told her she needed after the 1% hc, diphenyhydramine & cimetidine did not clear in the first place. Nope - the FP took the "cautious" & potentially damaging route to not treat, delayed her recovery & caused yet one more visit to another specialist. How is that any better than an NP or PA? Probably worse!

Oh.....the last "clinical" communication I had with a patient was my Norco guy last night. Now - he's not a drug seeker, never has been. But, his usage has increased. He wanted more than the regular 120 which had been prescribed. So - he got a refill ok. From who??? The medical receptionist!!! The physician is in the office only 2 days a week & this guy was asking for a refill 13 days early. The medical receptionist says - no problem - the dr will say ok, altho he's not there until Monday. Now...this is a pain specialist & I know the dr has contracts with his pts. This guy has been slowly, very slowly increasing his dose. We had a long talk as to why - lots of issues. But, the biggest issue is his fear of the "strongr" medications whch the receptionist said she couldn't ok over the phone so its best to stay with this. This advice is coming from someone who has ABSOLUTELY NO MEDICAL KNOWLEDGE WHATSOEVER is giving me the ok to fill early? Aaaaaah - no! The guy needs to see the dr & discuss options. Now - the dr is a bit nuts to employ someone like this - but nonetheless, this is more common than you might think, Taurus.

I'm not going to suggest changes in therapy - we talked about options, which surprisingly the physcian had talked about as well. But, he said - the receptionist was just fine about giving the ok for refilling the Norco....all the while he is getting >4G/day of acetaminophen. Does the receptionist even know about what the implications of this are??? Most importantly - does the doctor know about the frequency of refills? I think not! We'll see when I actually talk with the physician Monday. I have had conveersations with him before about previous pain management pts & he definitely wants to know what is being used & how often. The problem is getting past the "front office". You might say this is an "outlier" practice - but it is more common than you might think - in a variety of practices.

Taurus - do you even work in an outpt setting in a private location? Do you even know what private patients need to go thru to get thru to talking to their physicians?

In my area - it is next to impossible to get a call back the same day. For refill ok's - it takes 72-96 hours routinely. For call backs to pts its a minimum of 48 hrs & that is a call by the nurse (hmmm - lvn, ma???).

Our system, where I live is entirely broken & your thought process is outdated for a large metropolitan city with a huge population. I respect your desire to want to follow each & every patient - goodness knows, my own daughter has that same idealistic notion. That worked decades ago & still does in some places.

The reality is - it does not happen for the largely populated areas with few physicians per 1000 patients.

Personally, like Old Timer, I've sent pts to the ER with a variety of issues which have panned out the way I thought - 2 with strokes in progress, 3 with hpb bordering on heart damage/stroke, 1 with asthma unrelieved by inhaled albuterol, one elderly individual with unremitting diarrhea x 3 days with occasionally vomiting & 1 with a rapidly progressive drug reaction which I felt might be dangerous. Oddly - all were hospitalized.

Now - certainly...there were others which I probably didn't send for many reasons. I'm not perfect - but, they didn't call their physician first...they came to me.

We do the best we can with what we have. We don't try to take your place. We try to fill the void which exists. That void is real & we would love to go back to the time we actually talked to you, had patients talk to you & you'd see them from their office visits to inpt stay to outpt discharge monitoring. But - that time is past. We've been doing this a long time & we haven't been sued often - usually negilgence in dispensing. We don't do it for money (immunizations - its a public health issue), nor for fear of litigation. We use our best judgement, know our limits & our collaborative agreements & abide by them. You, in no way need to participate in those agreements - no one forces you to do so. But, they have existed for years (a decade at least) & will continue to exist. You can either join in & be a productive force for the future of accessible medical care, or stay where you are & keep it where it is. I wish you well, whatever path you take!

For MacGyver - I have no answer to the paranoia which you demonstrate, but I've expressed that before. I would suggest contacting your own medical provider.

 

[Taurus]

I would hope that any health professional, not just a pharm, can do a superficial screening if a patient is in imminent danger of a life-threatening condition. An RN who gives a flu shot should be able to do that.

