Consultant Pharmacists: Saving Lives and Money

INTERVIEW WITH STEVE FELDMAN, RPH, FASCP

Nursing Homes/Long Term Care Management Editor Linda Zinn spoke with Steve Feldman, RPh, FASCP, president of the American Society of Consultant Pharmacists, about how the role of the consultant, or senior care, pharmacist has evolved and continues to evolve in an era of increasing regulations and shrinking revenues.

Zinn: How has the role of the consultant, or senior care, pharmacist in nursing homes changed in the past few years, as a result of changes in the long-term care industry as a whole?

Feldman: Since 1974, when the federal mandate was issued, we’ve seen the addition of more and more layers of regulations related to drug therapy management, and we expect to see more this year. Because of all those requirements, our role continues to expand all the time.

The primary services consulting pharmacists provide to nursing homes fall under four categories: clinical consultation, education, regulation compliance, and cost containment, with cost containment gaining importance over the past few years. With the advent of the Prospective Payment System (PPS), we began to see pharmacists taking a more active role in trying to keep therapy costs down for facilities. Before PPS, nursing homes weren’t concerned about how much drugs cost, because Medicare, Medicaid, or residents were paying for them. When PPS was implemented and the costs of drug therapy became part of the per diem reimbursement for the Medicare part A population-which consists of residents who have been discharged from hospitals to nursing homes-it was a different situation. Since under Medicare part A facilities receive a flat amount, based on a resident’s Resource Utilization Group (RUG) level, obviously an expensive drug can have serious impact on the actual cost of providing care.

Zinn: How have long-term care pharmacies and consultant pharmacists adapted to these Medicare changes?

Feldman: To help facilities control costs, they have provided better pricing by offering lists of “preferred products.” Since most nursing homes do not have a strict formulary like hospitals do, a preferred-drug list assists prescribers and facilities in choosing the best-suited product(s) from within a therapeutic category. These products are “geriatric friendly” and sometimes less expensive. It should be noted that although some of these preferred products are not less expensive to purchase than older drugs indicated for the same conditions, they are included because they are more effective or safer to use in geriatric patients. By reducing the frequency and severity of medication-related problems, they bring down the overall cost of healthcare and drug therapy. Conversely, less expensive drugs that take longer to achieve the desired effect, or those that cause more adverse effects that require additional treatment, can’t be considered bargains.

Another cost-containment measure some pharmacy providers will take is risk sharing. They enter into contracts with their facility clients in which they agree to be paid a flat fee per resident per day for drugs. Thus, they share the risk of higher-cost treatment with the facility. There are usually some exclusions, such as IV drug therapy and biotech drugs.

Zinn: Of course, Medicaid reimbursement varies widely from state to state. Have the cuts in some states been so severe that it’s become difficult for consultant pharmacists to provide their services? On the flip side, are there any states with a particularly favorable Medicaid climate for pharmacists?

Feldman: The demands on consultant pharmacists have grown in recent years, as regulatory requirements relating to drug therapy issues have grown and cost-containment pressures have taken more of these professionals’ time. The challenge for consultant pharmacists is that some nursing facilities want Cadillac service at Hyundai prices. They are often unwilling to pay market prices for the type of service and expertise they need.

Overall, pharmacies are being paid less and less, both for products and the dispensing process. In states where Medicaid cuts have been most severe (e.g., Massachusetts) and where pharmacy providers have been negatively impacted, these providers must either charge facilities more or provide less service. This has become so problematic that some large, national long-term care pharmacies are faced with considering whether they can afford to remain in the business of consulting.

In contrast, there is better news in some states, such as New Jersey. Medicaid regulations there provide additional reimbursement to pharmacies that fill prescriptions for nursing homes in unit-dose packaging, which enables the pharmacies to take returns of unused medi-cations. This dramatically reduces the amount of waste, so it saves both the state and the facilities a great deal of money.

Zinn: What do you see as a solution for all this?

Feldman: The big problem with Medicaid is that states are looking at line items and drug expenditures. They focus on reducing costs in only two ways: Pay less for products and dispensing, or influence utilization (e.g., by restrictive formularies and prior approvals). What government agencies often don’t understand-and the American Society of Consultant Pharmacists [ASCP] is spending a lot of time trying to help them understand-is that pharmacists can evaluate medication regimens and find ways to decrease utilization and improve therapy outcomes, but they need to be paid for these services. Instead of decreasing drug costs, per se, we should be looking for ways to reduce medication-related problems, which are costly not only financially, but also in terms of compromising residents’ health and quality of life.

A few years ago, the ASCP Education and Research Foundation conducted a large study, the Fleetwood Project, to examine the value consultant pharmacists bring to nursing homes. The study determined that within the nursing home population, every dollar that is spent on medications translates into another $1.33 in costs of medication-related problems, such as treatment failures, side effects management, etc. But so far, most Medicaid agencies haven’t had enough insight to see that. They want an absolute guarantee of how much can be saved-a quick fix.

