The burden of chronic diseases ranks as one of the leading causes of morbidity and mortality in the U.S. and yet it is steadily increasing. Approximately 71 percent of the U.S. total healthcare spending is associated with care for individuals with more than one chronic condition. It is reported that, among Medicare fee-for-service beneficiaries, those with multiple chronic conditions account for 93 percent of total Medicare spending.¹ Thus, to meet the demand, improve public health and decrease cost, health care is shifting towards a multidisciplinary, team-based care approach.

Pharmacists are uniquely positioned to play a role in the healthcare delivery system through the utilization of collaborative practice agreements (CPAs). CPAs are formal practice agreements between pharmacists and physicians that expand clinical responsibilities of pharmacists.² Michigan law allows pharmacists to enter into CPAs under physician delegation which allows Michigan pharmacists to support patient care and engage with providers at the highest level of licensure.³ CPAs identify the patient population and diseases that are covered under the CPA. This specification may include single or multiple disease states such as hypertension, asthma, COPD, diabetes, etc., or age restrictions, just to name a few. Once the patient population has been identified, the CPA will then outline patient care activities that pharmacists can provide under specified situations and conditions. Practitioners can determine the interventions that pharmacists are authorized to make, which may include initiating, modifying, discontinuing or monitoring drug therapy. Other examples of delegated responsibilities include obtaining labs such as ordering A1C levels for a diabetic patient, adjusting antihypertensive therapy as necessary, performing follow-up calls post-patient discharge, vaccine administration and dispensing naloxone.² Note that Michigan does not have a statute that restricts or provides guidance regarding CPAs between physicians and pharmacists. The restriction is based on the agreement and the scope that the delegating physician authorizes. Given that pharmacists are ideally suited to improve medication use, adherence and outcomes, CPAs benefit not only the patient, but health care overall.

Patients receive a multitude of benefits from CPA practices. Research consistently shows that patients who engage with pharmacist-provided clinical services are more likely to meet their health outcome goals and to be on guideline-directed preventative therapies. This downstream allows patients to live healthier lives, which ultimately decreases hospital readmission rates and prevents issues that result from uncontrolled chronic conditions. These results are especially significant for the most vulnerable patients with an increased disease burden who are offered pharmacist services. Most commonly, these services have been studied as part of the management of diabetes and asthma. Importantly, patients report increased satisfaction with their overall health care when a pharmacist is part of the clinical team.^4-6 Figure 1 displays clinical outcome data following pharmacist interventions and CPA.

Figure 1.  Reported benefit to patient outcomes following pharmacist interventions made under authority of a CPA.

*indicates Michigan data.

CPAs also display cost-saving within the healthcare system. Touchette and colleagues reviewed studies on the economic impact of clinical pharmacy services and found that the benefit to cost ratio varied from 1.05:1 up to 25.95:1.⁷ A survey of hospitals in Illinois, Indiana and Michigan completed by Thomas and colleagues showed that hospital administrators believe that pharmacist drug therapy management contributes to the strategic vision of the hospital.⁸ These outcomes provide benefits for both the pharmacist and the health-system by allowing for a broader impact of healthcare services.

With health care shifting to an outcomes-based model, patient benefits also end up benefiting the overall health-system. Bunting and colleagues demonstrated a direct cost decrease of $725 per patient per year with their asthma medication management services.⁴ This offers a significant opportunity for health-systems to retain valuable medical dollars by reducing the number of re-hospitalizations. In their diabetes management clinic, Anaya and colleagues similarly demonstrated a significant mean cost savings of hospitalizations and emergency department admissions of nearly $1,800.⁹ These cost savings add up and are significant for health-systems to maximize their capitated reimbursement.

Developing CPAs requires trust and open communication between the two parties. As trust between the providers is being established, it is important to identify the roles of both the pharmacist and practitioner during this time to better understand each other’s skills and competence. This is made possible through frequent interaction, which is highly encouraged to further strengthen the pharmacist-practitioner relationship. Once a relationship has been established, the CPA can be created based on the agreed upon guidelines between the two parties.

CPAs illustrate practice relationships between pharmacists and prescribers and integrate pharmacists into the team-based care model. It allows pharmacists to screen for qualifying patients and provide treatment based on standards identified within the protocol or procedure.

References:

1. Centers for Disease Control and Prevention. Multiple Chronic Conditions. https://www.cdc.gov/chronicdisease/about/multiple-chronic.htm. Accessed June 2019.
2. National Alliance of State Pharmacy Associations. Pharmacist Collaborative Practice Agreements: Key Elements for Legislative and Regulatory Authority. https://www.accp.com/docs/positions/misc/NASPACPAWG.pdf. Accessed June 2019.
3. Choe HM, et al. Michigan Pharmacists Transforming Care and Quality: Developing a Statewide Collaborative of Physician Organizations and Pharmacists to Improve Quality of Care and Reduce Costs. J Manag Care Spec Pharm 2018; 24(4):373-378.
4. Bunting BA, et al. The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma. J Am Pharm Assoc 2006; 46:133-147.
5. Chisholm-Burns MA, et al. US Pharmacists' Effect as Team Members on Patient Care: Systematic Review and Meta-Analyses. Med Care 2010; 48:923-933.
6. Garwood CL, et al. Preliminary Data from a Pharmacist-Managed Anticoagulation Clinic Embedded in a Multidisciplinary Patient-Centered Medical Home: A Coordinated Quality, Cost-Savings Model. J Am Geriatr Soc 2014; 62:536-540.
7. Touchette DR, et al. Economic Evaluations of Clinical Pharmacy Services 2006-2010. Pharmacotherapy 2014; 34(8):771-793.
8. Thomas J, et al. Survey of Pharmacist Collaborative Drug Therapy Management in Hospitals. Am J Health-Syst Pharm 2006; 63:2489-2499.
9. Anaya JP, et al. Evaluation of Pharmacist-managed Diabetes Mellitus under a Collaborative Drug Therapy Agreement. Am J Health-Syst Pharm 2008; 65:1841-1845.