Touro Scholar

Faculty Publications & Research of the TUC College of Pharmacy College of Pharmacy

2015

Inserting Pharmacists in Primary Care Roles in an Ambulatory Care Setting

Keith Yoshizuka Touro University California, [email protected]

Katherine K. Knapp Touro University California, Touro College of Pharmacy (New York), [email protected]

Patricia A. Shane Touro University California, [email protected]

Debbie H. Lu Touro University California, [email protected]

Follow this and additional works at: https://touroscholar.touro.edu/tuccop_pubs

Part of the Pharmacy Administration, Policy and Regulation Commons

Recommended Citation Yoshizuka, K., Knapp, K., Shane, P., & Lu, D. (2015). Inserting pharmacists in primary care roles in an ambulatory care setting. California Journal of Health-System Pharmacy, 27(1), 15-28. Inserting Pharmacists in Primary Care Roles in an Ambulatory Care Setting

KEITH YOSHIZUKA, PHARMD, MBA, JD, FCSHP, KATHERINE KNAPP, PHD PATRICIA SHANE, PHD, MPH, DEBBIE LU, PHARMD, MPH PHARMACISTS IN PRIMARY CARE

arely are health system administrators not concerned with finding adequate financial R resources to provide quality care to the communities they serve. The Patient Protec­ Requests for Information: tion and Affordable Care Act (PPACA) promises to bring more patients to hospital doors Keith Yoshizuka, PharmD, MBA, while, at the same time, reducing reimbursement for their hospitalization costs. The Center JD, FCSHP for Medicare and Medicaid Services (CMS) threatens reduced reimbursement for rehos­ Asst. Dean for Administration pitalization of patients within 30 days for similar diagnoses. To further exacerbate these Chair, Social, Behavioral, and Adm inistrative financial pressures, the lack of primary care physicians forces hospitals into competition Sciences for physician services they can ill afford. What can be done? Touro University - College o f Pharmacy [email protected] In this report, we suggest how pharmacy personnel may be used to alleviate some of the pressures currently impacting health system administrators. We look back to the role(s) of the hospital pharmacy and the hospital pharmacist historically and outline changes that have occurred and how these changes may be helpful to address several problem areas in the ambulatory care venue. The American College of Clinical Pharmacy defines clinical pharmacy as “a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention.”1 Clinical pharmacists assume responsibility and accountability for achieving therapeutic goals in all areas of pharmacy including critical care, anticoagulation, cardiology, geriatrics, immu­ nization, infectious disease, nephrology, neurology, pediatrics and oncology. They serve as consulting pharmacists for long-term care facilities to ensure patients are receiving optimal medication therapy. They manage patient therapy in direct patient care settings working under protocol for conditions such as diabetes, anticoagulation management, immunization, and oncology/chemotherapy management. Hospital pharmacies were historically sites for procuring medications and managing medication orders. Clinical pharmacy in hospitals was spawned by the expansion of new and expensive medications and the need for monitoring medications with possible serious side effects and/or very high costs. The clinical pharmacist often needed to be at the bedside thereby moving pharmacy for the first time out of the (usually) basement-based pharmacy and onto the hospital’s service units. The presence of pharmacists “on the floors” has gradually led to integration of pharmacists into the hospital healthcare team. A significant benefit of this shift is the presence in California of a larger cohort of pharmacists with clinical skills who can be mobilized to fill new roles that require clinical expertise.

Hospitals Utilization of Clinical Pharmacists: We now see smaller units, including hospitals, building clinics that offer other out-of-hospital services for high risk patients in order to make financially and clinically feasible strategies for sustained, successful operation. The role of pharmacists in these expanded operations is one factor to be considered as these models are rolled out. For example, in 2009 Jack et al piloted an