It sounds like MTM is the pharm reading off a checklist of symptoms to which the patient answers yes/no. No real history taking and PE. That's sounds like a huge letdown for some of the pharm students on here who would like to see pharms become more clinical.

I'll give you my perspective as someone in medicine who has spent time in both outpatient and inpatient settings. I see two problems with MTM agreements. First, physicians these days have really packed schedules. 3-4 patients per hour is the norm. Do I want a pharm calling me every hour telling me that Mrs. Jones has a stomach ache and if I would talk to her? No. Send her to the ER if you think it's serious. Second, since I can't directly supervise a patient visit with a pharm and the pharm is following a "protocol", there's the chance that the pharm will miss some subtle sign or symptom. If something adverse happens, my name is on that formal collaboration agreement with the pharm. Like I've been saying, I don't want to be held responsible if I didn't talk to or examine the patient myself.

Are physicians tripping over themselves to sign MTM agreements with pharms? I see a whole lot of downside and little to no upside.

As I was thinking about this, I think that this whole discussion about pharms becoming more clinical is moot. In the future, if the pharm suspects something, do you know what they will do? They'll send the patients over to the in-store clinic to be quickly evaluated by the PA or NP. That's the protocol that the Wal-Mart's, CVS's, and Walgreen's will use. From a liability point of view for the companies, it makes more sense. Pharms will be back to square one, trying to figure how to reinvent themselves.

 

[genesis09]

First, most pharmacies do not have clinics. Walgreens plan is to have one clinic for about about every 7 stores or so.
For MTM, Medicare part D allows pharmacists to bill in one year per patient for 1 30 minute meeting and 2 15 minute meetings.
Collaboration between pharmacists and physicians is the norm at VAs already. It is also the norm here at UIC. UICMC physicians trust the pharmacists to choose the correct warfarin, statin, optimization of asthma therapy on their own. For transplant, the MDs really don't bother with the medication therapies anymore. Pharmacists cannot legally enter into collaborations with NPs and PAs. In Illinois, you have up to 48 hours to document your interaction/change with the patient and send it to their doctor.
MTM and collaborative practice are different. MTM is a vaguely described Part D service, and collaborative care agreements tend to be very rigid. Some Part D programs call sending drug information sheets MTM.
The fact is the average person takes his/her medications incorrectly. For OTCs, the numbers are even worse. The goal of MTM is to get the patient to take medications correctly and decrease duplication therapy. The goal of collaborative care is the optimize therapy between doctor's visits.
Here's some info about MTM
http://www.pharmacist.com/AM/Templa...EMPLATE=/CM/ContentDisplay.cfm&CONTENTID=4577
http://www.pharmacist.com/AM/Templa...aggedPageDisplay.cfm&TPLID=96&ContentID=11481

 

[Taurus]

So the pharm loves this MTM because it expands their role.

What's the upside for the physician except more paperwork, liability exposure, and probably reduced patient visits? I ask again, are the physicians tripping over themselves to sign these MTM or any collaboration agreements? If they are, then I want to understand their rationale.

Like I said before, the VA system is pretty unique and you can't apply it to the private sector entirely. Same thing with a university environment. Profs can be coerced to agree to do things that you won't find in private practice.

Don't kid yourself. If the in-store clinics are hugely profitable, there will be one in every store. This is especially true if pharmacies are loss leaders now because they're selling $4 generics, giving away free abx, and have to deal with Medicare prescription plan. My local grocery giant is advertising on TV "400 generics at $4 everyday".

 

[bananaface]

Are physicians tripping over themselves to sign MTM agreements with pharms? I see a whole lot of downside and little to no upside.

That's because you don't understand how MTM works and because you are not far enough along in your career to have had patients that you would like to refer for higher level pharmaceutical care. When the time comes that you have a patient on 20 different meds who is having trouble keeping disease states under control because of med management difficulties, you will probably be glad to have an expert to refer them to for that extra help and maintenence that you don't have time for. One thing to keep in mind is that MTM is a supplement to good physician care, not a replacement for it.

 

[Taurus]

I can see the value of pharms when you have a very complicated, unstable patient who needs their 20 meds optimized. That's why we have pharms on the inpatient teams. The physicians don't have time or really want to manage that aspect.

