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Consultant Pharmacists: Saving Lives and Money

August 1, 2003
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Interview with Steve Feldman, RPh, FASCP, President, American Society of Consultant Pharmacists
Consultant Pharmacists: Saving Lives and Money

INTERVIEW WITH STEVE FELDMAN, RPH, FASCP Practicing senior care pharmacy is one of the most challenging roles pharmacists play. People's longevity is increasing, and so are the numbers of available drugs-therapies aimed at both prolonging life and improving its quality. It is not unusual today for an elderly person to be taking 10 or more different medications daily; add to the mix the fact that seniors are among those most vulnerable to the adverse effects of drugs and to other medication-related problems, and the magnitude of the challenge becomes clear. In 1974, in recognition of the complexities involved in medication use in the elderly, the U.S. Department of Health, Education and Welfare, through Medicare's Conditions of Participation, required that pharmacy services provid-ed in nursing homes include consultant pharmacists. These individuals-who may be employed by long-term care pharmacy providers or who may work independently-have the training and expertise to assist long-term care organizations with drug therapy management in a geriatric population.

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.