January/February 2015 California Journal of Health-System Pharmacy cjhp 15 Pharmacists in Primary Care

intervention at San Francisco General for patients with chronic illnesses in order Hospital and Trauma Center to test to retain a patient base. The emergence of the effects of a care transition program clinics to provide care for patients with designed to minimize hospital utiliza­ common, chronic medical conditions tion after discharge. The intervention like diabetes began, not surprisingly, in included a clinical pharmacist calling organizations like the Veterans Admin­ patients 2 to 4 days after discharge to istration and Kaiser Permanente where reinforce the discharge plan and review the organization had an obligation to Clinical pharmacy in medications. The authors found that care for a defined population on a fixed participants in the intervention had budget. These organizations were also hospitals was spawned a significantly lower rate of hospital the first to place pharmacists in clinic by the expansion of utilization and hospital utilization settings alongside physicians and nurses cost savings that averaged $412 per to help patients maintain health and new and expensive discharge as compared with those avoid complications. These efforts were medications and the receiving usual care.2 Kern Medical successful and have become a permanent Center’s utilization of clinical pharma­ feature of the care package. In a recent need for monitoring cists is another example of a community publication by Hill et al, for example, the medications with hospital tapping into existing healthcare authors described the comprehensive resources to improve health outcome ambulatory clinical pharmacy services possible serious side and reduce healthcare cost. Kern that are available at Kaiser Permanente Medical Center is a 222-bed acute care Colorado (KPCO).4 KPCO has approxi­ effects and/or very teaching hospital owned by Kern County mately 530,000 members and 150 clinical high costs. in Bakersfield, California. It has affili­ pharmacists who provide clinical phar­ ations with UCLA and UCI Schools of macy services. The primary roles of the Medicine and USC and UOP Schools of clinical pharmacists in these settings were Pharmacy. Pharmacists at this medical to assist providers in optimizing medica­ center provide services including tion therapy to improve clinical outcomes diabetes management, anticoagulation while minimizing the total costs of care.2 management, blood pressure manage­ Clinical pharmacists at Kaiser Perma­ ment, oncology services, and smoking nente work in a wide variety of service cessation program. Overall, 32% of areas including asthma/allergy, behav­ patients in the Medicine Clinic are seen ioral health, gastroenterology, infectious by a clinical pharmacist. An evaluation disease, inpatient, nephrology, cardiology, of the KMC’s Pharmacy Diabetes Clinic diabetes/endocrinology, dementia care, indicated that the services provided by and emerging area of continuing care.2,5 clinical pharmacists assisted patients in A 2011 Report to the Surgeon General meeting clinical guideline for Ale, blood provided extensive documentation of the pressure, and cholesterol level goals.3 value produced by pharmacists working in clinic settings. Oncology is an area Changes in the Hospital where pharmacists have started their Environment: The Emergence services in the inpatient setting and tran­ of Clinics sitioned into the ambulatory care setting. The historic successful co-existence of As oncology treatment migrated from office-based physicians, medical groups hospitals to infusion centers and other and hospitals was based on the ability of ambulatory care settings, pharmacists each entity to succeed independently with were hired into these outpatient settings relatively non-binding relationships with to prepare medications, dose, and manage other entities. The emergence of health symptoms related to chemotherapy. plans and changes in reimbursement Today there are over 1,600 pharmacists structures forced hospitals to vertically who are Board certified in oncology.7 integrate, adding services such as clinics

16 cjhp California Journal of Health-System Pharmacy January/February 2015 Pharmacists in Primary Care