But is this really the panacea that pharms are looking for? Outside of inpatient setting and where most patients are, physicians manage their patient meds just fine, although I'm sure quite a few here would disagree.

Since routine office visits for DM, HTN, and lipids are the bread and butter of outpatient medicine, I don't see a physician movement toward MTM. For some practices I've seen, these visits comprise 25-50% of their patient population. Referring patients to pharms for MTM probably means lost business. The private practice physician is already under assault by litigation, midlevels, insurance companies, and reduced Medicare reimbursements. I don't think they want to see more of their practice erode. If I have a really complicated patient that I can't manage their meds, I'll refer them to a pharm for MTM. I have yet to see that happen in the outpatient setting.

If the state medical society was against Illinois expanding pharm scope, I think I see why. I wonder how many physicians have really jumped on board to this whole pharm collaboration thing. If physicians are excited about signing these collaboration agreements or MTM, I would like to see some links so I can understand their rationale.

 

[All4MyDaughter]

http://www.mc.uky.edu/pharmacistcare/

 

[Old Timer]

I would hope that any health professional, not just a pharm, can do a superficial screening if a patient is in imminent danger of a life-threatening condition. An RN who gives a flu shot should be able to do that.

It sounds like MTM is the pharm reading off a checklist of symptoms to which the patient answers yes/no. No real history taking and PE. That's sounds like a huge letdown for some of the pharm students on here who would like to see pharms become more clinical.

I'll give you my perspective as someone in medicine who has spent time in both outpatient and inpatient settings. I see two problems with MTM agreements. First, physicians these days have really packed schedules. 3-4 patients per hour is the norm. Do I want a pharm calling me every hour telling me that Mrs. Jones has a stomach ache and if I would talk to her? No. Send her to the ER if you think it's serious. Second, since I can't directly supervise a patient visit with a pharm and the pharm is following a "protocol", there's the chance that the pharm will miss some subtle sign or symptom. If something adverse happens, my name is on that formal collaboration agreement with the pharm. Like I've been saying, I don't want to be held responsible if I didn't talk to or examine the patient myself.

Are physicians tripping over themselves to sign MTM agreements with pharms? I see a whole lot of downside and little to no upside.

As I was thinking about this, I think that this whole discussion about pharms becoming more clinical is moot. In the future, if the pharm suspects something, do you know what they will do? They'll send the patients over to the in-store clinic to be quickly evaluated by the PA or NP. That's the protocol that the Wal-Mart's, CVS's, and Walgreen's will use. From a liability point of view for the companies, it makes more sense. Pharms will be back to square one, trying to figure how to reinvent themselves.

I rarely take to calling people names. I will however make an exception for you. You are a rude, arrogant and condescending jerk. I cannot participate in a discussion with someone as prehistoric as you appear to be.
Good luck with your education, but I can tell you you are in for a rude awakening in real life once you leave the cocoon of school. I am out of this thread.

 

[Priapism321]

Just because this is keeping me entertained, how do you feel about the arrangements discussed in the linked article Taurus?

http://www.memag.com/memag/article/articleDetail.jsp?id=112460

 

[SpirivaSunrise]

Just because this is keeping me entertained, how do you feel about the arrangements discussed in the linked article Taurus?

http://www.memag.com/memag/article/articleDetail.jsp?id=112460

Nice article Priapism!

 

[Taurus]

Just because this is keeping me entertained, how do you feel about the arrangements discussed in the linked article Taurus?

http://www.memag.com/memag/article/articleDetail.jsp?id=112460

Having a pharm in a practice of course would be beneficial. So would having more partners, midlevels, etc.

The issue comes down, not suprisingly, to money. Seems like the pharms, like other groups, are pushing for scope expansion. If Illinois gave them prescription rights, who knows what other states will follow. And genesis likes to remind us that they have their own Medicare billing codes. Do you think that the pharms want to rely on the physicians to refer them DM, HTN, and lipids patients? Don't be so naive. I honestly don't see there being enough patients who the physicians don't feel comfortable enough controlling their meds who would need a pharm consult. You really only see pharms working with physicians in the inpatient setting because the patients are unstable and there is so much scut work to do. I have never seen in the outpatient setting a stable patient who may be on 20 meds being referred out to a pharm. I'm sure the pharms would like every patient who is on any med to be referred out to them.

