Community Pharmacy Clinical Interventions: How
Pharmacists Can Improve the Cost Effectiveness and
Quality of Healthcare
Ted Williams
Pharm. D. Candidate
Oregon State University
Introduction
Healthcare practioners and administrators must collaborate to ration
resources to provide maximal healthcare services to the highest risk patients.
Significant effort over the past 15 years has been directed at treatment systems in
which physicians, nurses, and pharmacists work collaboratively to improve
outcomes. There have been several high profile projects conducted within large
healthcare systems (Kaiser, Cigna) and large self-insured entities (Asheville
Project). These projects have demonstrated that pharmacist-lead interventions
provide significant cost savings and revenue increases. Pharmacy residents have
been instrumental in demonstrating the applicability of these principles on a
smaller scale and in retail community settings. These intervention programs
have been slow to penetrate the community pharmacy culture. The focus of this
paper is to provide the community pharmacy manager insight into how large
scale project can be downsized to their practice. The business case for post
primary care physician (PCP) interventions will be made. Then the case for
pharmacist lead interventions will be presented, with an emphasis on how
students and resident pharmacists can act as cost effective agents of change.
Strategies for selecting a disease state to manage and keys to maintaining
profitability will also be discussed.
Why Interventions
The introduction of a pharmacy intervention program should be approached
as a business case. Both non-profit and for-profit organizations must be
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cognizant of finances. For-profit organizations have shareholders to answer to;
non-profit organizations must be going concerns if they are to continue
delivering services to the community. Any proposal for an intervention program
should be built on the cornerstone of cost benefit analysis. An organization’s
cash flow can be improved by either cost savings or revenue increases.
A meta-analysis of the research literature from 1996 to 2000 showed cost
benefit ratios of 2:1 to 17:1 with most being closer to 5:11. Most of these studies
focused on increased revenue, rather than cost savings. Many studies also
neglected to consider the cost of the intervention services provided. The studies
surveyed nonetheless demonstrated that pharmacist interventions can produce
cost benefits in the areas of 1) Drug Cost, 2) Morbidity and Mortality 3) Cost of
hospital care.
Cost savings from interventions depend upon the nature of the pharmacy
and how they fit into the healthcare organization. Integrated health systems,
insurance companies, self insured companies, or any entity interested in
reducing healthcare costs across delivery channels will be interested in pharmacy
interventions. Drug misadventures, either drug-drug interaction (DDI) or
adverse effect of drugs, costs at least one dollar in damage control for every
therapeutic dollar spent2. The disease states best suited for interventions will be
discussed later in this paper. Chain and independent community pharmacies do
not reap the benefits of reductions in overall healthcare costs. Community
pharmacies must build their case on creating new revenue streams without
incurring significant cost increases.
Pharmacist provided intervention services for Medicare Part D are one of the
most exciting opportunities for pharmacies to bill for and expand clinical service
offerings. Medicare Part D mandates any provider of Medicare drug benefits
programs to provide Medication Therapy Management (MTM) services to high
risk patients.3 The reimbursement guidelines lack specificity, complicating cost
benefit analysis. One study focused on designing a fee schedule for MTM
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services based on CMS guidelines for payments and expected pharmacy costs2.
This study demonstrated a positive cost benefit ratio for moderate to severe
interventions, but not for mild interventions. Only counseling sessions lasting
over 15 minutes, provided direct economic benefit.2 Patients interested in these
services were willing to pay the out of pocket fee in order to obtain the service
when insurance plans did not cover the cost. A study conducted by Kaiser
Permanente indicated that their pharmacists could conduct counseling services
from 3 to 9 minutes while maintaining a positive cost benefit ratio.4 These
studies indicate that patient counseling may have a positive revenue impact
under certain circumstances.
Another motivation for community pharmacies to provide intervention
services is the level of professional satisfaction experienced by the pharmacist.
One study reported the overwhelming majority (88.5%) of pharmacists involved
in hyperlipidemia interventions reported being “very satisfied” with their
professional role and additional 11.5% reported being “satisfied” with their
professional role.5 In an era of pharmacist shortages, generating employee
satisfaction may be enough motivation for community pharmacies to provide
intervention services.
Who Intervenes
The choice of who conducts the intervention depends on several factors: cost,
expertise, accessibility. Pharmacists are not the only healthcare professionals
