American Journal of Pharmaceutical Education 2014; 78 (2) Article 43.
LETTERS
nonprescription medications, information technology systems, and wellness services, making them valuable to primary care. Collaborative practice agreements are in place in 47 of 50 states.11 Pharmacists can legally immunize adults and children in all states.12 Pharmacists are well trained to provide chronic care management–including disease state patient education and associated medication non-adherence and preventative care counseling. Pharmacists have demonstrated improved outcomes when compared directly to physician-driven standards of care.13-16 Pharmacists have also shown achievement of improved outcomes compared with physicians in the provision of patient self-care education .17 Why should providers, healthcare industry, pharmacy community, and pharmacy educational academy adopt primary care pharmacists? First, the critical need for primary care practitioners has not been available since the 1960s when nurse practitioners were designed to meet the breach. This opportunity may never again be placed before the profession. It becomes imperative that the entire profession plan strategically and with expediency. Pharmacists have the education, skills, and talent to provide primary care services. Pharmacy education costs are currently unstainable in the current job market with graduating ratio of educational debt-to-income over 100%.4 Pharmacy graduates must have the opportunity to increase income to offset this debt. If pharmacy graduates do not have the ability to increase their income over their career, then why choose a career in pharmacy? Providing the potential for income growth through pharmacistprovided primary care services would serve to sustain recruitment of the best and brightest minds. Projected reduction in the dispensing workforce with an increase in clinical services have been stated for almost a decade.18 This projected decline in dispensing positions is not yet apparent because of the medication needs of the baby boom generation. There are several factors that suggest this may not occur in the near future. Consumers are demanding more of a HIT-driven access to healthcare, which has increased demand for mail-order pharmacy services. Physician-based dispensing practices are increasing. Importantly, the high rate of prescribing medications for the baby boom generation will subside by attrition, leaving a pending job crisis. If the profession moves towards primary care pharmacist practice, then future graduates will enter a growing, clinically based job market. Primary care is central to healthcare in the United States. An opportunity exists for pharmacists to assume a primary care role. Only through a unified coalition of professional organizations that share a vision for the advent of primary care pharmacists will we realize this opportunity. May we succeed in seizing this moment!
Primary Care Pharmacists: Provision of Clinical-Decision Services in Healthcare To the Editor. Today, there remains a critical deficiency of physicians in the United States.1,2 Reasons for the shortage are multi-factorial and appear protracted over the foreseeable future, requiring other professions to provide primary healthcare services.3 Maintenance of the physician shortage has been attributed to an oversupply of medical specialists, Medicare caps on graduate medical training programs, and an unsustainable physician ratio of debt-to-income levels.3,4 Decades will be necessary to train sufficient number of primary care physicians.5 There are also insufficient nurse practitioners and physician assistants.6 Because these barriers are not changing quickly, the provision of primary healthcare is one of the most important issues of our time. Implementation of the Affordable Care Act identifies millions of newly insured patients needing primary care. Eighty million baby boomers are living with at least 1 chronic medical condition, accounting for more than 75% of healthcare costs.6 Acute care services provide healthcare for many patients, making the United States the world’s most expensive system. A new paradigm is needed to improve care.7 Future healthcare models will offer an integrated primary care experience that is quickly adaptable to patient needs, localized around population-identified disease pockets, and operates under a value-based reimbursement system. A patient will provide their health information through an easy-to-use Web-based portal, prior to the visit. Patient self-identified healthcare needs and symptom acuity will allow a planned, individualized clinic visit by a healthcare team. Each visit will focus on keeping the patient healthy through performing basic and complex diagnostics, minor surgical procedures, prescribing by mid-level practitioners, and life-checks (ie, My Life Check: Live Better with Life’s Simple 7).8 Each visit will be devoted to following the 4 “P’s” of 21st century healthcare delivery: personalization, prediction (of disease), prevention and disease preemption, and patient responsibility.9 Pharmacists are well positioned to be providers of primary care. Projected graduation rates of pharmacists in 2015-2016 appear to be sufficient to fill the projected 9% fall in primary care clinicians by 2020.5,10 Pharmacists have the education and training in basic pathophysiology, physical assessment, basic and complex diagnostic testing, pharmacotherapy, diagnosis of ailments requiring 1
American Journal of Pharmaceutical Education 2014; 78 (2) Article 43. Mark A. Munger, PharmD
11. American Pharmacists Association. Collaborative practice agreements vary among the states. http://www.pharmacist.com/ collaborative-practice-agreements-vary-among-states. Accessed November 11, 2013. 12. American Pharmacists Association, Rothholz MC. The role of community pharmacies/pharmacists in vaccine delivery in the United States. http://www.cdc.gov/vaccines/acip/meetings/downloads/ slides-jun-2013/01-Pharmacies-Rothholz.pdf. Accessed November 11, 2013. 13. Chen T, Kazerooni R, Vannort EM, et al. Comparison of an intensive pharmacist-managed telephone clinic with standard of care for tobacco cessation in a veteran population. Health Promot Pract. November 14, 2013 [e-publication ahead of print]. 14. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management of blood pressure control: a cluster randomized clinical trial. JAMA. 2013; 310(1):46–56. 15. Yu J, Shah BM, Ip EJ, Chan J. A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. J Manag Care Pharm. 2013;19(2):102– 114. 16. Rubio-Valera M, March Pujol M, Fernández A, et al. Evaluation of a pharmacist intervention on patients initiating pharmacological treatment for depression: a randomized controlled superiority trial. Eur Neuropsychopharmacol. 2013; 23(9):1057–1066. 17. Verret L, Couturier J, Rozon A, et al. Impact of a pharmacist-led warfarin self-management program on quality of life and anticoagulation control; a randomized trial. Pharmacother. 2012; 32(10):871–879. 18. Knapp DA. Professionally determined need for pharmacy services in 2020. Am J Pharm Educ. 2002;66(Winter):421–429.
