I want to share my perspective with you—based on many years of experience as a practicing pharmacist—on how our healthcare system fails patients (often inadvertently) as a result of distinct and separate well-intentioned patient care services provided by doctors and pharmacies. Here are some scenarios that capture serious problems I’ve encountered:
No refill without an appointment
Meet our fictitious patient, John Doe, who is completely out of his diabetes medications. When his pharmacy requests a refill from John Doe’s doctor, the response is denied due to waiting for his appointment to recheck his A1c in 2 months. This logic escapes me, as denying him his diabetes medication will only result in an A1c that is out of control in 2 months. Although refill denials are a common occurrence for many patients and for many reasons, most refill denials are not so illogical. I respect that there are numerous legitimate reasons why doctors need to deny a refill, but patients are ultimately forced to go without medication which is a major contributing factor to ER visits and uncontrolled chronic care.
Except for a small group of high-risk medications, denial of routine chronic care medication refills only exacerbates the problem of helping patients manage their health. Despite reading about healthcare slowly moving towards value-based reimbursement, I believe our legacy fee-for-service model still dominates most physician behavior. I continue to attribute the majority of refill denials to our fee-for-service remuneration system—a broken system that forces doctors to require an appointment for every prescription issue (including refills for routine chronic medications) and that leads to overworked doctors reduced to 10-minute appointments.
Not my problem
Meet another fictitious patient, Jane Doe, who just got out of the hospital for a flare up of her heart failure and who has had changes to most of her medications after seeing several specialists while institutionalized. Jane received one-time prescriptions for her new medications from the hospital; however, her primary doctor also sent in refills of all her old medications. Jane’s pharmacy reaches out to her primary care provider to obtain clarification and is told to fill the old doses of her medications until she is seen again for follow up since the PCP was unaware of her hospitalization. Jane reports to the pharmacy that she already had a follow-up appointment with her cardiologist and needs refills for the medications started/changed while in the hospital. The cardiologist is only willing to write refills for the patient’s heart medications, so any other medications changed during her hospitalization have not been addressed.
Because Jane’s pharmacy serves as a medication coordinator for Jane’s multiple specialty providers, her pharmacist is constantly assessing her entire regimen to review for therapy duplications/interactions and keeping all her prescribers informed. This often leads to one prescriber deferring to another doctor and a game of “not my problem” ensues with the pharmacist in the middle and the patient left without therapy or with sub-optimal dosing. Complex patients have a multitude of highly sophisticated doctors caring for them but it is the limitations of our current system that inhibits the care team from functioning optimally for our patients.
No direct prescriber-to-pharmacist communication
In a worst case scenario that occurs far too often, the prescribing doctor is unable to take responsibility for clinical medication issues that arise when the patient has multiple prescribing specialists, the prescribing doctor hasn’t seen the patient for months, or incomplete medication information is stored in the EMR. The pharmacist can spend hours on the phone trying to sort out a patient’s regimen in these cases, and often spends the entire process relaying highly complex medication issues through the front office staff or medical assistants who must be entrusted to relay the nuanced information correctly to providers.
Sometimes, front office staff or medical assistants are empowered to speak on behalf of providers, and pharmacists are left confounded in the face of this adversity when the provider’s designee is adamant those are the medication instructions or visit notes as written in the EMR and refuses to obtain further clarification.
On the flip side, frontline medical personnel are often placed on hold for long periods of time when contacting pharmacies and often must relay medication clarification information through pharmacy technicians, which can increase the likelihood of miscommunication and can put patient safety at risk. In our current healthcare environment, direct communication between pharmacists and prescribers is often a luxury that is not afforded when needed. Our lack of transparency in communicating healthcare events and ineffective means to share electronic information between EMR systems leaves our patients to fend for themselves and, ultimately, ends in confusion and hospital admissions/readmissions.
Too much (and not enough) information
Our final fictitious patient is Stan, who has come in for a Medication Therapy Management comprehensive medications review with his community pharmacist. Stan meets with his pharmacist annually in this formal process for a 1-hour appointment to review all of his medications for efficacy, potential side effects, optimal medication use, and adherence. He leaves the pharmacy with a better understanding of his medications, and his pharmacist is faxing his doctor with recommendations on issues uncovered during the session.
Pharmacists take on this task because it’s good patient care and because aside from dispensing medications, it is one of the few activities for which they can seek reimbursement. The list of medication recommendations that the pharmacist generates to send to the physician is often lengthy and quite comprehensive, as the pharmacist can only typically be reimbursed for this service once yearly. I have personally seen that this massive push of information to the doctor often results in much angst due to “information overload” and may generate a need for yet another doctor appointment to help address the issues identified.
In addition to being “too much information”, these recommendations are often focused on clarifying patient-reported misinformation instead of addressing critically important clinical issues. Without access to the patient’s past doctor visit summaries in the EMR, the pharmacist must rely on what the patient reports that the doctor has instructed them to do. Pharmacies and doctors are set up to have exactly half of the most accurate information available to each party. While doctors have a well documented medical history, they must rely on patient-reported medications or the occasional prescription bottle brought in to a follow-up appointment. Pharmacies have the most accurate active medication list from multiple doctors, but they have no access to the documented medical histories, visit summaries, or medication monitoring labs. This misaligned care example highlights how two players on the patient care team (doctors and pharmacists) lack access to shared medical and medication information resulting in miscommunication both ways.
Stay tuned! In my next article, I will present potential solutions that could strengthen the weaknesses I have identified within our current system-wide care processes. In the meantime, I encourage anyone interested in problem-solving some of these issues to join me in the comments for an inter-professional conversation to better understand how we can bring the community pharmacist back on the care team for the benefit of doctors and patients.