Safety Net Clinics Median 2012 annual salaries before One of the factors limiting the incor­ benefits as reported by the Bureau of poration of clinical pharmacists into Labor Statistics (BLS) are: physicians the multi-disciplinary care team in the ($187,200), registered nurses ($65,470) clinic setting is the financial burden, as and pharmacists ($116,670).8’9,10 The pharmacists are not reimbursed for their relatively high pharmacist salaries and services by third party payers. Recog­ reimbursement issues (discussed in nizing the important role that clinical other sections) have caused hospital pharmacists play in patients’ health, administrators and others to demand particularly underserved populations financial justification for adding with complex medical conditions, many pharmacists to clinics. While there is colleges of pharmacy have developed abundant evidence of both financial and partnerships with community medical clinical value of clinical roles for phar­ clinics to enhance the pharmaceutical macists in clinics; much of the evidence care in these populations. Examples of comes from governmental or managed this include community partnerships care organizations. Different business between the University of Southern models and circumstances often make California School of Pharmacy and the this justification a required step prior Los Angeles County community clinics,2 to adding pharmacists. Their justifica­ Touro University and San Francisco tion is generally based on demonstrating General Hospital and Trauma Center, reduced overall patient utilization of LifeLong Medical Care, and Clinic Ole expensive services (hospital and emer­ in Napa. The pharmacists in these clinics gency department use) and savings provide clinical services including, but on expensive medication use. Experi­ not limited to, a review of the patients menting with pharmacist roles is often medication experience, updating an initial step. Many organizations medication allergies and adverse reac­ experiment with new roles for pharma­ tions, reviewing medication history and cists by adding a pharmacy resident(s). current medication record for indication The resident’s salary cost is less (approxi­ for use, product, dose, duration, and how mately $46,000-$48,000 annual salary) the medication is actually being taken. and residency training is highly oriented Pharmacists also review active drug to experimentation and data collection. therapy problem lists and therapeutic Pharmacy residencies generally last treatment plans for appropriateness, one year—sufficient time to integrate effectiveness, safety, and medication into a service and observe the impact. adherence for vulnerable population in There are many examples where data- safety net clinics. driven, successful residencies result in converting the residency position to a staff position. (Residency training Considerations for Placing programs are described below). Pharmacists in Ambulatory Care (am care) Clinics Generally, adding pharmacists to clinics Available evidence cited above suggests occurs in the setting of existing clinics that when a hospital decides to initiate run by physicians overseeing nurses or expand ambulatory care clinics as who work directly with patients (case part of its service package, it is logical management). Pharmacists are often to consider a role for pharmacists. The introduced into this traditional model principal issues to be considered when by initially working as a consultant to moving in this direction are 1) financial the nurses for patients with complex considerations and 2) establishing a medication regimens. Gradually, the plan for introducing pharmacists into a pharmacist establishes an integrated clinic model.

January/February 2015 California Journal of Health-System Pharmacy cjhp 1 7 Pharmacists in Primary Care

role that is best described as a referral Residency-trained role where both physicians and nurses Pharmacists and refer those cases where the pharmacist’s Certification in Specialty Areas expertise in medication management is Nationally, there has been rapid growth likely to improve patient outcomes. in pharmacy residencies. Based upon Pharmacists have identified a niche 2013 data, available through the Phar­ in managing chronic diseases treated macy Online Residency Centralized primarily with medication, diet, and Application System (PhORCAS), there exercise (such as hypertension, diabetes, were over 1,600 residency programs that and hypercholesterolemia); and collectively offered over 3,000 positions. managing anticoagulant drug therapy. Despite the expansion of pharmacy Pharmacists have also played an impor­ residencies there continues to be unmet tant role in oncology through managing need, as evidenced by the volume of chemotherapy, symptom management individual PGY1 and PGY2 applications support, pain management, assessment (n=5,808) received that year, Pharmacy of response and toxicities, and manage­ residencies are defined as an organized, ment of nausea and vomiting through directed, postgraduate training program antiemetic therapy. This is contrasted in a defined area of pharmacy practice.13 with the roles of nurse practitioners The majority of pharmacy residencies are and physician assistants who play major pursued immediately after graduation roles in urgent care clinics, physical from pharmacy school and last one year. assessment screenings, emergency These residencies are identified as Post- departments, and working with ortho­ Graduate Year 1 (PGY1) residencies. pedic surgeons. The American Society of Health-System Pharmacists (ASHP) is the main accred­ iting body for accrediting health-system Availability of Appropriately pharmacy residencies. Pharmacists who Trained Personnel: Can You complete an ASHP-accredited PGY1 Find the Right People? residency or a residency with Candidate There are approximately 35,000 licensed status with ASHP are eligible to take pharmacists in California about 25% of a Board of Pharmaceutical Specialties whom practice in hospitals (<9,000).11,12 (BPS) examination in Pharmacotherapy The number of pharmacists already that, if passed, identifies them as BPS- working in clinics is unknown but likely certified in Pharmacotherapy.14 The less than 3,000. California law requires Board-certified designation is helpful that in order to work in a clinic setting, to hospitals for internal credentialing, a pharmacist must have either success­ credibility and comfort with assigning fully completed a pharmacy residency or clinical roles. have demonstrated clinical experience in direct patient care delivery. Many Specialty residencies—referred to as pharmacists who have worked in an PGY2 programs—offer additional acute care setting in California have this postgraduate training in areas such as clinical experience through the protocols ambulatory care, critical care, psychiatry, of the hospital in managing the dosing of nutrition support, oncology and infec­ various antibiotics, parenteral nutrition, tious disease. Pharmacists who complete and anticoagulation therapies. PGY2 residencies are eligible to take BPS examinations in specialty areas. Current areas of specialization include ambula­ tory care, nuclear pharmacy, nutrition support, oncology and psychiatric