We found in our study that if a consultant pharmacist intervened in a facility, he or she could rather quickly change that $1.33 to $0.67-a 50% reduction in the cost of medication-related problems commonly associated with decreasing drug utilization. Nursing home residents take more medications than any other population, so in real numbers, that $1.33 is really $4 billion. We’re talking about the potential to save at least $2 billion per year!

There are some models being used, one in Ohio and two in North Carolina, that acknowledge the value of consultant pharmacists’ expertise in controlling costs by recommending the most appropriate drug therapy. Medicaid officials in Ohio were ready to decrease reimbursement to pharmacies filling prescriptions. Nursing home pharmacy providers told the state, “We know you have to save money, but we believe that if you pay us to use our cognitive ability to reduce medication-related problems, we can save you more than we can by cutting our dispensing rates.” Acting on this suggestion, Ohio launched a demonstration project called CATALYST, giving the pharmacists a chance to show how much they could save and how long it took.

The demonstration saved the state enough money that it agreed to split the savings with the pharmacists. This enabled the participating long-term care pharmacies to hire additional consultant pharmacists-the equivalent of approximately two FTEs per pharmacy. This model resulted in the state and the pharmacies getting back approximately $200,000 each per year and, therefore, the demonstration project became policy for the Ohio long-term care segment. This is a voluntary program; pharmacies may choose not to participate.

One of the projects in North Carolina was launched by the city of Asheville and the Mission of St. Joseph Health System. The city manager there, who oversees the city’s risk management, was trying to find a way to save money. He examined the rising costs of medications and healthcare for city employees, noting that costs were especially high for those with diabetes. Some pharmacists proposed that they could save the city money by offering patient education to the employees with diabetes and therefore achieving better patient compliance with treatment. The city manager told the pharmacists that if they could prove they could save money, the city would pay them for their time. The patient-education effort improved patient outcomes and saved so much money that the city ended up being able to pay the pharmacists retroactively to day 1 of the initiative. Because of its success, the educational program has been expanded to include four additional disease states, including asthma and hypertension. [For more information on the Ashville project, visit https://www.ncpharmacists.org/current_news.html.]

Another North Carolina project, called the North Carolina Nursing Home Poly-pharmacy Initiative, was implemented by the state Medicaid program, in collaboration with the North Carolina chapter of ASCP, to reduce costs of medications for nursing home residents. This approach uses a pharmacist-physician team to evaluate high-cost drug regimens for residents. For every $1 invested in this project, $13 in savings has resul-ted. [Note: The North Carolina Nursing Home Polypharmacy Initiative is discussed in a recent report from the Center for Health Care Strategies: “Clinical Pharmacy Management Initiative: Integrating Quality Into Medicaid Cost Containment. April 2003; available free at www.chcs.org/publications/purchasing.html#cpmi.]

Zinn: What can consultant pharmacists do when a state has a restrictive formulary and the best drug for the treatment of a Medicaid resident is not included?

Feldman: My advice is not to accept that; pharmacists must do whatever they can-they should be “in the face” of the Medicaid decision makers, giving them evidence to substantiate the need for that particular medication. Pharmacists shouldn’t sit back and surrender. Many states have a prior-approval process; if a pharmacist can make a good argument during this process, he or she might gain the approval of a restricted drug. Unfortunately, some are not willing to fight that battle.

I served on my state’s Drug Utilization Review (DUR) Board for many years. If someone showed that a restriction was causing patient harm, the board certainly had to figure out how to deal with it, either by lifting the restriction or allowing a review process for people who really needed certain nonformulary medications. The same should be true for all state Medicaid agencies.

Unfortunately, we are hearing from our members about many problems with state Medicaid Preferred Drug Lists, especially with regard to their negative impact on seniors. The ASCP board of directors just approved a statement on this issue, which is available on the ASCP Web site (www.ascp.com).

This is a huge issue. It’s one of many moral questions society needs to answer: Is Medicaid (which accounts for 70% of residents in nursing homes) a premium health insurance, or entitlement, that should allow people to get whatever they want? Or is it a way for those who can’t afford healthcare to get what they need? We already can’t afford Medicaid as we know it today. In the next 20 years, the system won’t work; we need to change it. Ohio’s Medicaid program and the projects in North Carolina could serve as models for some of that much-needed change.

Zinn: Has the consultant pharmacist’s role evolved in the assisted living environment?

