The following column is written by Robert Mirsky, MD, MMM, FAAFP, president at Resilient HealthOutcomes Advisors, a seasoned healthcare executive who has held leadership positions at health plans and health systems, and a member of the Cureatr Strategic Advisory Board.
My experience working with pharmacists dates back to when I was a practicing family physician. Family medicine lends itself to team-based care: a collaborative, multidisciplinary model of care where we rely on all kinds of professionals to help our patients, including specialty physicians, nurse practitioners, physician assistants, social workers, and pharmacists, as well as peer coaches and family caregivers.
While pharmacists were not collocated with or integrated into my practice, I still interacted with them often, particularly when I had questions about dosing and drug/supplement-drug interactions, as well as guidance on appropriate medications for specific conditions in the context of multiple medical and mental health comorbidities. Our conversations helped lead to the best possible choice of medication regimens that would be the safest and achieve the best outcomes.
These conversations informed my first appreciation of the value of pharmacists — an appreciation that has only grown as so many new medications have been developed over the past 10 or so years. It has become essentially impossible for physicians to understand everything they need to know about so many medications and new indications.
When I began working at health plans, these interactions with pharmacists helped inform the way I endeavored to support primary care physicians in their practices. I wanted to build an ecosystem that sees team-based primary care practices as the center of care for patients.
In some of my health plan experiences, the pharmacy team and capabilities were well-developed and integrated. This was particularly the case when I worked in a Medicaid/special needs plan where we served members with multiple medical problems, behavioral health issues, and social determinants of health challenges who required extensive support. As such, leveraging a multidisciplinary care team — and one that included a pharmacy capability — was particularly impactful.
However, most health plans lack a fully developed pharmacy team or set of pharmacy capabilities. Those few that do have only helped me appreciate the value pharmacists bring to providers and patients and think about how to bring that set of capabilities to plans more broadly.
The Challenges for Retail Pharmacists
Unfortunately, outside of a health plan or health system with well-developed pharmacy capabilities, patients are likely to struggle to get the medication support they need. Patients used to be able to lean on their retail pharmacists for help beyond filling prescriptions. Not only are there simply not enough retail pharmacists to fill openings, but their prime directive — which is to fill prescriptions — takes up most of their workday. Retail pharmacists lack the bandwidth to spend time with patients where they could add significant value to a patient's full understanding of their conditions and medication regimen. Retail pharmacists usually also lack all the important data and information about their patients needed to effectively see the full picture that can only be obtained from a fully integrated electronic record.
Furthermore, when you think about the complexity of the various conditions and medication regimens as well as important factors like behavioral health and social determinants of health issues, it becomes an even taller order for pharmacists to support patients much beyond filling their prescriptions and pointing out obvious medication concerns.
At the same time, so many patients now get prescriptions delivered to their door, either because they took advantage of a retail pharmacy's shipping service or they ordered from an online pharmacy. While such access to 90-day fills and convenient delivery supports compliance in some ways, it is a lost opportunity for interaction with pharmacists.
All this adds up to the unfortunate situation where interactions that used to occur more frequently and in-depth between patients and pharmacists have become increasingly less frequent.
Enter the Clinical Pharmacist
The good news is we're seeing a different type of pharmacist filling these gaps in patient care, interaction, and support: the clinical pharmacist. Their job is not filling prescriptions. Rather, they have access to a vast array of clinical data and essentially all the medications a patient is taking. Armed with this information, the clinical pharmacist engages directly with patients at an optimal point in time in their care journey to help ensure medications prescribed are appropriate and safe.
This golden moment is often at a transition of care. Consider a patient who goes to the hospital or emergency room. They arrive taking certain medications, they get treated in those settings, and they usually come out with new prescriptions or changes to existing prescriptions. Then they go home and have all the other medications they were taking before they went into that facility.
It's at that transition after the patient has left the hospital or emergency room when they're home sorting through their old and new medications, that they need the most support. It’s at that golden moment where an interaction with a clinical pharmacist who will help reconcile all their medications with their current state of health is essential. Traditional settings typically lack the ability to provide this support, and we can no longer expect retail pharmacists to help address these needs.
The lack of medication support for patients challenges us to find ways to address these gaps. Undoubtedly, one of the most worthwhile approaches is to add clinical pharmacists to more care teams. Armed with extensive data on each patient’s conditions and medications, these professionals can spend the time to interact, understand concerns, and help educate patients on all aspects related to their medications. Clinical pharmacists then bring that information back to a patient's providers with recommendations for changes to the medication regimen.
Once any changes are made, the pharmacists double back to make sure the patient understands the reasons why they're taking those medications, what they should and should not be taking, at what dose and when, and what effects to expect. This robust approach will enhance the patient experience, improve outcomes, and avoid unnecessary trips to a physician or emergency room, as well as reduce the likelihood of readmission.
While many patients would benefit from the services and support of clinical pharmacists, the value they bring is particularly apparent when you think about our older population — those in their 70s, 80s, and beyond. They've had the experience of interacting with pharmacists in their local or neighborhood pharmacy. They developed a long history and trusted relationship with their pharmacists, who they very often knew by name and vice versa.
In the past, when these individuals went into the pharmacy, it was not just to pick up prescriptions and maybe do a little shopping. It was an opportunity for the pharmacist to gauge how the patient was doing, look at their medication history, provide instructions about medications, and deliver some of the other help I've described.
I believe many seniors long for the opportunity to spend time with a pharmacist because they know and have experienced what that relationship can do for them. Since we know this is not occurring in a retail setting much anymore, these clinical pharmacists can bring that set of capabilities back to the trusted pharmacist-patient relationship, and we can all reap the benefits.