College of Pharmacy, University of Utah, Salt Lake City, Utah
REFERENCES 1. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff. 2002;21(1):140–154. 2. Dill MJ, Salsberg ES. The complexities of physician supply and demand: projections through 2025. Washington, DC: Association of American Medical Colleges; 2008. 3. Cooper RA. Unraveling the physician supply dilemma. JAMA. 2013;310(18):1931–1932. 4. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973–1975. 5. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff. 2013;32:1881–1886. 6. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the US health care workforce do the job? Health Aff. 2009;28(1):64–74. 7. Cortese DA. A health care encounter of the 21st century. N Engl J Med. 2013;310(18)1937-1938. 8. My Life Check. Home page. http://mylifecheck.heart.org/ PledgePage.aspx?NavID55&CultureCode5en-US. Accessed November 11, 2013. 9. Institute for the Future. Four Ps represent the future of medicine. http://www.iftf.org/future-now/article-detail/four-ps-represent-thefuture-of-medicine/. Accessed November 11, 2013. 10. Brown DL. A looming joblessness crisis for new pharmacy graduates and the implications it holds for the academy. Am J Pharm Educ. 2013;77(5):Article 90.
2
LETTERS
nonprescription medications, information technology systems, and wellness services, making them valuable to primary care. Collaborative practice agreements are in place in 47 of 50 states.11 Pharmacists can legally immunize adults and children in all states.12 Pharmacists are well trained to provide chronic care management–including disease state patient education and associated medication non-adherence and preventative care counseling. Pharmacists have demonstrated improved outcomes when compared directly to physician-driven standards of care.13-16 Pharmacists have also shown achievement of improved outcomes compared with physicians in the provision of patient self-care education .17 Why should providers, healthcare industry, pharmacy community, and pharmacy educational academy adopt primary care pharmacists? First, the critical need for primary care practitioners has not been available since the 1960s when nurse practitioners were designed to meet the breach. This opportunity may never again be placed before the profession. It becomes imperative that the entire profession plan strategically and with expediency. Pharmacists have the education, skills, and talent to provide primary care services. Pharmacy education costs are currently unstainable in the current job market with graduating ratio of educational debt-to-income over 100%.4 Pharmacy graduates must have the opportunity to increase income to offset this debt. If pharmacy graduates do not have the ability to increase their income over their career, then why choose a career in pharmacy? Providing the potential for income growth through pharmacistprovided primary care services would serve to sustain recruitment of the best and brightest minds. Projected reduction in the dispensing workforce with an increase in clinical services have been stated for almost a decade.18 This projected decline in dispensing positions is not yet apparent because of the medication needs of the baby boom generation. There are several factors that suggest this may not occur in the near future. Consumers are demanding more of a HIT-driven access to healthcare, which has increased demand for mail-order pharmacy services. Physician-based dispensing practices are increasing. Importantly, the high rate of prescribing medications for the baby boom generation will subside by attrition, leaving a pending job crisis. If the profession moves towards primary care pharmacist practice, then future graduates will enter a growing, clinically based job market. Primary care is central to healthcare in the United States. An opportunity exists for pharmacists to assume a primary care role. Only through a unified coalition of professional organizations that share a vision for the advent of primary care pharmacists will we realize this opportunity. May we succeed in seizing this moment!
