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Out From Behind The Counter, Pharmacists Bring Their Own Take To Health Care

By Soumya Karlamangla, Los Angeles Times (TNS)

LOS ANGELES — Jose Alvarez clutches a red drawstring bag as he hobbles into a small office. He leans his crutches against the wall and takes a seat in the corner. His seven pill bottles, of varying heights, create a miniature skyline of orange and white.

A heavyset man with a scraggly beard, Alvarez has diabetes, high blood pressure, and asthma. He’s here at this clinic in East Los Angeles for his two p.m. appointment with Sangeeta Salvi.

“I was in denial for a very long time,” Alvarez, 42, says about his diabetes. Now he comes in every three weeks to discuss his medications, diet and exercise with Salvi.

Despite the white coat slung over the back of her chair, Salvi isn’t a physician, but a pharmacist.

She’s one of a growing number moving out from behind grocery store pharmacy counters across the country and seeing patients in new ways, part of a push to reduce health care costs, address social issues that impede people’s health, and ease a national shortage of primary care physicians.

Steven Chen, a University of Southern California clinical pharmacy professor, runs this pilot initiative at ten clinics belonging to AltaMed, a nonprofit clinic network that serves largely low-income populations in L.A. and Orange counties.

In a health care system that often seems impersonal and intimidating, pharmacists can act as a much-needed sympathetic ear and source of advice, spending extra time with patients.

“That’s the reason why we’ve been very successful,” Chen says, “because someone is taking the time to sit with the patient.”
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Team-based medical care, in which multiple health care professionals work together to treat a patient, is a central feature of the Affordable Care Act. But as different workers collaborate, there’s concern that pharmacists could overstep their bounds.

“Every member of the team is critical but not interchangeable,” says Reid Blackwelder, board chair of the American Academy of Family Physicians.

Pharmacists’ role is fundamentally different from doctors’; whereas doctors try to diagnose a root problem, pharmacists just try to make the symptoms better. Pharmacists are best trained to determine appropriate uses and dosages of medications to help patients with their problems.

Nearly 90 percent of patients with chronic illnesses take medication as the first line of treatment. In the United States, between a third and a half of patients don’t take their medicines properly, which — along with poor prescribing and diagnoses — costs the health care industry as much as $290 billion a year, according to the New England Health Care Institute.

On average, clinical pharmacists in the USC program find ten drug-related problems per patient — things such as taking the wrong dosage or missing a needed medicine.

But they also act as a sort of medical counselor, helping patients with a range of issues, including diet, exercise and stresses of all kinds. Many pharmacists taking part in the USC initiative — funded by a $12-million federal grant — also call insurance companies and drug manufacturers to make sure patients can get needed medications.

“Our patients need that,” says Rosie Jadidian, director of pharmaceutical services for Community Clinic Association of Los Angeles County. “They’re waiting on bus schedules, and their lives are organized in different ways. They need that one-stop shopping.”
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Sitting face-to-face in her cramped office, their knees almost touching, Salvi and Alvarez review the medicines he’s taking.

Three times a day. Eight milligrams. Before meals. When I wake up.

Pharmacists at AltaMed clinics are paired with patients they can help most: those with chronic illnesses.

When Salvi first started treating Alvarez, she realized he was using only a quick-relief inhaler, not one for long-term control.

Now that he’s taking the preventive inhaler regularly, Alvarez, who lives in Boyle Heights, says he hasn’t experienced much shortness of breath.

“It’s only been a month and a half, two months, and I’ve noticed a difference,” he says.

Salvi says the fast-paced work of clinical pharmacy was more appealing than working behind a counter.

“We’re directly involved in their care,” says Salvi, who’s been treating patients at AltaMed clinics for two years. “We develop a strong relationship.”

Patients usually see their pharmacists once a month, while they see their primary care doctors a few times a year. And pharmacist visits are typically longer, lasting up to an hour.

Alvarez has had diabetes for more than ten years. He lost his job as a chef last year because of a foot ulcer that made it impossible for him to stand all day in the kitchen. After he lost a toe in January, he decided to start trying to keep his diabetes under control.

After consulting her notes, Salvi asks Alvarez whether he’s still eating eggs and two pieces of wheat toast for breakfast. He says he’s reduced it to one slice.

“I used to drink a two-liter Coke by myself at lunch,” he says. Now, he has half a 23-ounce Arizona iced tea with his midday meal, but he’s working to cut that out too, he says.
Salvi tells him that breaking a habit cold turkey is always difficult. “Remember to take baby steps,” she says.
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Clinical pharmacists are part of a burgeoning number of recent medical interventions that aim to increase access to medical care. Across the country, patients can see a nurse or a pharmacist at new retail clinics, urgent-care clinics, and kiosks. Some patients can also now talk to a health care professional on video chat.

“It’s probably exhilarating and also a little overwhelming,” says Dr. Ateev Mehrotra, a Harvard Medical School professor who studies innovations in health care delivery.

Because these innovations often take care out of the hands of doctors, many of them also help with the shortage of providers across the country that worsened with the expansion of health insurance under the Affordable Care Act.