If you follow the trajectory of other groups like the NP's and CRNA's, they will want independence. I can just see it now. They want to set up their own practices and optimize the meds for DM, HTN, asthma, etc patients who have already been diagnosed by the physicians. That's what they need. Once the patient has been diagnosed, then it's fair game who does the treatment. If the pharms can prescribe and bill, who needs the physician once the diagnosis is made?

You may think I'm being paranoid about this future, but just wait as the Wal-Mart's, CVS's, and Walgreens' start to implement more technologies that will decrease pharmacist manpower needs. The pharms will be looking for new fertile areas to develop a niche in.

Anyways, I think I'm done with this discussion.

 

[bananaface]

I can see the value of pharms when you have a very complicated, unstable patient who needs their 20 meds optimized. That's why we have pharms on the inpatient teams. The physicians don't have time or really want to manage that aspect.

But is this really the panacea that pharms are looking for? Outside of inpatient setting and where most patients are, physicians manage their patient meds just fine, although I'm sure quite a few here would disagree.

Since routine office visits for DM, HTN, and lipids are the bread and butter of outpatient medicine, I don't see a physician movement toward MTM. For some practices I've seen, these visits comprise 25-50% of their patient population. Referring patients to pharms for MTM probably means lost business. The private practice physician is already under assault by litigation, midlevels, insurance companies, and reduced Medicare reimbursements. I don't think they want to see more of their practice erode. If I have a really complicated patient that I can't manage their meds, I'll refer them to a pharm for MTM. I have yet to see that happen in the outpatient setting.

If the state medical society was against Illinois expanding pharm scope, I think I see why. I wonder how many physicians have really jumped on board to this whole pharm collaboration thing. If physicians are excited about signing these collaboration agreements or MTM, I would like to see some links so I can understand their rationale.

Again, MTM is not intended to take the place of regular physician's office visits. The people who are being identified and targeted for it (mostly by pharmacists in my experience - because they are more familiar with the service) are those who are having trouble managing their disease states despite regular visits with their physician. Those patients definitely exist - ask any primary care physician. MTM should not translate into lost business, but rather improved patient outcomes.

I can't speak for others, but I don't see MTM as a panacea. I see it as yet another service that pharmacists can offer. Pharmacists are definitely pushing for an expansion of practice opportunities. The issue goes deeper than "money". Pharmacists are looking for a way to offer indispensible services and keep their jobs secure - just what you suggested they do in the face of dwindling reimbursements and so forth. MTM is an attractive niche for many pharmacists, because it currently isn't anyone else's turf. Perhaps that is why at my last job, we had no problem getting MTM protocols.

The popularity of prescriptive protocols varies by state, because of state law and culture. They were pretty widespread in my old state (WA). I there are quite a few threads in the pharm forum on that topic. The most common protocols are for inpatient medication adjustments, flu shots, and emergency contraception. The only protocol I've heard of anyone having difficulty obtaining (in states that allow them) is emergency contraception, and that was because of moral issues on the part of local prescribers, not because of turf issues.

 

[pharmacogenomic]

Having a pharm in a practice of course would be beneficial. So would having more partners, midlevels, etc.

The issue comes down, not suprisingly, to money. Seems like the pharms, like other groups, are pushing for scope expansion. If Illinois gave them prescription rights, who knows what other states will follow. And genesis likes to remind us that they have their own Medicare billing codes. Do you think that the pharms want to rely on the physicians to refer them DM, HTN, and lipids patients? Don't be so naive. I honestly don't see there being enough patients who the physicians don't feel comfortable enough controlling their meds who would need a pharm consult. You really only see pharms working with physicians in the inpatient setting because the patients are unstable and there is so much scut work to do. I have never seen in the outpatient setting a stable patient who may be on 20 meds being referred out to a pharm. I'm sure the pharms would like every patient who is on any med to be referred out to them.

