Dispensing advice

Pharmacists are being relied on more as medical counselors, but some physicians are concerned about the new role

November 17, 2008|By Kelly Brewington | Kelly Brewington,kelly.brewington@baltsun.com

Shirley Davis struggled with diabetes for 30 years before she understood how to keep it under control.

Doctors, she said, told her to watch her weight, improve her diet and sent her home with a prescription for insulin. The visits were brief and the follow-up minimal. Davis, 74, ignored doctors' advice and her diabetes advanced.

Then, she began seeing pharmacist Jeffrey Brewer. Part prescription manager, educator and coach, Brewer collaborated with Davis' doctors on her care, taught her the relationship between insulin and blood sugar and convinced her to avoid her weakness - lemon meringue pie.

"Hardheaded old people like me think we know more than young people sometimes, but he got through to me in a nice, but stern way," she said. "I took heed to it because he showed a concern about my health and a whole lot of doctors I have been going to hadn't."

Brewer's work embodies a new brand of pharmacy known as medication therapy management, in which pharmacists counsel patients on managing chronic diseases and are core members of the medical team.

In a nation with a large aging population, a staggering array of prescriptions on the market and increasingly complex drug therapies, pharmacists say their medication expertise is needed more than ever. Unlike busy primary care physicians, pharmacists say, they have the time to advise patients about medications. Such advice is critical to patient safety, they point out, and can reduce health care costs.

"I describe myself as the first mate and the doctor as the captain of the ship," said Brewer, who sees patients at the internal medicine division of Johns Hopkins Community Physicians at Wyman Park. "One person cannot manage a patient in today's complex medical world."

But some insurance companies don't cover such services by pharmacists, maintaining that relatively few patients ask for them. And some physicians fear the trend could erode the role of the primary care doctor as the coordinator of a patient's care.

"If you basically start carving out certain sections of the primary care responsibility and assign them to other practitioners, then you sort of endanger the entire concept," said Stephen Johnson, interim executive director of MedChi, the state medical society. "The idea is that every patient has a place that is their home where a physician knows them and knows their problems and can manage their care."

But pharmacists say the model is struggling, as overburdened primary care doctors have less time for patient counseling. Meanwhile, more patients have chronic diseases and are taking numerous medications, increasing the need for supervision and advice.

The medication therapy management model can succeed only if doctors and pharmacists join forces, said Brewer, who has partnered with the Wyman Park practice for a decade. Brewer is employed by Hopkins and bills for his services separately from the doctors at the practice. His patients' insurance covers their visits with him.

Statewide, it's unclear how many pharmacists and doctors have such an arrangement, although many in the industry project the number to grow.

Typically, pharmacists like Brewer are employed by hospitals and work with family practices affiliated with the institutions. In 2002, a state law enabled pharmacists and doctors to enter such agreements directly. The agreements must be approved first by the Maryland Board of Pharmacy. In some cases, the agreements allow pharmacists to change a patient's medication dosage without sending the patient to a physician first.

The concept is actually an old one, dating back generations when pharmacists at neighborhood apothecaries knew their patients' names, what ailed them and how to treat it.

Today's clinical pharmacy is geared toward patients like Davis, with complex medical histories and numerous medications. Besides diabetes, Davis, a retired manager at the Social Security Administration from Baltimore, also has hypertension, high cholesterol, angina and glaucoma in her left eye. She takes six prescription medications.

Brewer said his job is also to help prevent chronic diseases and when possible, prescribe fewer medications. He sits down with patients for 20-minute to 30-minute sessions, usually quarterly, but sometimes as often as every month. They map out goals and strategies to manage diseases and prevent new ones.

"If we can focus on the underlying causes of these diseases - tobacco, obesity, lack of exercise - then you can really start to get a handle of the medication being prescribed," he said.

While many pharmacists have long done more than count pills and dispense drugs, some insurers have not embraced the expanded role.

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