1 8 cjh p California Journal o f Health-System Pharmacy January/February 2015 Pharmacists in Prim ary Care pharmacy. Pediatrics and critical processes regarding the use of medi­ care have recently been added as BPS cations and to experiment with new specialties with certification examina­ services, processes and procedures. An tions to begin in Fall 2015.15 Passing the example would be the initiation of a examination(s) qualifies the pharmacist new ambulatory clinic with pharmacists as BPS-certified in a specialty area. The participating on a medical team. Cali­ Board-certified specialty designation fornia residents are required to present is again helpful to hospitals for creden- their projects at the Western States tialing, credibility and comfort with Residency Conference (www.western- assigning clinical roles. states-rx.org) which is held annually in May. At the conference, hospitals and Residency programs can apply for clinics with residency programs have accreditation through the American the opportunity to identify “talent” in Society of Health-System Pharmacists specialized or general clinical areas. (ASHP). Accreditation implies that the program has met ASHP standards for California has always been a leading residency training. Continued accredi­ state in providing residency-trained tation requires periodic re-application pharmacists. In 2014, California had and site visits. A listing of ASHP- approximately 1 2 1 accredited PGY1 accredited programs is available on programs and 33 accredited PGY2 the ASHP website (http://accred.ashp. programs. PGY2 specialty areas include org / aps/pages/directory/residency- administration, ambulatory care, ProgramSearch.aspx). Many residency cardiology, critical care, drug informa­ programs do not apply for ASHP accred­ tion, emergency medicine, infectious itation for a variety of reasons. There diseases, oncology, pain management is no reliable listing of non-accredited and palliative care, pediatrics, pharmacy programs but it is estimated that ASHP- informatics, psychiatry and solid organ accredited programs account for about transplantation (data provided by ASHP, two-thirds of residencies. 2014). Many residency programs—PGY1 programs in particular—support more Hospitals wishing to explore or start than one resident.17 The University of residency programs can find help. ASHP Southern California, for example, has 4 ofFers specific information about starting PGY1 and 2 PGY2 residency programs residency programs.16 Many hospitals with over 40 residents annually. For will find willing partners in schools or the 2013-14 year (July 1 to June 30), colleges of pharmacy. Pharmacy schools there were about 314 pharmacists who make good partners for the research completed either PGY1 or PGY2 resi­ projects that residents are required to dencies in California (data provided by complete and pharmacy schools prefer the California Society of Health-System to have their students train in hospitals Pharmacists, 2014). Anecdotally, we where residency training is concurrent. observe that the majority of California- Professional meetings of ASHP, CSHP trained pharmacists seek to remain in and the American College of Clinical California to practice. Pharmacists (ACCP) almost always include programming about starting and managing residencies. Legislative Issues As is often the case, the changes in Whether PGY1 or PGY2, residents are practice preceded changes in the law to required to complete a research project. allow them to happen. This is not to say These projects often present opportu­ that these pharmacists were operating nities for hospitals to assess internal

January/February 2015 California Journal of Health-System Pharmacy cjhp 1 9 Pharmacists in Primary Care

