Magazine Artlicle 3/2000
This is a summary of an article published in the March, 2000 issue of The Pharmaceutical Journal, the official journal of the Royal Pharmaceutical Society of Great Britain
Pharmaceutical Care in Minneapolis ? Initial Impressions
By Graham Calder, MPhil, FRPharmS
The author describes a short visit to Minneapolis to learn about pharmaceutical care there. The emphasis on pharmacists taking responsibility for patients? drug related needs and being accountable for those needs concurs with the clinical governance agenda.
Bill Brown, a former, well respected senior lecturer at the School of Pharmacy, University of London, who also for a time was the chief pharmacist at St. Bartholomew?s hospital and an influential member of the Noel Hall committee, had a priceless gift of putting into one telling phrase a multiplicity of contemporary philosophies. In the late 1960?s and early 1970?s, when the American version of clinical pharmacy was thought by many to be the solution to all British hospital pharmacy problems, Bill was quoted as saying that, to get ahead in the 1970?s as a hospital pharmacist, you did not need an MSc, a PhD or even a PharmD. What you did need was an entirely new degree ? a ?BTA? (Been To America) ? and there is still a tendency to think that the grass is greener on the other side of the Atlantic.
Patient Centered Care
In pharmacy, one of the current buzz phrases is ?pharmaceutical care?, a term which was drawn to the attention of the profession in part by the work of Professor Linda Strand and her colleagues in Minneapolis. However, the original pharmaceutical care definition has been refined and changed and adapted. Moreover, it appears that how it is defined is determined by what one wants it to mean politically. The system and the practice of pharmaceutical care, as described by Cipolle et al2 was and is the subject of an intensive and extensive and successful trial in Minneapolis. It is apparently attractive to the US Government, to health insurance groups and also to patients since it puts patients and the management of their medications at the core of the practice of pharmaceutical care. The medicinal product and its management is no longer the center and focus of a caring pharmaceutical practice. In short, the focus has shifted from product to patient.
In the past, I have visited and worked in the US, Denmark, Sweden and France and tried to bring into my practice those aspects of pharmacy practice from these countries that are relevant to Scotland. I have recently completed an MPhil study on the remuneration of community pharmacy in Scotland.3 While I was undertaking this study, I was impressed by the Minneapolis model since it appeared to have achieved on a reasonably large scale a sound and acceptable method of paying for the provision of pharmaceutical care. Moreover, the level of payment achieved seemed acceptable to pharmacists. Public and private health insurance organizations seemed, in addition, to accept both the methods of payment and level of rewards generated. Mindful of past experience in which the reality in a foreign country (including other parts of the United Kingdom as well as ?abroad?) was not always as it appeared on paper. I thought it wise to go ahead and see for myself.
The College of Pharmacy Practice has a project financed by the Scottish Pharmaceutical General Council on the cost of pharmaceutical care. With help from a grant from the John Harris traveling trust and an invitation from Professor Linda Strand, I visited the Peters Institute of Pharmaceutical Care at the University of Minnesota in Minneapolis in December 1999.
Impressions
My initial impressions of the Minnesota system and its relevance to the UK and, in particular Scotland, are as follows.
Clinical pharmacy as a specialty is dead in US hospitals. Pharmaceutical care as practiced in Minneapolis, and increasingly in many other places in the US and also in Taiwan, Germany, Spain and the Republic of Ireland, makes the pharmacist responsible and accountable for ensuring that a patient?s treatment with medicines is carried out in an efficient and effective manner. The taking on of this responsibility and accountability is what clinical governance is all about. It is the individual pharmacist who accepts the responsibility and is accountable and not the proprietor of the business or the superintendent of the company. The taking on of that responsibility and accountability by pharmacists has encouraged the insurers to pay well for the service. A quote from Professor Strand sums it up: ?Nobody cares how much you know, until they know how much you care.?
Pharmaceutical care as developed by Cipolle et all is a generalist?s practice. In other words, the pharmacists do not target patients with specific conditions, such as hypertension, asthma or diabetes. Their patients may well have these conditions, but patients are not chosen on the basis of their diseases. Thus pharmaceutical care is not a ?specialty?; neither does it attempt to provide an elitist service. It is a very high standard of generalist care as required by a high number of community pharmacists who at first were afraid of what they thought was required, adapted very quickly once the penny dropped.
The teaching and orientation course developed by Cipolle et al2 is superb and is being replicated throughout the US and being completed by an increasing number of community pharmacists. The course takes into account the fact that the community pharmacist has to make a living. It recognizes that the provision of pharmaceutical care may require an adjustment to the method of doing business. Therefore, the training program includes assistance and a template business plan for those who wish to change the nature of their business. On successful completion the pharmacists become ?accredited pharmaceutical care practitioners?. Accreditation is by the American Pharmaceutical Association or the state or both. I was told that until community pharmacists grasped what was implied in taking responsibility for the care of a patient it was easier to teach pharmaceutical care to nurses than to pharmacists. Nurses are taught from day one the philosophy and practice of patient care whereas pharmacists are not. Many pharmacists have, of course, acquired the necessary skills by themselves without being fully aware of it.
Multiples in the US are increasingly introducing the service to their practice. For example, the fourth largest multiple, which has 3,800 branches, is increasingly introducing the model to its pharmacies. I was told that they have found that patients receiving pharmaceutical care in the branches show a loyalty to the pharmacist and not the pharmacy. If the pharmacist is moved to another branch, the patients receiving care from that pharmacist move with him or her even where such a move causes the patient inconvenience. If this also occurred in Scotland and the rest of the UK, it would have a profound effect on the organization and delivery of pharmaceutical care within the National Headquarters.
Dispensing is poorly paid in the US and payment PBMs reduce the mark up on pharmaceuticals.
Good documentation of the whole pharmaceutical care process (including the monitoring of the care provided) is necessary if payers are going to pay for the service.
Paper documentation is an anachronism and will delay the introduction into community pharmacy of pharmaceutical care because of the time involved in completing the paperwork.
In my view, the real achievements of Minneapolis, as far as Scotland is concerned, is the development over 10 years of two flexible, user-friendly, relatively inexpensive software packages, which fully document and audit the process and calculate the fee to be charged. In addition, the packages used together provide a database of considerable value to pharmacists and other health care providers as well as licensing authorities and the pharmaceutical industry. Other countries are now using those packages.
The second relevant achievement is that payers are paying for the service because the costs of the service come from the patient care budget and not from the product and supply budget, which has traditionally been the case in the US and the UK.
The Peters Institute research team has a medical anthropologist (Dr. Peter Morley, who is not a pharmacist) on the team, which brings a refreshing dimension to the work.
The Minneapolis team wants to learn from us as well as sharing its experiences and mistakes along the way. Far from being ivory tower gurus, they are a sound, feet on the ground research and practice orientated group. Dr. Cipolle, for example, comes from a family who owned several community pharmacies in Chicago in which he began his professional practice. He fully appreciates and accepts the need and the desire of community pharmacists ?to make a dollar?.
Conclusion
Fads come and go. The good leave their mark while the bad are best forgotten and put down to experience. I suspect that pharmaceutical care as a political, semantic occupational strategy has little prospect of a lasting success. However, pharmaceutical care that is acceptable to patients, the National Health Service and pharmacists (where the pharmacists take responsibility for the care provided) and is remunerated will leave a positive mark on our profession in the years to come. |
