Collaboration with Pharmacists after graduating
Coming from a pharmacy background (3rd year UBC pharmacy student), there is a lot of talk about the expanding roles of pharmacists to further enhance patient outcomes through collaboration or other expanded pharmacist roles. One example of the expanded role can be seen by a trial of 50 pharmacists working collaboratively with physicians to enhance patient outcomes.
My question, as a medical student, how is this topic of working collaboratively with pharmacists perceived amongst other medical students?
We would be thrilled to work with pharmacists. However conversations with current physicians the current issue of who pays the pharmacist. Also what is the role pharmacist see themselves on the team?
Let's say that there is a family doctor clinic - the family practitioner can either have 1) a pharmacist who either has to be paid by the physician or by temporary government funding [your link] or 2) family doctor can hire a general internist who is paid by MSP, has a wealth of experience dealing with complex cases including medications AND internists can independently change medications/ prescribe medications without the family doctor taking on the responsibility?
I totally see where you are coming from. Payment is a major obstacle for collaboration. So hypothetically, let's say payment is not an issue (and not cumbersome for the physician in anyway) and pharmacists can prescribe for minor ailments. With these obstacles (payment and responsibility) more or less taken care of, can you see the potential for greater utility in collaboration with pharmacists (medication experts)?
You highlight some great points and payment is definitely a common concern that comes up in conversations about collaboration. I’d like to offer a different perspective on your scenario about hiring either an internist or a pharmacist. When you hire an internist in your office, you will run into problems with MSP paying 2 physicians to see the same patient, especially on the same day. They will either disallow it or this would result in audits. I’m assuming that you mean an internist who has specialized beyond being a general practitioner. Pharmacists are a lower cost resource than an internist physician and can help you to enhance your practice, gain greater job satisfaction, practice to your full scope without being bogged down by less impactful tasks, and help you to optimize care and treat more patients. By being able to treat more patients and having pharmacists bill Pharmacare for medication reviews, you might even make more revenue while optimizing your patient’s care.
Pharmacists are specialized in drug therapy and management and have spent 4 years or more learning about drugs. As part of the healthcare team, pharmacists focus on optimizing drug therapy. This includes deprescribing medications that are no longer needed (sometimes requiring a specialized taper and guiding the patient that could take days to months), choosing the best possible medication for an individual patient, maximizing the efficacy of drug therapy while minimizing side effects, and ensuring the drug is compatible with the patient’s coverage and financial situation. For example, did you know that there are 47 different molecules that lower blood pressure? Most physicians do not know all of these molecules and their unique characteristics while most pharmacists will. In real life, physicians prescribe the antihypertensive that is most familiar to them rather than selecting one of the 47 molecules that is best suited to the individual. Knowing the nuances and differences among these molecules allows the pharmacist to work with the patient and the healthcare team to make the best possible selection for the patient. For a drug you could be taking for the rest of your life, wouldn’t you want the one that is best for you as an individual? I believe that this is the value that pharmacists bring to the healthcare team.
Pharmacists have been trained in therapeutic drug monitoring and the new grads have been taught how to monitor drug efficacy and safety using physical assessment tools. By involving pharmacists in a family doctor clinic, physicians can spend more time seeing patients and focus on diagnosis without wasting time on drug coverage, medication consultations, and drug monitoring that could be done by a pharmacist. Nurses are currently employed in many family doctor clinics, why not pharmacists?
Some people have doubts about this type of practice model, but I know that it is possible because I’ve seen it in action at BioPro Biologics Pharmacy in collaboration with Artus Health Centre. There are few clinics doing this now, but I think we’ll see an increase over the next several years.
Alyssa Low (2nd year pharmacy student)
There is a msp billing code 10004 for $46.23 that can be billed on the same day on top of their regular visit if an allied health professional was consulted ( > 15 minutes) which is probably the only direct revenue for the physician.
I do have couple questions about the pharmacare billing model.
