Outpatient settings need pharmacists, but lack of reimbursement makes that tough

But according to pharmacists, those figures should be higher. “We know there has been growth (of pharmacists) across the board, but we’d like to see more pharmacists,” said David Chen, senior director of pharmacy practice leaders at the American Society of Health-System Pharmacists, or ASHP. “We know that pharmacists provide value as part of the interprofessional team, especially as patients become more complex and high risk.”

Indeed, Jennifer Sternbach, corporate director of clinical pharmacy services at RWJBarnabas, said it would be ideal to have “an army” of pharmacists.

In healthcare, pharmacists traditionally haven’t been considered a vital part of the care team. Part of the reason is cultural. Doctors don’t often train with pharmacists so they don’t understand the value they bring to the table, said Melanie Smith, director of ambulatory-care practitioners at the ASHP.

For instance, the first time Dr. Su Wang, a primary-care doctor at RWJBarnabas, saw a pharmacist in a clinic, she said she wondered what they were doing there.

An even bigger barrier is financial. Because a pharmacist’s services can’t be reimbursed at the federal level, Lew has had to get “creative” to offset their salaries. Patients aren’t charged for visits with pharmacists, so along with encouraging patients to use the retail pharmacy at RWJBarnabas to fill prescriptions, the health system has partnered with nearby Fairleigh Dickinson University to deploy pharmacy faculty and residents at the school in their clinics, allowing them to split the cost of the pharmacists with the university.

The health system is also exploring how to leverage its robust acute-care pharmacy workforce in new ways to decrease the need for new ambulatory-based pharmacists. Like other health systems, most of RWJBarnabas’ services have traditionally been focused on the acute-care setting so most of its pharmacists work in its hospitals.

Lew said hospital-based pharmacists may soon be asked to conduct telehealth or over-the-phone consultations with patients to address drug-related concerns such as medication adherence. The service would be largely for circumstances that aren’t complex.

“We are still fee-for-service in a lot of instances, but as we move to a value-based care model, we have to think about what we can do with these talented acute-care pharmacists,” she said. “We have more pharmacists on the acute-care side. How can we utilize them where we have much more patients, which is on the ambulatory side?”

When pharmacists are brought into the clinical setting, other staffers can see a noticeable difference. CHI Franciscan began implementing pharmacists in its clinics about six years ago. There are now eight pharmacists embedded across 15 of its clinics, but staff are always asking if more pharmacists can be added, Wymore said.

Pharmacists provide an array of duties in clinics. For instance, ambulatory-care pharmacist Ammie Patel, who splits shifts between two primary-care offices that are part of RWJBarnabas, is asked by physicians to set up visits with patients to offer smoking cessation counseling, review their medications and explain how to appropriately take them, such as showing a patient how to use an inhaler.

Patients not taking their medications or not taking them as prescribed is also a major reason for many of their visits with pharmacists, said Alyssa Gallipani, an ambulatory-care pharmacist at RWJBarnabas. The issue is estimated to cost the industry $100 billion to $300 billion annually.

Given the intensive topics covered, pharmacy visits with patients can last up to an hour, Patel said. By comparison, physicians at RWJBarnabas are scheduled for 20-minute visits with each patient.

Pharmacists help doctors have more efficient visits with patients by allowing them to focus on other important areas of the patient’s health they want to tackle rather than spending so much time on drug therapy, said Dr. Francis Mercado, division chief of primary care, prompt care and medical specialties for the Pierce Region of Franciscan Medical Group, which is part of CHI Franciscan. “They do improve the clinician’s productivity,” he said. “They may allow the provider to see one additional patient per day.”