outside of the law; only that the law was that the scope of procedures performed silent on the matter because the existing by the pharmacist must relate to the laws were developed before anyone had condition for which the patient was first envisioned such services. The California seen by the physician. The protocol shall legislature recognized this and promul­ require that the patient’s medical record gated legislation to keep up with the be accessible to both the pharmacist changing environment. and the physician, and that any change, adjustment, or modification of an In California, a pharmacist in a medical approved pre-existing treatment or drug clinic who has successfully completed therapy be provided in writing to the clinical residency training or demon­ treating or supervising physician within strated clinical experience in direct 24 hours. patient care delivery has been able to legally adjust a patient’s drug regimen In order for a pharmacist to be quali­ per clinic approved protocol since 1996 fied to perform these functions in a (AB 2802 Granlund).18 In 1999, the law clinic setting under B&P §4052.2, the was expanded such that a pharmacist pharmacist must have either success­ could adjust a patient’s drug regimen fully completed a clinical residency pursuant to a protocol as part of the training program, or have demonstrated care of a single physician (not neces­ clinical experience in direct patient care sarily restricted to a clinic setting) (AB delivery. Many of the pharmacists who 261 Lempert).19 In 2001, that scope was have worked in an acute care setting in expanded to include initiating a drug California have this clinical experience regimen, not restricted to adjusting a through the protocols of the hospital drug regimen that had already been in managing the dosing of various commenced (AB 826 Cohn).20 In 2006, antibiotics, parenteral nutrition, and anti­ the section of the Business & Profes­ coagulation therapies as described above. sions Code identifying this scope for In 2013, SB 493 (Hernandez) was a pharmacist in a clinic setting was approved by the California legislature to renumbered to B&P §4052.2 (AB 2408 expand the scope of every pharmacist in Negrete-McLeod).21 California to furnish hormonal-based Examining the requirements for the contraceptives, emergency contracep­ application of B&P §4052.2 dealing with tion, travel medications for international a pharmacist’s scope of practice in a travel, immunizations on the Centers clinic setting, all of the procedures logi­ for Disease Control (CDC)-recom- cally involve patients on drug therapy or mended schedule, and nicotine-based who will receive drug therapy. Specifi­ smoking cessation aids, pursuant to cally, a pharmacist may assess the drug state approved protocols and subject therapy, including ordering laboratory to specified training.22 In addition, the tests, administer drugs and biologicals, bill created a new category of licensed and initiate and adjust drug regimens pharmacist known as an Advance pursuant to an approved protocol. The Practice Pharmacist (APP), who would protocol must be developed by a multi­ not necessarily be restricted to practice disciplinary team that includes both within a hospital or clinic. In order to physicians and direct care registered qualify for licensure as an Advanced nurses, who shall determine the breadth Practice Pharmacist, the pharmacist and limitations of such protocol. The must have completed two of the three protocol must require that the patient following criteria: must first have been seen by a physi­ cian before referral to a pharmacist, and

continued on page 25

2 0 cjhp California Journal of Health-System Pharmacy January/February 2015 Pharmacists in Prim ary Care continued from page 20

4210(a) (2) (A): Earn board Senate under S 31425 and in the House of certification, Representatives under HR 59226. This is encouraging since bills have been intro­ 4210(a) (2) (B): Complete a post-grad­ duced in both the Senate and the House uate clinical residency, and/or of Representatives, and both appear to 4210(a) (2) (C): Have at least one year have bipartisan support. of experience practicing as a clinical pharmacist. Implications of Healthcare Law Under current law, there is no Changes for Hospitals requirement for a pharmacist working Healthcare law changes in 2013-2014 in a clinic under B&P 4052.1 or have the potential to trigger changes in 4052.2 to be licensed as an Advanced affordable care and spur development Practice Pharmacist. of models that allow hospitals to utilize staff more efficiently. Furthermore, To date, the proliferation of clinical forecasts for meeting the demand for pharmacists in the ambulatory care primary care predict that primary care (clinic) setting has occurred largely in physician shortages will increase dramat­ managed care organizations such as ically by 2025, and there is growing Kaiser Permanente and the Veterans evidence that primary care shortages are Administration, since fee-for-service shifting the debate on expanding scope- reimbursement is not an issue in these of-practice laws.27 Given the current environments. A limiting factor outside mismatch with patient needs, emergency managed care is that pharmacists are room use for primary care problems is not yet recognized as providers under on the rise in several regions, and health Medicare Part B for reimbursement, so care leaders in those markets believe services rendered by pharmacists in the that is due to a shortage of primary clinic are not reimbursable under Medi­ care physicians. The use of emergency care. HR 4190 was introduced into the departments by Medicaid patients for House of Representatives in Washington, primary care services is a problem for DC in March 2014 by Representatives insurers who cover that population, Bret Guthrie (R-Ky), G.K. Butterfield but it’s also an indication of what may (D-N.C.), and Todd Young (R-Ind), a be ahead for privately insured patients, bill to amend the Social Security Act to who cannot get timely appointments provide for coverage under the Medi­ with primary care providers. Hospitals care program of pharmacist clinical in California are typically located where services.23 This bill would have allowed people are located. The geographic pharmacists in the clinics to bill for distribution indicates that hospitals their services through Medicare Part B. are primarily distributed in proportion A recent letter from the Administrator to the number of people, rather than of CMS affirming that incident-to Part income. However, a recent analysis of B Medicare billing by physicians for hospitals by population income in LA pharmacist-provided services is lawful County suggests that people who have under specified conditions suggests the the least amount of money, may have CMS would not be opposed to such relatively easy geographic access to legislation.24 Unfortunately, the term of hospitals but limited access to primary the 113th Congress ended before the care.28 Low income areas in California bill could be passed. Now that a new may be surrounded by hospitals, but lack session of Congress is underway, bills primary care resources. have been introduced on both sides of Congress to allow pharmacists to bill for How pharmacists get reimbursed services under Medicare Part B in the directly affects the workforce and scope