Feldman: Our role in that setting is really just beginning. Unfortunately, many long-term care pharmacy providers have serviced assisted living facilities as nursing homes and haven’t understood the huge difference between them. This lack of understanding has created an environment of frustration for the assisted living industry. When I was a consultant pharmacist for Marriott’s senior care division, one of my responsibilities was to create a model for how consultant pharmacists should operate in the assisted living setting, where the emphasis should be on wellness and risk reduction. It is not usually possible to conduct a traditional drug regimen review in that setting because of the lack of a comprehensive medical record. But a wellness/risk assessment can be done, and it is useful in that it will identify previously undetected or untreated diseases or medical problems and risks. The consultant pharmacist can work with the residents’ physicians to reduce residents’ risk factors. [For more information, see ASCP’s Assisted Living Resource at www.ascp.com/public/pr/assisted.]

Zinn: Shifting to the clinical side of your role, what do you consider to be the most common medication error involving seniors that you encounter?

Feldman: The most common error in nursing homes is omitted doses; residents sometimes don’t get the drugs that have been ordered for them. We know this by observing medication passes.

Another significant problem, and we’re seeing it more and more, is the perception by physicians that medication doses should always be kept low in elderly patients. “Start low and go slow” is a good rule of thumb in this population; the trouble is, though, that some doctors’ fear of giving too much medication prompts them to keep their patients at the initial low dose. They never titrate the dose upward to the efficacious dosage. For some medications that have no standard dose, doses have to be increased over time until the dose the patient needs is found. For example, low doses of cholinesterase inhibitors used for the treatment of Alzheimer’s have no efficacy. But, because these agents all have a potential side effect of nausea, you have to start patients on a low dose for a few weeks before you can increase it to the amount they need to achieve a therapeutic benefit. Keeping patients at the starting dose, where the drug has no effect, is simply a waste of money. A similar problem is seen with the use of antidepressants in the elderly.

Zinn: What about pain management? Are physicians still withholding adequate doses of pain medications because they fear elderly patients will become addicted?

Feldman: Overall, I think we are aware that our history in nursing homes is to undertreat pain. The concern is really more related to central nervous system depression than addiction. Old people are very sensitive to narcotics; too high a dose can be very risky, so one must be cautious in prescribing pain medications for them. For example, regarding the transdermal patch used to deliver pain medication: The lowest-dose patch, which administers the dose over three days, delivers too large of a dose for some seniors with low body fat. So the smallest dose available can, in some patients, actually be an overdose. The risk is that pain medications can cause elderly individuals to fall and to appear totally tranquilized. So there are a lot of issues to consider when treating pain in the elderly.

I believe we are making progress in pain management, though. One positive thing that’s happened in long-term care is its exposure to hospice providers; these practitioners are the true pain experts. They know how to use drugs and aren’t frightened by some of the myths surrounding pain medications. In the last 10 years, hospice nurses have taught nursing home staffs a great deal about pain management. Consulting pharmacists are also promoting better pain management through educational efforts.

Incidentally, the health department in California considers pain the “fifth vital sign,” so every resident of a nursing home in that state is routinely assessed for pain. The Joint Commission also has focused attention on proper pain management within their standards of accreditation.

Zinn: What measures can facilities adopt to reduce medication-related problems?

Feldman: If anyone can make a difference in this regard, it’s the consultant pharmacist. But in the current economic climate, consultant pharmacists are being pulled in many different directions. Nursing facilities need more and more help with regulatory compliance, cost containment, quality-improvement issues (e.g., quality indicators and quality measures), and other areas. If a facility wants more from the pharmacist than can be done within the allotted time, someone will have to pay for the additional time.

Also important are partnerships between the medical director and the consultant pharmacist. Such relationships can have a significant impact on the risk management of medication-related problems. For example, doses of drugs that are cleared by the kidneys need to be reduced in residents with renal insufficiency. The medical director can request that the pharmacist evaluate the drug regimens of all those residents with reduced renal capacity and recommend dosage adjustments, and the pharmacist can perform the pharmacokinetic calculations involved. This takes extra time, but it’s an essential service that the pharmacist can provide if the medical director empowers him or her to do so.

If this assessment is only done on a case-by-case basis and is only addressed with residents’ attending physicians rather than through a policy with the facility’s medical director, the desired outcome will occur in fewer patients. The medical director, director of nursing, and consultant pharmacist should collaborate to establish a policy for the facility’s prescribers to follow. The pol-icy should state that the pharmacist will consult/set doses based on renal function for drugs that are renally cleared.

This is just one example of what consultant pharmacists can do to improve risk management and, as a result, help with cost containment in a way that improves, rather than erodes, quality of care. Inappropriate medication use in the elderly can be like gasoline and a match-a bomb waiting to explode-whereas appropriate medication use can improve quality and quantity of life. Consultant pharmacists are trained in all areas of geriatric pharmacy and they can help, as long as they are empowered to do so and their services are not underutilized. NH