A Far Different Pharmacy

People who come to the Care Partners Pharmacy in Chino Hills these days will see a lot more going on than pharmacists pouring pills into prescription bottles.

On any given day, pharmacist Roger Klotz and his wife, Patricia, a registered nurse, may be showing someone how to work the controls on a new wheelchair, checking a diabetic patient’s blood sugar levels or counseling a patient on how to quit smoking.

The Klotzes are helping to transform the neighborhood pharmacy by providing health services that traditionally have been the province of doctors, nurses and other health professionals working in medical clinics or hospitals.

As managed care has trimmed the profits of many health care businesses, pharmacists across the nation who are no longer able to thrive solely by dispensing pills are attempting to reinvent themselves to survive in the changing medical care marketplace.

Klotz, who says he “can’t make money from prescriptions,” is carving out new territory for his business by attempting to fill gaps in health care services, such as helping people to better manage their medications and offering more preventive health services.

“This country has not done a good job doing preventive medicine,” says Klotz, who offers blood pressure screenings, immunizations and weight-loss programs at his pharmacy. “We need to teach people how to manage their cholesterol, for example.”

The desire of pharmacists to extend their practice scope goes back several decades, says Paul Lofholm, a Marin County pharmacist.

“There was a fundamental shift in the pharmacy profession in the late ‘60s to look at how drugs are used, how we can improve drug therapy and minimize risk,” he says. “It was a focus more on the patient,” rather than the drug.

The movement didn’t gather much momentum until the past decade, however, when pharmacist organizations, such as the California Pharmacists Assn., began hearing more complaints from members who were having trouble staying afloat financially. The problems have been exacerbated as more consumers have bypassed local pharmacies to buy their prescriptions by mail order or the Internet.

At the same time, pharmacists began noticing that many of their customers seemed overwhelmed with questions about their illnesses and their medications. And patients were complaining that their doctors had little time to answer their questions.

“I think pharmacists are seizing an opportunity,” says Eddie Bubar, owner of Eddie’s Pharmacy, an independent pharmacy in West Hollywood that specializes in serving people with HIV. “With the time constraints on the doctor under managed care, who teaches the asthma patient to use an inhaler? Who helps the diabetic patient manage the disease? Pharmacists have a unique opportunity to step in and bridge the gap.”

While only a handful of pharmacists in California and elsewhere have gone as far as the Klotzes, more pharmacies will likely follow suit, experts predict. For one thing, pharmacies can provide some health care services more cheaply and conveniently than doctors.

In Washington state, pharmacists successfully pushed for passage of a law that allows them to dispense emergency contraceptives, which must be taken within 72 hours of unprotected intercourse. The pharmacists argued that their more convenient hours, including 24-hour locations, made them the logical choice.

And, in California, pharmacists are marketing themselves as cheaper, more convenient providers of immunizations.

‘We’re Better Off Letting Doctors Be Doctors’

Pharmacists are treading gingerly, however, because they know that doctors may view their efforts as yet another encroachment on their territory. Nurses and psychologists also have been staking out some traditional doctor duties and pushing for laws expanding their scope of practice.

“One of the problems we have in health care is that everybody wants to be a doctor, because most health care professions are being squeezed by declining revenue. But we’re better off letting doctors be doctors,” says Dr. Sam Fink, a Tarzana internist.

The California Medical Assn., the state’s largest physician organization, initially opposed groundbreaking legislation designed to give pharmacists the ability to monitor and evaluate individual patients in collaboration with the patient’s doctor.

The bill, AB 261, passed and went into effect in January, with the CMA relenting after physician oversight provisions were strengthened.

The law has encouraged more pharmacists to pursue additional training and credentialing in specific medical specialties such as diabetes or asthma, pharmacists say.

At Plaza West Pharmacy in Northridge, pharmacist Leo McStroul manages a group of diabetic patients, following treatment guidelines set by their doctors.

Patients can get finger-stick blood tests to check their glucose on the spot. The pharmacy can also review information from patients’ home glucose-monitoring devices.

“We teach the patient how to manage the disease, such as by making dietary changes,” he says. “As they get better and get the disease more under control, we’ll call the doctor and suggest lowering the patient’s medication. The greatest pleasure I get is recommending to a doctor to take a patient off medication.”

At Klotz’s Care Partners Pharmacy in Chino Hills, having a registered nurse on staff has allowed perhaps the greatest expansion of pharmacy services. The pharmacy is equipped with two private treatment rooms and a small lab.

Klotz, with 34 years of experience in the pharmacy business, trains other pharmacists and has a waiting list of pharmacy students seeking internships.