January/February 2015 California Journal of Health-System Pharmacy cjhp 25 Pharmacists in Primary Care

of practice. Payment policies have an and the California Pharmacists Asso­ immediate effect that produces change ciation). Effects of changes in health in the volume and type of care delivered. system management hold the promise Historically, health plans have been slow of achieving efficiencies in staffing and to change the way they reimburse for producing improvements in outcomes. care. Increasingly, there is an impetus Almost 20 percent of Americans, 56 to find reimbursement and workforce million people, have inadequate or mechanisms to prevent a diabetic from no access to primary care physicians requiring an amputation, rather than a because of a shortage of providers, and a reimbursement schema that rewards an majority of them are insured, according orthopedic surgeon for the amputation. to a report issued by the National In the absence of creating new efficien­ Association of Community Health cies to address physician shortages, Centers and the American Academy systemically, we could inadvertently of Family Physicians.31 Multiple 2014 develop greater inefficiencies, such as studies and surveys indicate that the increases in emergency department number of uninsured fell as a result of use, longer waiting times for appoint­ expanded Medicaid eligibility and health ments, higher costs for imaging services insurance exchanges established through and pharmaceuticals, and utilization PPACA. Overall, RAND’s Health Reform of specialty care lacking coordination, Opinion Study (HROS) in March 2014 magnified by health reform driven estimated that 9.3 million more people improved access to and demand for had health care coverage. The increase needed health care. was driven by enrollment in health insurance marketplace plans and by Health Care Reform & Physician increases in employer-sponsored insur­ Shortages in California ance and Medicaid enrollment increases. The shortages in primary care physicians Data from August 2014 showed that 7.3 are evident when mapped and indicate million people had enrolled through the that these short falls are a geographic marketplace and paid their premiums.32 issue. Only 16 out of 56 California counties have enough primary care Behind the Physician Shortages physicians.29 Effectively, when applied The U.S., relative to other countries, to the resident population of the state, has low physician to population ratios. less than one third of Californians live The physician workforce is aging. The in a place where access to primary population is aging and doctor visits care physicians meets the needs of the increase substantially for those over 65. population.30 With increased demand Equally important, the supply of new for health care services and a shortage of primary care physicians is not sufficient. physicians, the potential gaps in direct Estimates are that new U.S. educated patient care are likely to widen unless physicians account for an increase each alternatives are brought into play. year of about 1 percent of the current In California a “Bridging the Provider primary care physician workforce. Gap” campaign was initiated through First year MD enrollment in relation to the coalition Californians for Acces­ 100,000 population has been in steady sible Healthcare (comprised of the decline since 1980. Limited residency California Association for Health slots are a contributing factor. “In 1997, System Pharmacists, the California the federal government essentially froze Society of Health System Pharmacists, spending on residency slots, limiting the California Optometric Association, the number to around 100,000 over