If you follow the trajectory of other groups like the NP's and CRNA's, they will want independence. I can just see it now. They want to set up their own practices and optimize the meds for DM, HTN, asthma, etc patients who have already been diagnosed by the physicians. That's what they need. Once the patient has been diagnosed, then it's fair game who does the treatment. If the pharms can prescribe and bill, who needs the physician once the diagnosis is made?

You may think I'm being paranoid about this future, but just wait as the Wal-Mart's, CVS's, and Walgreens' start to implement more technologies that will decrease pharmacist manpower needs. The pharms will be looking for new fertile areas to develop a niche in.

Anyways, I think I'm done with this discussion.

Thank goodness you're done! (Oh - btw...it is anyway - not anyways, which is the more rustic version of the written formal use of anyway. i get you are trying to convey - "in any case") -but, we digress.

All your medical student rheteoric & idealism is giving you a perspective which is not at all reality.

As I said before - you may live & exist in a place in which the PCP does the DM, HTN, lipid management of your patients on a continual 3-4 month recall. That does not happen where I live.

However, as much as you would like it to not be so - it is not so in real life & not just in the VA nor Kaiser. We all do medical therapy management.

All those physicians who are not participating in collaborative practice agreements? - Well, I just left a 10 hour shift of outpt practice with 20 patients, who, in which I utilized the parameters of my various cpas to provide medication to patients who needed it. Oh - who btw - the physicians are not avaible until Monday of NEXT week because of the holiday. So - I had to use the cpas's to dispense the medications, which the physicians either chose to ignore my refill requests or who decided to let me use my judgement. I chose to use my judgement since I have documentation to support it.

So - the physicians are taking time off - but, the patients still need medication & I've been able to provide it since I have a cpa to "cover" my adjustments - or not. Sometimes, I just continue which is more often than not the case since physicians don't often see the actual "need" to have a valid prescription to "cover" what is dispensed.

I don't have any CVS's near me, but I have Walmarts. I'd never refer any patient to a Walmart or any doc-in-box clinic. I've seen too many mistakes from those......often committed by poor hx from PA's!!!!

I think bananaface is mistaken "the most common protocols are for ec, flu shots & emergency contraception". That is not the case where I am.

I would agree the MTM agreements are for better patient care. No one wants your money. I actually gave 2 yellow fever waivers which took me 1-1/2 hours of counseling & actually dispensed NOTHING. I did not receive compensation for anything - I just gave the yellow fever waivers - but, only after extensive counseling & education of these patients. You might have received a medical office visit, but this couple could not get an appointment until 2 weeks after they were leaving on their cruise. I saw them within 3 days.

I could see them this weekend & I coud give them their waiver. Do I love it? No - but, it is part of my job. Apparently, part of your job you chose to let go for reasons which might be justified - might not - who knows? Its not for me to judge you - or for that matter, you to judge me for what I'm legally & professionally bound to do.

Now that you're gone.....go think about how accessible medical care really is. See how long it takes to get an appointment. You might be able to in your area within 2 months. That's just not possible where I live.

 

[bananaface]

What I listed for the most common protocols (just based on my exposure, obviously) were inpatient medication adjustments, flu shots, and emergency contraception. What is more common in your area?

 

[Taurus]

The people who are being identified and targeted for it (mostly by pharmacists in my experience - because they are more familiar with the service) are those who are having trouble managing their disease states despite regular visits with their physician.

Ok, one last post.

From what I have seen, the typical patients who have trouble managing their disease states are the ones who are non-compliant. It's amazing what regular exercise, dieting, and losing weight can do for people's health, but few follow what they are told to do. Then you have some people who won't even take their meds. The drugs we have today are very powerful and you would be hard-pressed to find patients who don't respond adequately. Furthermore, if a PCP is having trouble managing a patient's DM or asthma, do you think that the first thing that pops into their minds is a referral to a pharm? Of course not! Then I would send the patient to see a specialist like an endocrinologist or pulmonologist.

Let's be honest with ourselves. Is how a pharm manages a patient's drugs really any different than how a physician would do it? Do pharms know of some "special sauce" that enables them to have greatly better management than physicians? I really doubt it. Even if pharms have something up their sleeves, how hard would it be for physicians to learn it? It's just a matter of tweaking some drug dosages or picking different drugs or knowing that certain drug combinations work better.