While independent pharmacists like Klotz have been most eager to expand services, chain pharmacies are also getting into the act. “Pharmacists in every practice setting are saying, ‘I can do more,’ ” says Susan Winkler, director of policy and advocacy for the American Pharmaceutical Assn. in Washington, D.C.

While the sheer number of prescriptions filled by chain drugstores may make it harder to offer more service, new automated pill counting and labeling devices are expected to relieve the pharmacist of some of the more mundane work, Winkler says.

In a pilot project of CVS, the giant drugstore chain, and Pfizer Health Solutions, three CVS pharmacies in New Bedford, Mass., Philadelphia and Washington, D.C., are offering doctor-like services to patients with chronic illnesses and other health problems to see if the services will appeal to customers.

To participate, patients must get permission from their doctors, who oversee treatment and can discontinue the service at any time, says Jeffrey Gross, president of the venture, called Community Health Care Solutions.

So far, most doctors have agreed to participate in the program, called Health Connections, when asked, and several insurers have agreed to pay for care that their members receive through the program.

Specially trained pharmacists see 500 to 700 patients a year and do countless other consultations and screenings. But, Gross says, CVS is not ready to take the program, launched in late 1997, nationwide--yet.

Finding a Niche in Immunization

Big drugstore chains in California have been reluctant thus far to take the plunge into new services. The one exception is immunizations, such as flu shots or hepatitis vaccines, which are widely offered by many independent pharmacies.

Thirty states allow pharmacists to provide immunizations, and about 250 pharmacies in California offer the service, says Lofholm, a former professor of pharmaceutical science at UC San Francisco.

By providing extra services such as immunizations, pharmacists say they save customers time and money.

“People are making a decision that they want this,” says Lofholm. “They will choose to pay us $70 for hepatitis B immunizations [which require three shots over six months] because we’re convenient.”

The hepatitis B shots, which are required for children prior to seventh grade, are an example of a service that pharmacists can excel at, says Michael Pavlovich, president of the California Pharmacists Assn. Thousands of California families have struggled to get their sixth-graders immunized on time.

“If the health care system had organized to utilize pharmacists, I think we’d see far fewer problems with hepatitis B vaccination,” he says.

Pharmacists also point to the well-known problem of misuse of medications as justification for their increased involvement.

“The country is realizing that medications are safe and effective when used correctly. We used to leave off that last phrase, ‘when used correctly,’ ” says Winkler.

Up to a quarter of nursing home admissions are due to the patient’s inability to take or manage their medications correctly, says Bubar.

“The cost of misusing drugs is huge,” he says. “We feel pharmacists can make big inroads in this area.”

For example, studies show that as many as 60% of patients on cholesterol-lowering drugs stop taking them within the first year. However, a recent study in the Journal of the American Pharmaceutical Assn. found that pharmacists who manage patients in collaboration with a doctor can improve patient compliance dramatically. In the study, more than 90% of the patients stayed on their medication and 62% lowered their cholesterol to a target goal.

But some doctors are questioning whether pharmacists should be providing these extras and point out potential problems, such as a potential lack of continuity in a patient’s care.

Fink, for example, says he has encountered patients who have received two flu shots--one at the pharmacy and one at the doctor’s office.

“Pharmacists are wonderful; they can catch drug interactions and can let us know when a patient is taking too many drugs,” says Fink. “But a physician should manage a patient’s medication.”

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It is the competition for scarce health care dollars that has motivated pharmacists to seek an expanded role.

“The fact is that managed care has taken the profit out of filling prescriptions,” says McStroul. “Unless we charge for [other services], we can’t stay afloat.”

But pharmacists are struggling with the question of who pays for such things as glucose tests, smoking cessation counseling and other services. Few managed care companies will reimburse a pharmacist for extra services. One of CVS’ biggest hurdles has been to establish reimbursement levels for pharmacy care, notes Gross.

On a national level, the American Pharmaceutical Assn. has urged the federal government to allow pharmacists to provide medication management if a prescription drug benefit is offered under Medicare.

But, right now, there is no overarching system to reimburse pharmacists, and patients usually pay out-of-pocket for extra services, says Klotz.

“Most patients pay for it because their [insurers] won’t pay for well care anyway; such as immunizations, smoking cessation, blood pressure checks, a weight loss program.”

Convincing consumers that such money is well-spent--and convincing their doctors that pharmacists are addressing an important need--will be crucial to pharmacists who want to expand, says Klotz.

“If this is successful, it will because patients and doctors accept it.”