The nationwide shortfall of primary care doctors is expected to grow to about 45,000 by 2020. Almost a quarter of Californians already live in a primary care shortage area, according to state data.

A California law went into effect last year that allows pharmacists to bill for medical care — seen as a step toward solidifying their expanded roles outside pharmacies. Congress is considering a similar bill, but critics say that an already costly health care system can’t afford to pay another provider.

Early data from the AltaMed initiative shows that bringing in a clinical pharmacist saves money overall by reducing hospitalizations and other expensive medical treatments, but initially increases costs both to pay the pharmacists and to provide more medicines.

Historically, that’s made clinical pharmacists a hard sell because clinics haven’t been financially responsible if a patient ends up in the hospital, so there is little incentive to pay for the extra service. That’s slowly changing with the Affordable Care Act, as payment models shift so providers are rewarded if patients stay healthy, and penalized if they don’t.

At AltaMed clinics, pharmacists’ schedules are almost always booked.

Salvi takes Alvarez’s blood pressure one last time. With a smile, she tells him she thinks they’ve covered everything for the day.

She tentatively schedules him an appointment in three weeks, because he’s not sure when he’ll be free next month.

“I’m sure we’ll be calling you anyways,” Salvi says. “You know how we are.”

Photo: Allen J. Schaben via Los Angeles Times/TNS

More U.S. Consumers Are Seeking Medical Care, Report Shows

By Chad Terhune, Los Angeles Times

A historic slowdown in U.S. health care spending in recent years may be drawing to a close.

An industry report published this week and health care experts point to a steady rise in medical care being sought by consumers seeing specialists, getting more prescriptions filled and visiting the hospital. Other factors such as millions of newly insured Americans seeking treatment for the first time and higher prices from health care consolidation could also help drive up costs.

Experts aren’t predicting an immediate return to double-digit increases in medical spending. But the emerging trend underscores how difficult it will be for policymakers, employers and health plans to control health care costs going forward.

“2013 was a rebound year for health care,” said Murray Aitken, executive director of the IMS Institute for Healthcare Informatics, an industry research firm that released Tuesday’s report. “We saw health care usage overall up for the first time in three years. We think that is reflective of a strong economy, more patients with insurance and also some pent-up demand for services that may have been delayed or deferred since the economic downturn.”

David Gruber, director of health care research at Alvarez & Marsal, said he’s expecting a similar trend of higher demand coupled with consolidation among hospitals and large physician groups pushing up prices. He said the demand for services is being driven by an influx of Obamacare enrollees, aging baby boomers and people with chronic conditions who can no longer delay care.

“At some point you can’t defer anymore,” Gruber said. Health spending “isn’t going up by double digits, but it could spike to 6 percent or 7 percent.”

There are other forces at play that could serve as an effective counterweight and bear watching. The growing use of narrow provider networks by employers and health insurance companies and a shift away from conventional fee-for-service reimbursement for medical providers can be potent cost-containment tools, Gruber said.

On Monday, the Congressional Budget Office cited the prevalence of narrow networks as one reason premiums for Obamacare coverage in government-run exchanges will be lower in the next few years than previously expected.

David Axene, a fellow at the Society of Actuaries, estimates that rates for individual consumers under the health law may rise, on average, 6 percent to 8.5 percent next year. He cautions that rates will vary across the country, and some health insurers such as industry giant WellPoint Inc. have already warned about double-digit rate hikes in some markets.

“Many exchange health plans got better discounts than anticipated from providers, but there is really a strong pushback now from hospitals and physicians who are concerned about having enough money to cover their costs,” said Axene, an actuary in Murrieta, Calif. “I hope we can stay south of double digits, but there’s no guarantee we will.”

From 2009 to 2012, U.S. health care spending grew annually at less than 4 percent, according to federal data. That’s been the lowest rate of growth in half a century, and has sparked considerable debate about the underlying reasons.

Many health economists and industry officials have attributed the slowdown primarily to lingering effects of the Great Recession, when millions of Americans cut back on medical care. But the Obama administration and other experts have pointed to fundamental changes in health care reimbursement and the delivery of care spurred by the Affordable Care Act.

The IMS Health report found that total U.S. spending on pharmaceutical drugs grew 3.2 percent last year to $329.2 billion. That came after a 1 percent drop in 2012 — the first decline since IMS began tracking the data in 1957.

Patent protections expiring on major drugs and cheaper generic substitutes flooding the market helped drive that previous decrease. Aitken said patent expirations had less impact last year and there was greater use of health care in general.

IMS Health also found that the number of physician office visits, hospitalizations and prescriptions filled all rose last year.

At the doctor’s office, visits to primary care physicians fell less than 1 percent, but trips to specialists jumped 5 percent. The number of hospital visits also grew last year, primarily among commercially insured patients who received outpatient treatment.

Any upswing in medical costs could further squeeze workers. Their health insurance premiums keep taking a bigger bite of their paychecks, as employers shift more health care costs to employees.

There was some good news for consumers. The IMS report found that 57 percent of all retail prescriptions filled last year cost consumers $5 or less. But patients often bear a growing share of the cost for high-priced specialty medications for cancer, rheumatoid arthritis and other chronic conditions.

Will O’Neill via Flickr