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Tiffany Erickson is accustomed to seeing type 2 diabetes patients struggling to manage a complicated treatment regimen of pills, blood glucose monitoring, and multiple daily insulin injections.
Erickson isn't, however, a physician. She's a clinical pharmacist—a PharmD—at Harborview Medical Center in Seattle, and it's her job to help patients sort their way out of the medication morass they sometimes find themselves in.
Carey Jackson, MD, is one of several Harborview primary care physicians who regularly sends patients to Erickson. Having Erickson on hand for diabetes medication management means all of Jackson's patients, particularly those still learning English, get better quality care, he says. "We can use our time to make diagnoses and handle new problems" while Erickson provides needed diabetes counseling, explains Jackson, medical director of the hospital's International Medicine Clinic.
Each month Erickson sees about 50 people who for one reason or another—perhaps youth, mental disability, cultural barriers, or misunderstanding—need extra guidance monitoring their blood glucose levels and taking what can be a complicated set of diabetes medications. Her unusual clinical role derives from a 1979 Washington state collaborative practice law that grants pharmacists the authority to adjust and monitor medications through individualized agreements forged with physicians. About 45 states now have such laws; Washington is considered a collaborative practice leader because of the many physician-pharmacist agreements the law has fostered there, say industry observers.
The collaborative laws aim to promote more continuous health care management, says Stuart T. Haines, PharmD, FCCP, FASHP, professor and vice chairman of University of Maryland's School of Pharmacy in Baltimore. They target any number of diseases or health issues, but diabetes-focused ones are prevalent because of the complexity of diabetes management.
Perhaps one of the best-known of these collaborations is the Asheville Project in North Carolina, which significantly decreased patients' and employers' health care costs, according to a yearlong study (DOC News, April 2006, page 14).1 Following this project's success, in 2005 the American Pharmacists Association launched the Diabetes Ten City Challenge, which involves partnerships among self-insured employers, diabetes educators, and pharmacists in the interests of encouraging prevention, better outcomes, and cost reduction.2
There can, however, be drawbacks to such collaborations, including fragmentation of care and lack of insurance reimbursement, so careful record-keeping and creative budgeting are key to their success, says J. Mark Beard, MD, an assistant professor in the family residency program at University of Washington in Seattle.
MULTIPLE BENEFITS
In the Harborview collaboration, pharmacists with appropriate postdoctoral training do everything from measuring blood pressure and glucose and reviewing meter results to coordinating medication adjustments and examining feet for ulcers.
"Basically, the pharmacists are side by side with physicians," says Cindi Brennan, PharmD, MHA, president of the American Society of Health-System Pharmacists in Washington, D.C. "The physicians evaluate patients, then refer them to the pharmacist for medication prescribing, education, adjustment, etcetera. It is far easier to establish collaborative relationships when you work together in the same clinic."
As primary care physicians see ever more diabetes patients, pharmacists can help save them time while ensuring rigorous patient tracking and staving off patient complications, says Beard. For example, research suggests that pharmacist collaborations can benefit patients' blood glucose control. A University of Washington study, published in 2005 and conducted in the university's neighborhood clinics, found pharmacists' intervention allowed for glycated hemoglobin (A1C) control comparable with that achieved through physicians' intervention, and accomplished with fewer visits to physicians.2 Studies appearing before and after 2005 in various other states have produced similar findings.3–6
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These blood glucose reductions, in turn, result in lower diabetes complication rates. "National and international studies have documented that better control of diabetes lowers the risk of cardiovascular, renal, and ophthalmological complications, and we believe this is happening with our patients," says Beard.
These collaborations also can bring returns from pay-for-performance insurance programs tied to patient compliance, says Beard. Medicare—among the major proponents of pay-for-performance—awards a premium on reimbursement to providers whose patients meet compliance goals set by the Centers for Medicare and Medicaid Services.
CHALLENGES REMAIN
Electronic medical records are key to collaborative agreements' success, but patient care can suffer if there is lack of communication between providers about treatment goals, some physicians note. Poor communication and tracking of patient treatment also could impede pay-for-performance reimbursement, Beard says.
"Partnering with pharmacists can be a wonderful option, but care must be taken not to fragment care to different providers," Beard cautions. A lack of communication between providers can mean repeat testing and thus increased costs, he says.
Another challenge facing collaborative agreements is inadequate reimbursement for pharmacists' clinical services, says Brennan. Pharmacists are not considered "providers" by Medicare, which means they cannot bill like physicians, nurse practitioners, and physician assistants. Many other third-party payers follow Medicare's lead so, unless patients can pay out of pocket for pharmacists' services, they cannot afford them.
The collaborative agreement at Harborview Medical Center, however, finds a way around this problem: When primary physician Jackson sends a patient to pharmacist Erickson for diabetes management, for example, the hospital covers the cost of her services as a physician extender—to save on using physician time.
Obviously, the affordability of such arrangements depends on the individual
facility. Time will tell if others follow suit. 
Footnotes
More information about the Diabetes Ten City Challenge is available at www.aphafoundation.org/programs/diabetes_ten_city_challenge/62.cfm.
The Pharmacy Access Partnership explains how collaborative practice agreements work at www.go2ec.org/CollabPracticeAgreements.htm.
To learn more about the Asheville Project collaboration on diabetes care between primary care providers and pharmacists, see www.pharmacytimes.com/files/articlefiles/TheAshevilleProject.pdf and www.aphafoundation.org/programs/Asheville_Project.
References
2. Odegard PS, Goo A, Hummel J, et al.: Caring for poorly controlled
diabetes mellitus: A randomized pharmacist intervention. Ann
Pharmacother 39:433–440, 2005.
3. Clifford RM, Davis WA, Batty KT, et al.: Effect of a pharmaceutical
care program on vascular risk factors in type 2 diabetes: The Fremantle
Diabetes Study. Diabetes Care 28: 771–776, 2005.
4. Nau DP, Pacholski AM: Impact of pharmacy care services on patients' perceptions of health care quality for diabetes. J Am Pharm Assoc 47:358–365, 2007.[Medline]
5. Horning KK, Hoehns JD, Doucette WR: Adherence to clinical practice guidelines for 7 chronic conditions in long term care patients who received pharmacist disease management services versus traditional drug regimen review. J Manag Care Pharm 13:28–36, 2007.[Medline]
6. Carmichael JM, Alvarez A, Chaput R, et al.: Establishment and
outcomes of a model primary care pharmacy service system. Am J
Health Syst Pharm 61:472–482, 2004.
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