Pharmacists are definitely pushing for an expansion of practice opportunities. The issue goes deeper than "money". Pharmacists are looking for a way to offer indispensible services and keep their jobs secure - just what you suggested they do in the face of dwindling reimbursements and so forth. MTM is an attractive niche for many pharmacists, because it currently isn't anyone else's turf.

So pharms are facing job insecurity and dwindling reimbursements and they need to find new niches to justify their existence. MTM is indeed scope expansion and it is far from being benign. Pharms are trying to expand into an area that is already crowded by physicians, NP's, and PA's. Unlike these groups, pharms are a huge disadvantage because they can't diagnose and therefore have to depend on one of those groups to feed them patients. Why on earth would any of these groups voluntarily refer their patients to a pharm and potentially lose future patient visits? Insurance companies or Medicare doesn't want to pay two groups to monitor the same patients for the same diseases. It's redundant and a waste of money for both a pharm and a physician to be managing the chronic conditions of the same patient.

Moreover, insurance companies or pharms can't force physicians into MTM agreements. With MTM or collaboration agreements, not only is there a strong likelihood that physicians will see fewer office visits by their chronic disease patients but physicians are also exposing themselves to liability if a pharm misses something during one of these visits and the patient has an adverse event such as an MI or stroke. By signing an MTM agreement, physicians are assuming medical responsibility, even if they never talk to or examine the patient and only have the assessment by the pharm. It's better to end the physician-patient relationship than to sign one of these agreements. If the physicians aren't on board, what will pharms do? Can they still get patients and how many patients would rather see a pharm over a physician?

You can't necessarily take what the VA is doing and apply it to the private sector. Those physicians are paid on a salary. Who does the treatment for the chronic condition is not as important to them as the private sector physician who earns his income for every patient visit. Routine office visits for chronic conditions is a significant part of any practice. If a practice loses just 10% of its patient visits, that might be enough for it to go out of business. Pharms should not think that physicians will stand by and do nothing if they start to see their patients being siphoned off.

Pharmacy students need to stop drinking the Kool-Aid that their schools are passing out. The schools are painting this rosy picture, but the reality is far from different. MTM is just another powergrab by yet another group dressed up in a fancy term. Physicians will see through this and just not support it. What then? If they don't initially see it, physician practices that begin to lose patients to MTM will spread word to other practices so that eventually most will avoid MTM.

The fundamental challenge of the MTM paradigm is that the service it offers is not really that different to what a PCP, NP, or PA does. I don't know of any physician who feels that he's not capable of addressing a patient's chronic disease states. In my opinion, pharms need to distinguish themselves more and provide a service that is so specialized that a PCP can't comfortably handle. There's a reason why PCP do consults to ortho, ENT, neuro, etc.

If pharms want to work in the outpatient setting, their best chance at success is to not compete with physicians for patients directly. They need to market themselves as drug consultants who go around to different practices and show physicians how they can best optimize the drugs. But based on what I've seen, I doubt that there is much demand for this type of service.

 

[genesis09]

The Illinois Medical Society is against anything which would expand the scope of practice of any other health care field. They were against NPs dependent prescription rights, pharmacists being allowed to vaccinate, and so on. The fact is recently more so than not, they've been loosing. In Illinois, pharmacists were able to get protocol prescribing because the two large pharmacy organizations stopped fighting each other.
The MTM codes are the only pharmacist CPT codes in existance at this point. The threshold for MTM for Part D varies by insurance. It averages about 3-5 chronic conditions. The population with 3 chronic diseases is very large in the elderly. How many times a day do we fill a person with a prescription for a statin, anti-hypertensive, and anti-diabetic?
Most community pharmacies are already at the bare number of pharmacists they need to stay open. For non-24 hour pharmacies, most of them need 2 or 2.5 pharmacists to operate. The 24 hour pharmacies need one extra pharmacist.
So many people go to many doctors and pharmacies and so things get lost in the cracks.
What I've been wondering about recently is which pharmacy chain will be the first to charge extra for counseling.