qualified to conduct intervention services. The salary difference between case
management nurses ($50k/year)6 and pharmacists ($90k/year)7 makes nurses a
less expensive alterative to pharmacists. Medicare Part D also leaves the door
open for reimbursement of nurse-lead MTM services. Integrated healthcare
systems must therefore weigh the costs and benefits of nurses acting under the
supervision of a pharmacist vs. a pharmacist conducted system. Several models
address cost issues by leveraging resident and intern pharmacists. There do not
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appear to be any studies directly comparing the efficacy and cost: benefit of
nursing directed and pharmacist directed interventions. This may be an area of
interest has Medicare Part D goes into effect.
A study of nursing interventions for asthma patients proved effective in
reducing indirect costs, direct cost as well as lost school and work time in asthma
patients.8 These interventions included drug reviews and patient education on
how, when, and why to use their medications. One soon-to-be published study
found that nurses working in a collaborative team with physicians and
pharmacists, nurses could also effectively reduce the HA1C levels of diabetes
patients.9 These data strongly suggest that pharmacists may not be suited to all
types of interventions.
The accessibility of community pharmacist is a compelling factor when
deciding who should deliver intervention services. The medication-centric
clinical experience and training of pharmacists makes them uniquely qualified
for interventions involving 1) complex medication management, 2) high risk of
side effects, and 3) high risk of drug-drug interactions (DDI)10. The 30 day refill
paradigm also increases the frequency of pharmacist patient interactions when
compared to the monthly or semi-monthly interaction common in intervention
programs. 8,10,11,12,13 The clinical pharmacist also has a strong influence on the
prescribing patterns of physician.2 When the pharmacist works in the same clinic
as physician, few, if any of the pharmacist’s recommendations are rejected. 2 At
least one study suggested that pharmacists work as well, if not better than nurses
when managing complex drug regimes.10 Another meta-analysis found that
physician or pharmacist directed diabetes programs had the greatest effect on
outcomes.14 When physician concordance is critical and clinician accessibility is
limited, pharmacist interventions may be indicated.
Pharmacy interns and residents are important agents of change for a variety
of interventions. Resident’s often publish the results of the projects in the
pharmacy journals like the JAPhA. But non-resident initiated projects also
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leverage the enthusiasm and cost savings of student pharmacists. One
cardiovascular wellness program used residents to establish the treatment and
administrative protocols.15 The resident’s lower salary kept the project’s cost:
benefit ratio above one despite the start up costs. Ongoing interventions will be
cost effective with either a resident pharmacist or a staff pharmacist.15 Pharmacy
interns also are more inclined to reach under served communities and can
provide significant cost savings for conducting basic screenings.16,17 One of these
studies developed a mobile screening clinic/service which generated over
$70,000 in revenue. 16 These studies demonstrate the cost and clinical
effectiveness of student pharmacists in wellness and disease state management
programs.
Despite a general consensus among community pharmacists that there is a
need and a benefit for interventions, only a small portion of pharmacists are
interested in setting up intervention services in their pharmacies.18 The barriers
cited to setting up intervention services were time (47%), staff (18%) and
reimbursement (8%). One resident set about solving these problems by
redesigning the workflow of a community to use existing staff and time to
conduct interventions.19 The project was able to create a clinical pharmacist
position without increasing personnel or time while generating a positive cash
flow. This suggests that the perceived barriers to providing clinical services in a
retail setting may be a function of perception rather than a function of resources.
This fresh perspective on old problems is yet another benefit of student
pharmacists.
Most pharmacy colleges support, if not require, student involvement in
wellness programs.20 Although the skills of first and second year pharmacy
students are limited, they have been effective in screening and basic counseling
activities, when supervised by pharmacists. 17 These early clinical experiences
build the skills pharmacist will need to conduct interventions after graduation.
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Employing pharmacy interns provides financial benefits for pharmacies and
invaluable experience for interns.
When to Intervene
Delivery of healthcare is not exempt from the basic economic principle of
scarcity. Every patient chart cannot be meticulously reviewed for all possible
lifestyle, pharmacological and complementary/alternative medicine (CAM)
complications. Healthcare administrators must ration scarce resources to
provide maximum benefit to the most vulnerable patients. The APhA
recommends using the criteria in