Primary Care Pharmacists: Provision of Clinical-Decision Services in Healthcare To the Editor. Today, there remains a critical deficiency of physicians in the United States.1,2 Reasons for the shortage are multi-factorial and appear protracted over the foreseeable future, requiring other professions to provide primary healthcare services.3 Maintenance of the physician shortage has been attributed to an oversupply of medical specialists, Medicare caps on graduate medical training programs, and an unsustainable physician ratio of debt-to-income levels.3,4 Decades will be necessary to train sufficient number of primary care physicians.5 There are also insufficient nurse practitioners and physician assistants.6 Because these barriers are not changing quickly, the provision of primary healthcare is one of the most important issues of our time. Implementation of the Affordable Care Act identifies millions of newly insured patients needing primary care. Eighty million baby boomers are living with at least 1 chronic medical condition, accounting for more than 75% of healthcare costs.6 Acute care services provide healthcare for many patients, making the United States the world’s most expensive system. A new paradigm is needed to improve care.7 Future healthcare models will offer an integrated primary care experience that is quickly adaptable to patient needs, localized around population-identified disease pockets, and operates under a value-based reimbursement system. A patient will provide their health information through an easy-to-use Web-based portal, prior to the visit. Patient self-identified healthcare needs and symptom acuity will allow a planned, individualized clinic visit by a healthcare team. Each visit will focus on keeping the patient healthy through performing basic and complex diagnostics, minor surgical procedures, prescribing by mid-level practitioners, and life-checks (ie, My Life Check: Live Better with Life’s Simple 7).8 Each visit will be devoted to following the 4 “P’s” of 21st century healthcare delivery: personalization, prediction (of disease), prevention and disease preemption, and patient responsibility.9 Pharmacists are well positioned to be providers of primary care. Projected graduation rates of pharmacists in 2015-2016 appear to be sufficient to fill the projected 9% fall in primary care clinicians by 2020.5,10 Pharmacists have the education and training in basic pathophysiology, physical assessment, basic and complex diagnostic testing, pharmacotherapy, diagnosis of ailments requiring 1
American Journal of Pharmaceutical Education 2014; 78 (2) Article 43. Mark A. Munger, PharmD
11. American Pharmacists Association. Collaborative practice agreements vary among the states. http://www.pharmacist.com/ collaborative-practice-agreements-vary-among-states. Accessed November 11, 2013. 12. American Pharmacists Association, Rothholz MC. The role of community pharmacies/pharmacists in vaccine delivery in the United States. http://www.cdc.gov/vaccines/acip/meetings/downloads/ slides-jun-2013/01-Pharmacies-Rothholz.pdf. Accessed November 11, 2013. 13. Chen T, Kazerooni R, Vannort EM, et al. Comparison of an intensive pharmacist-managed telephone clinic with standard of care for tobacco cessation in a veteran population. Health Promot Pract. November 14, 2013 [e-publication ahead of print]. 14. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management of blood pressure control: a cluster randomized clinical trial. JAMA. 2013; 310(1):46–56. 15. Yu J, Shah BM, Ip EJ, Chan J. A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. J Manag Care Pharm. 2013;19(2):102– 114. 16. Rubio-Valera M, March Pujol M, Fernández A, et al. Evaluation of a pharmacist intervention on patients initiating pharmacological treatment for depression: a randomized controlled superiority trial. Eur Neuropsychopharmacol. 2013; 23(9):1057–1066. 17. Verret L, Couturier J, Rozon A, et al. Impact of a pharmacist-led warfarin self-management program on quality of life and anticoagulation control; a randomized trial. Pharmacother. 2012; 32(10):871–879. 18. Knapp DA. Professionally determined need for pharmacy services in 2020. Am J Pharm Educ. 2002;66(Winter):421–429.
College of Pharmacy, University of Utah, Salt Lake City, Utah
REFERENCES 1. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff. 2002;21(1):140–154. 2. Dill MJ, Salsberg ES. The complexities of physician supply and demand: projections through 2025. Washington, DC: Association of American Medical Colleges; 2008. 3. Cooper RA. Unraveling the physician supply dilemma. JAMA. 2013;310(18):1931–1932. 4. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973–1975. 5. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff. 2013;32:1881–1886. 6. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the US health care workforce do the job? Health Aff. 2009;28(1):64–74. 7. Cortese DA. A health care encounter of the 21st century. N Engl J Med. 2013;310(18)1937-1938. 8. My Life Check. Home page. http://mylifecheck.heart.org/ PledgePage.aspx?NavID55&CultureCode5en-US. Accessed November 11, 2013. 9. Institute for the Future. Four Ps represent the future of medicine. http://www.iftf.org/future-now/article-detail/four-ps-represent-thefuture-of-medicine/. Accessed November 11, 2013. 10. Brown DL. A looming joblessness crisis for new pharmacy graduates and the implications it holds for the academy. Am J Pharm Educ. 2013;77(5):Article 90.
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