 

[Aznfarmerboi]

Tarus, I just want to say that I agree with you on many points. The only thing that I want to disagree with you about is automation. An automation does not take over a pharmacist's role. Lets remember that a computer is only as good as what the human end puts in. We are not only checking to make sure that the drug is right, no interaction between drugs, and so on, but what the doctor prescribed was right. In the end, the law stills require a pharmacist to double check everything and this is where we get out right to practice from.
In terms of getting physical, a physical is taken ultimately so we can DIAGNOSIS how the patient is doing. Obviously, that should be left to the physician (we were taught that from day 1. . . come on). I am getting compensated well for what i do. There is no need for me to give out flu shots or take blood pressure. In fact, nurses who get paid less are the ones doing it in the in store clinics.
With that being said, I do think we should compensated (a small amount) for what we already do for free. We give out emergency contraception, free counseling, free advice on meds ands otc recommendations, we spend (for me 1 hour at least, and 2 hours average) a day talking to patients over the phone on what to do with their meds, their disease state (smokking cessation, diabetes (we can sell insulin without prescription), etc), and so on. We dont get compensated for any of this. We are held liable for giving drugs to known alcoholics and them dying from it. A few people like macguyver . . . . might disagree that we should get compensated for it, but this is what most hosptail and inpatient clinic pharmacists are getting paid to do anyway.

In addition, if pharmacists were to take physicals and MTM, there would be laws that they have to follow to protect them. Hence a lawyer cannot say did you not detect this or that, as long as the pharmacist follows the protocol. However, I firmly believe that this is not within our scope.

 

[pharmacogenomic]

What I listed for the most common protocols (just based on my exposure, obviously) were inpatient medication adjustments, flu shots, and emergency contraception. What is more common in your area?

MTM does not cover acute inpt work - those of us who work as pharmacists just do that as part of our daily work & have for decades.

Outpt, outside of Kaiser & the VA....we do statin, htn pts with comorbidity (ie dm), seroquel with dosing>300mg/d, dm with >2 po drugs or insulin + 1 po drug in addition to immunizations, ec & travel medications (yellow fever, japanese encephalitis, meningococcal, antimalarials & antidiarrheals). There may be more.....can't think of them right now.

Yes - we do get compensated as outpt pharmacists. Not by the pt (unless they are getting travelers meds), but by the MTM company their insurance has hired to have us follow them.

It is in the insurance interests to have the pt managed better because historically their payments are reduced - even if they have to pay pharmacists to follow their patients. Some are followed weekly (seroquel), some less often, but at least monthly.

 

[OHMAN0125]

MTM does not cover acute inpt work - those of us who work as pharmacists just do that as part of our daily work & have for decades.

Outpt, outside of Kaiser & the VA....we do statin, htn pts with comorbidity (ie dm), seroquel with dosing>300mg/d, dm with >2 po drugs or insulin + 1 po drug in addition to immunizations, ec & travel medications (yellow fever, japanese encephalitis, meningococcal, antimalarials & antidiarrheals). There may be more.....can't think of them right now.

Yes - we do get compensated as outpt pharmacists. Not by the pt (unless they are getting travelers meds), but by the MTM company their insurance has hired to have us follow them.

It is in the insurance interests to have the pt managed better because historically their payments are reduced - even if they have to pay pharmacists to follow their patients. Some are followed weekly (seroquel), some less often, but at least monthly.

I remember when I grad from pharm school 3 yrs ago our Profs were pushing for this and then I saw how these clinics work during a rotation in my last yr of pharm school. All I have to say, I really hope things have changed since going to med school. Cont pushing on if you guys want, but please mandate more clinical training then. Right now the clinical training is a JOKE.

 

[genesis09]

At my school, Ambulatory care is a required clerkship, and one of the electives in Advanced Community, in which you do a lot of vaccinations, lipid tests, and that sort of thing.
There are several major ways to decrease healthcare costs. One is to decrease the amount you reimburse healthcare providers. Another is actually to encourage adherence because adherence is normally low. That at front is the more expensive option but long term, is more successful.