Billing medication reviews/follow ups/flu shots are hit or miss as not all patients qualify. Biopro deals with complex rheumatology patients who are likely on multiple meds, but your average walk in or primary care clinics probably don't have the same patient population. Additionally, in most clinic that have the same set up, the pharmacist would pre-screen for eligible patients and try to book them all in the same day/ couple hour time frame. The pharmacist would only be on site for ~1 day per week and its not sustainable to employ the pharmacist on full time basis if thats the only source of revenue that the pharmacist brings. Most places that have this kind of set up the pharmacist are there mostly for other interests such as attracting more new patients for their pharmacy and make money dispensing their medications down the road. Since the physician cannot take a kickback from the pharmacist/pharmacy for their billings their direct financial gain is very limited. If they just want to employ someone to do the grunt work why not just employ an desperate IPG medical grad who can't get a residency and is willing to work for half your wage?
Fun note: the managing pharmacist for biopro also quit and went into med school 😀
Good points. May I offer rebuttals? I want to clarify that my position is that pharmacists, both community and hospital, are valuable. I am focusing on the points about expanded scope of practice for pharmacists plus funding and practicality. Especially regarding ChasePharmUBC2020's post regarding the 50 pharmacists in community GP clinics.
1. "Pharmacists are a lower cost resource than an internist physician and can help you to enhance your practice, gain greater job satisfaction, practice to your full scope without being bogged down by less impactful task"
Pharmacists cost about $50 per hour. A medication review is $70, can only be billed every 6 months, only if no other pharmacy has billed it, and is paid by government directly to the pharmacy, and only if patient has 5 prescription medications.
Andrea Yeung brings up a good point - "Since the physician cannot take a kickback from the pharmacist/pharmacy for their billings their direct financial gain is very limited." How can the clinic make enough to pay the pharmacist when the pharmacy will take a cut and pharmacy can't pay the clinic due to how it looks? Or the pharmacist is there for 'free' paid by the pharmacy?
Plus internists can bill MSP independently for every patient they see with no such restrictions [other than the patient is complex] and have almost 10 years of schooling + research + fellowship.
For pharmacists via general practice it's actually MSP 13005 - Advice about a patient in Community Care $15.05 and "This fee may not be claimed in addition to visits or other services provided on the same day by the same physician for the same patient". So what incentive will the physician
However MSP 10004 for $46.23 - ii) All specialists involved in the conference may each independently bill for this fee - so the comment regarding "you will run into problems with MSP paying 2 physicians to see the same patient, especially on the same day" is unfortunately not true regarding audits.
2. "Most physicians do not know all of these molecules and their unique characteristics while most pharmacists will" - True statement - however again a General Internist is by no means inferior to most pharmacists when it comes to drug therapy especially as they are the consult for complex cases in hospital.
3. Knowing the nuances and differences among these molecules allows the pharmacist to work with the patient and the healthcare team to make the best possible selection for the patient. For a drug you could be taking for the rest of your life, wouldn’t you want the one that is best for you as an individual? - You're absolutely right and it sounds like you have the patient's best interest at heart. In hospital there is a formulary and all drugs are mostly auto-subbed to a representative drug within its drug class such as ramipril or amlodipine. This formulary is regularly reviewed by hospital pharmacists and for the most part it is deemed that within these commonly prescribed medications and in their drug classes the mortality and morbidity benefit is negligible enough that all patients are switched unless a reason is noted. This system seems to work really well and as a counter point this system should be applied to the community where it can lead to cost savings for the vast majority of patients without affecting their health and perhaps the 47 different blood pressure medications should be reduced down to 10 at most. For example there seems to be no meaningful difference between cilazapril and quinapril. Plus I believe pharmacists in the community can adapt and change the 47 meds for hypertension already and get paid for it. It seems collaboration is already underway and I'm confused why pharmacists need to be paid by physicians in clinic.
4. "Nurses are currently employed in many family doctor clinics, why not pharmacists?" - LPNs are cheaper than pharmacists, unless pharmacists are willing to be paid around $25 - $30 per hour, and also count as "allied health professionals" for billing.
5. "By involving pharmacists in a family doctor clinic, physicians can spend more time seeing patients and focus on diagnosis without wasting time on drug coverage, medication consultations, and drug monitoring that could be done by a pharmacist." Correct me if I'm wrong but isn't this the current role of the pharmacists in the community? Why would the clinic need to pay for one more pharmacist for a redundant process?
Again. I want to iterate that pharmacists are very valuable to the healthcare team but I don't agree with 1) paying them out of the clinic's limited budget and 2) having a redundant position. I could employ a physiotherapist who is incredibly valuable to the healthcare team but what would be accomplished that a regular physiotherapy clinic cannot do?