Figure 1 to determine which cases

require MTM services. This


analysis will only consider the
three most severe disease states of
cardiovascular disease, diabetes,
and asthma.
Three studies published in the

last five years demonstrated the
benefits and variations in

interventions for cardiovascular
disease. Project ImPACT

produced impressive (90%)

persistence and compliance in

treatment of 397 patients.5
Pharmacists spent 30 to 60
Patient is referred for MTM services by a
healthcare provider.
Patient is receiving medications from multiple
prescribers
Patient is on four or more chronic medications.
Patient has at least one chronic disease (e.g.,
o congestive heart failure,
o diabetes,
o hypertension,
o hyperlipidemia,
o asthma,
o osteoporosis,
o depression,
o osteoarthritis,
o chronic obstructive pulmonary disease
Patient has laboratory values outside the
normal range that could be improved with
medication therapy.
Patient has demonstrated non-adherence to
the medication regimen for more than three
months.
Patient has issues of limited health literacy or
cultural differences, and intensive
communication is needed to maximize care.
Total monthly cost of medication exceeds
$200.
Patient has been discharged from a hospital or
skilled-nursing facility within 14 days and
prescribed a new medication regimen.
Figure 1. Considerations for MTM interventions
from the APhA
minutes with patient on their
initial visit, and 10-30 minutes on
follow up visits. The significant time investment was related to the severity of
their condition. These time investments should make such services compatible
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with CMS guidelines for billing for MTM services as part of Medicare Part D. 2 A
significant portion (62.5%) of Project ImPACT patients reached their target lipid
levels. The SCRIP study demonstrated similar goal achievement rates (57%). 21
The SCRIP study also had significant patient-pharmacist interactions at weeks 2,
4, 8, 12, and 16. A follow up to the SCRIP study, the SCRIP-plus study,
demonstrated important differences in counseling and outcomes. SCRIP-plus
noted lower levels of adherence and lipid level achievement.21 Some of these
variations may be due to the different durations of the studies. One important
difference may be that the SCRIP-plus study conducted patient interviews at
week two and six by telephone and in person during the third and sixth months.
These differences suggest that the quality and quantity of the intervention is
associated with successful interventions. This observation is consistent with the
assertion that the availability of pharmacists for face-to-face contact makes them
invaluable for interventions.
These cardiovascular interventions have been replicated on a smaller scale in
a community pharmacy intervention program coordinated by a resident.15 This
project used two community pharmacists (one staff and one resident) to serve a
single self-insured company of 107 employees with only 36 patients qualifying
for interventions. The start-up costs during the first year of the program were
offset by the reduced salary of the resident. Per patient savings for the self
insured company for the second year of the project were projected at $1,265$2,905, depending on the compensation for the staff pharmacist which would
replace the resident. The pharmacy benefited from the increased revenue
generated by the intervention services. This study demonstrated a cost effective
model for community pharmacies to provide intervention services to small self
insured companies.
The quintessential diabetes intervention project is the Asheville Project.22
This five year study demonstrated the ability of a pharmacy driven medication
therapy management projects to reduce direct and indirect employer costs. Of
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interest to community pharmacists, total prescription costs increased between
$1,500 and $2,200 dollar, per person, per year. This is a significant benefit for the
pharmacy. A meta-analysis of diabetes intervention programs identified the
most common patient perceptions as barriers to adherence to best practices:14

