Trends in Collaborative Drug Therapy Management

Karen E. Koch, PharmD

Disclosures
In This Article

Liability, Education, Credentialing, Reimbursement

Providing CDTM has opened up a can of liability worms for pharmacists. Although there is currently no case law involving pharmacists who provide collaborative management, pharmacists with dependent prescriptive authority who exceed their authority are at great risk for liabilities.[39] Pharmacists are familiar with their liability for dispensing activities. They may not, however, be aware of (or insured for) the new liabilities associated with their new responsibilities, and they may not know that nonphysicians have been tried for making sexual advances (criminal) and for failing to promptly diagnose an impending heart attack (malpractice).[39]

Pharmacists practicing CDTM expose themselves to three different types of sanctions:

  • Administrative -- practicing beyond the scope of authorizing license, for which the pharmacy board can revoke or suspend the pharmacist's license.

  • Civil -- acting within the scope of pharmacy practice, but performing in a substandard fashion and, because of the malpractice, the patient has suffered harm.

  • Criminal -- practicing medicine without a license, unlawfully prescribing controlled substances, or committing Medicare or Medicaid fraud.[39]

The best ways for a pharmacist to avoid litigation are obvious: be well trained, act within protocol framework, document thoroughly, and don't let patients assume you are a physician. Pharmacists providing CDTM should check also with their malpractice insurance carrier about coverage for their expanded activities.

[30,39]

In Washington state, pharmacists automatically qualify for malpractice insurance for CDTM activities that are included in the scope of pharmacy practice.

[30]

Curriculum Changes

An often-mentioned objection (by other health care professionals) to pharmacists' having collaborative management authority is that pharmacists are not trained to provide this care. This objection is not without merit, because many pharmacists do not have advanced clinical training or experience. Collaborative management frequently requires the pharmacist to assess patients and make decisions about their care. This is a considerable leap in responsibility from making sure "the right patient received the right drug at the right time." It requires pharmacists to have analytical skills and good judgment, both of which are difficult to teach in our current passive-teaching, lecture format.

Active learning curricula, such as problem-based studies, will better prepare pharmacy students for analyzing data and making decisions. The best training comes from doing; pharmacy students should gain CDTM experience by working with clinical pharmacy preceptors in ambulatory care clinics and acute care settings. Pharmacists should also expand their physical assessment skills through well-designed training that may require more time spent in internships or specific postgraduate programs.

Many pharmacy schools are incorporating active learning and providing collaborative training for new graduates. They are also making this training available to former graduates through nontraditional PharmD programs by providing evening, weekend, and distance learning courses and flexible clinical rotation schedules. Since the pharmacist's responsibility for the patient changes, so does his or her relationship with the patient. Patients share more personal information with CDTM pharmacists and also have a greater dependence on them. Pharmacists need the psychological training necessary for this new responsibility.[39]

Compensation

How are pharmacists compensated for exercise of this extra skill and responsibility? In a managed care environment, CDTM pharmacists can work as other advanced-trained nonphysician health care providers (eg, nurse practitioners) who are often perceived as physician extenders. In a fee-for-service environment, pharmacists have three options: they can work as part of a physicians' group practice and file for payment under the physician's provider number, they can apply for their own provider number, or patients can pay cash for their services. In the first scenario, a pharmacist would file a "level 2" visit claim for a typical anticoagulation visit, and the reimbursement would return to the practice for which the pharmacist works.[31] Pharmacists who are not directly hired by the medical group or work independently in ambulatory settings (eg, retail pharmacy) would need their own provider number. For example, in Washington state, pharmacists have their own Health Care Finance Administration (HCFA) provider identification numbers and use them to bill for influenza and pneumococcal vaccines and their administration.[30]

Outcomes

Although there is ample literature supporting good outcomes when pharmacists provide CDTM,[18] there is relatively little evidence about the cost-effectiveness of these good outcomes in ambulatory care settings. Mississippi is currently working with HCFA on an 18-month project (implemented in May 1998) that will assess the clinical and financial outcomes of cases managed by pharmacists. In this project, patients are referred by physicians to pharmacists for management of one of the following disease states: asthma, hyperlipidemia, anticoagulation, or diabetes. The patient can have up to 12 visits per year with the pharmacist, for which the pharmacist receives a $20 reimbursement per visit.

Credentialing

In response to the questioning of pharmacists' skills and training is the movement to credential pharmacists who provide CDTM. Several of the major pharmacy practice and educational organizations are collaborating to examine this issue.[40] With the implementation of the HCFA demonstration project, Mississippi implemented a credentialing program for the four disease states that consists of three components: a disease-specific educational program; a 150-question disease-state specific examination administered by the NABP; and clinical skills evaluation. Each disease state requires separate certification, and once credentialed, the pharmacist receives a provider number that enables him or her to provide care to Medicaid patients.

CDTM and Managed Care

Although primary care has traditionally been provided by physicians, the rise in capitated contracts has resulted in the increased use of nonphysician providers such as nurse practitioners and physician assistants. Since pharmacotherapy is essential to managing a number of disease states, pharmacists also can play an important role, through CDTM, in delivering primary care in capitated contracts. For example, Saltiel[24] describes a cost-effective, pharmacist-based cardiovascular risk reduction clinic as part of a managed care group practice at the Cedars-Sinai Health System, Los Angeles. In addition, two managed care plans have already contracted with two of the ImPACT project sites to use the CDTM practice model for their health plans' covered lives.[29] CDTM permits pharmacists to meet a managed care organization's goals by providing cost-effective care and good outcomes.

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