26 cjhp California Journal of Health-System Pharmacy January/February 2015 Pharmacists in Primary Care three-to-four years, and in turn one or more years of pharmacy of the use of pharmacists practicing freezing the number of newly licensed residency training which is focused in the ambulatory care environment physicians available for hire each on higher levels of clinical skills and has been hindered by the inability year to around 26,000.” While some experiences. Some hospitals separate to capture reimbursement for these increases have resulted from hospitals clinical pharmacists based on their services; however the Affordable that have established new residency training and role from the rest of the Care Act (ACA) is presenting some programs for primary care doctors, pharmacy staff while other hospi­ opportunities allowing pharma­ the volume is not sufficient, espe­ tals find it more practicable to have cists to qualify for “incident-to” cially given the estimated 50 million pharmacists able to perform both billing just as much as other clinical person increase in the U.S. popula­ traditional and newer clinical roles. team members, so long as such tion during that time period. “The services are permitted under their American Association of Medical Moving Forward state license and that “medication Colleges estimates that the U.S. will Pharmacists are currently able to management services” (billing codes face a shortage of 46,000 primary care legally function as mid-level prac­ 99605-99607) are not covered under doctors by 2020, equivalent to one- titioners in an ambulatory care Medicares Part B program, but are quarter of everyone practicing in that setting under approved protocols so instead billable under Medicare category today.”33 long as they have either (1) success­ Advantage or Part D medication fully completed a clinical residency plan.35 Another development is Workforce and training program, or (2) have demon­ HR 4190 introduced in Congress Capacity Issues strated clinical experience in direct earlier this year, which would allow Around 2006, the concept of a U.S. patient care delivery. Hospitals and pharmacists in the clinics to bill for shortage of primary care physi­ health systems looking to insert clin­ their services through Medicare Part cians was first publicized.34 Roles ical pharmacists into a medical clinic B. This bill has bipartisan support for advanced practice nurses and setting may draw from their internal and is currently being heard in physician assistants were emphasized resources as well as recruiting new committee in the House of Repre­ to “fill the gap”. Given the abun­ pharmacists with hospital experience, sentatives in Washington, DC. Given dant research (see the Report to the taking those pharmacists who have the current physician shortage, it Surgeon General) that has shown the been functioning in the acute care would make sense to expand the value of pharmacists in ambulatory setting practicing direct patient care use of pharmacists in primary care and primary care activities—both delivery to those hospitalized patients clinics as mid-level providers to from an economical and from an and providing them with the opportu­ manage chronic diseases such as outcomes perspective, pharmacists nity to practice in the ambulatory care diabetes, hypertension, hyperlipid­ can contribute to “filling the gap” venue (the attraction of a Monday emia, and other diseases managed created by the primary care physician through Friday stable work schedule primarily with medications. O shortage. may be appealing). Even though the number of pharmacy residencies is With approximately 35,000 licensed increasing, only about half of those pharmacists in California about pharmacists who apply actually get 25% of whom practice in hospitals Figure 1. ASHP Pharmacy Residency accepted. One strategy to consider and of those who are hospital-based is for hospitals to develop their own Program Growth less than half qualifying as clinical pharmacy residencies with rotations pharmacists, there are less than 4,500 in the clinic. Using this strategy, the clinical pharmacists available for facility gets a pharmacist (usually implem enting or augmenting clinical licensed within 90 days of starting) services in hospital or clinics in Cali­ to train in both the hospital and the fornia today. clinic for less than half of what it Nationally, hospital-based pharma­ costs for a clinical pharmacist for a cists accounted for about 25% of total year, and the opportunity to recruit pharmacy positions. Some of these the resident when they complete the pharmacists typically have completed one year program. The proliferation

January/February 2015 California Journal of Health-System Pharmacy cjhp 2 7 Pharmacists in Primary Care

Figure 2. Distribution of Hospitals within California by Figure 3. Medically Underserved Areas and Populations Median Income Medically Underserved Areas and Populations

Distribution of Hospitals within California o s jy p d ...... frjjftj; October 2010 by Median Income

Caitlin Morrison March 2012

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1 American College of Clinical Pharmacy. ACCP 14. Board o f Pharmaceutical Specialties. Specialties: Pharmacotherapy. Available at: 27. Carrier, ER, Yee, T, and Stark, L. Matching Supply to Demand: Addressing the The Definition of Clinical Pharmacy. http://www.accp.com/docs/about/Clinical- http://www.bpsweb.org/specialties/pharmacotherapy.cfm, accessed February 8, U.S. Primary Care Workforce Shortage. National Institute for Health Care Reform. PharmacyDefined.pdf 2015. Policy Analysis, No. 7, December, 2011. 2. Jack BW, Chetty VK, Anthony D et al. A Reengineered Hospital Discharge 15. Board of Pharmaceutical Specialties. Board of Pharmacy Specialties announces 28. Morrison, C. (March, 2012) Distribution of Hospitals in LA County by Median Program to Decrease Rehospitalization. Ann Intern Med 2009;150:178-187. new specialties in critical care pharmacy and pediatric pharmacy. Available at Income, http://gis.yohman.com/up206a/author/cmorrison/ 3. Gates R and Dehner M. 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