Diabetes not considered a serious disorder

Aggressive treatment will not prevent problems

The treatment/lifestyle protocol is too inflexible
An additional barrier identified was the clinician’s view that the patient would
not adhere to the presented guidelines. The study also found the physician or
pharmacist lead programs showed the greatest effectiveness.
Two studies of asthma treatments programs in different settings produced
reductions in direct and indirect costs. 8,13 The PRICE clinic study in Sacramento,
CA is the more interesting of the two for addressing the community pharmacy
delivery model. The PRICE clinic has developed a model that will be easily
adaptable to the requirements of Medicare Part D reimbursement. This clinic
relied heavily on student pharmacists, but did not rely on charitable donations.
The clinic reduced out-of-pocket costs for patients by increasing use of generics
from 51% to 56% of total prescriptions. The PRICE clinic was able to stay
profitable without MTM reimbursements serving Medicare patients. It therefore
stands to reason that the additional revenue from consulting services would
make asthma services viable in a for-profit community pharmacy as well.
Where to Intervene
The location of the pharmacist in relationship to both the patient and the PCP
has a significant impact on the effectiveness of the intervention. Clinical
pharmacy interventions in community settings have been present in HMOs like
Kaiser Permanente for over ten years.23 The accessibility of pharmacists makes
them ideal for face-to-face interventions. Recent literature has explored different
mediums of communication between pharmacists and patients. This discussion
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will focus on innovations to the location and medium pharmacists and
pharmacies use to conduct interventions.
Telephone interventions by pharmacist have been used effective for a variety
of disease states. Three telephone counseling sessions over 6 months for patients
on antidepressant medications reduced discontinuation from 49% in the control
group to 30% in the experimental group.11 Patients in this study demonstrated a
better understanding of their medication’s mechanism of action and how the
medication fit into their overall disease state management strategy.
One study considered the preferred method of recruiting patients with a high
risk of cardiovascular disease for intervention services.24 The study found that
significantly more patients attended when invited by telephone (72.3%) vs.
invited by mail (44.0%). These results make intuitive sense when compare to the
results of telephone vs. in-person intervention success rates discussed above.
There is an apparent relationship between the level of intimacy of the
intervention and the success of the intervention.
Wellness programs are often taken out of the clinic and into the community.
These programs can be highly effective for revealing undiagnosed disease states
and as sources of revenue.16 Such programs are particularly well received when
the clinics provide services, such as bone density screenings, that are not
commonly available.16 Community and senior centers are generally receptive to
providing facilities for screening and brown bags. Pharmacy colleges often use
their teaching facilities to provide these services.20 Wellness clinics provide cost
effective, readily accessible services to the community.
Intensive disease state management services requiring extensive medical
history evaluations are best conducted in a clinic. 10,17 When a pharmacist can
work in the same clinic as the PCP, there is greater physician and patient
concordance with pharmacist recommendations.10 One study attributed their
near complete physician deferral to the recommendations of the pharmacist to
the trust developed between the physician and the pharmacist.10This assertion
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suggests that the key to an effective clinical pharmacy practices are building
relationship between both the PCPs and the patients.
One study went so far as to create a computer system to guide call center
personnel to conduct interviews to predict adherent and non adherent patients.12
The system was able to correctly predict over 80% of adherence and
discontinuation.
Conclusions
Possessing the requisite clinical skills does not guarantee pharmacists a role
in patient care. Our profession must stay focused on delivering measurable
economic and clinical results. As individuals we must aggressively pursue
opportunities and leverage new and existing technology to deliver our services
effectively to the broadest patient base at the lowest cost. Community
pharmacists must follow the lead of healthcare pharmacists to forge relationship
with primary care physicians so we can improve the quality of life of our
patients. Pharmacies that challenge the notion that only large managed care
organizations like Kaiser Permanente can deliver cost effective clinical services
have reaped the professional and economic benefits of providing these services.
Student pharmacists should be instilled with a sense of purpose; they are the
agents of change. Resident and intern pharmacy student have fresh ideas and
enthusiasm to guide the profession into a future focused on clinical care, not just
distribution.
References
1
Schumock, G.T., et al. Evidence of the Economic Benefit of Clinical Pharmacy Services: 1996–
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2
The Lewin Group. Medication Therapy Management Services: A Critical Review. JAPhA
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3
American Pharmacists Association. Medication Therapy Management Community Pharmacy
Practice: Core Elements of an MTM Service Version 1.0. April 29, 2005. Available at
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http://www.aphanet.org/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&Co
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4
Oh, Y., McCombs, J.S., Cheng, R.A., Johnson, K.A., Pharmacist Time Requirements for
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5
Bluml, BM, McKenney, JM, Cziraky, MJ. Pharmaceutical Care Services and Results in Project
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9Bray
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10
Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Proactive Case Management
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11
Rickles, N.M., Svarstad, B.L., State-Paynter, J.L., Taylor, L.V., Kobak, K.A. Pharmacist
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Berger, B.A., Liang, H., Hudmon, K.S. Evaluation of Software-Based Telephone Counseling to
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Suh, D., Shin, S., Okpara, I., Voytovich, R., Zimmerman, A. Impact on a Targeted Asthma
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14
Knight, et Al. A Systematic Review of Diabetes Disease Management Programs. The American
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15
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16
Stratton TP, Williams RG, Meine KL. Developing a Mobile Pharmacist-Conducted Wellness
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17
Stebbins, M.R., Kaufman, D.J., Lipton, H.L. The PRICE Clinic for Low-Income Elderly: A
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18
Law, A.V., Okamoto, M.P., Chang, P.S. Prevalence and Types of Disease Management
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Pai, A.K. Integration of a Clinical Community Pharmacist Position: Emphasis on Workflow
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Deshpande, A., Wade, W.E., Johnson, T., Franic, D.M. A Survey of Pharmacy Student
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21
Tsuyuki, R.T, et al. A Randomized Trial of the Effect of Community Pharmacist Intervention
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22
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23
Johnson KA, Nye M, Hill-Besinque K, Cody M. Measuring of impact of patient counseling in
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24
Karwalaitys, T, Kaczorowski, J., Chambers, L.W., et al A random trial of Mail vs. Telephone
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