Dear Billy
Nice to be in touch again. Sorry to have delayed reply, I've been on two
weeks leave. Reading your message my first reaction is: I should have
thought it to be the other way round! Using the sorts of PC tools there are
around these days, generating a PC plan and carrying it through with the
patient ought to be a relatively easy process to determine, and thus
reasonably easy to cost, price it, and market it.
To illustrate this point let me say that I have the difficulty, in this
Health Service, getting clinical pharmacy services better resourced for
precisely the reasons given in your message as being what makes PC hard to
market - the outcomes (and thus cost-benefits) are hard to demonstrate! I
have only been able to convince management here that we are severely under
manned by benchmarking the resources required on a clinical pharmacist FTEs
per bed-type in comparison with other Services. We have simply had no data
to convince them that a new approach to Pharmacy will bring additional
health/cost-benefits, we can only make them understand we don't have the
same level of personnel that other Services have, 'therefore' our patients
are at a disadvantage. It's a pretty poor argument really. But let me get
back to your points.
Costing CP is harder, I think. The time required for defined clinical
pharmacy activities (such as MCR or generating a medication history &
profile) even within a fixed DRG, can vary markedly between individual
patients. It is therefore, in my opinion, as hard, if not harder, to cost CP
accurately than to estimate time requirements to generate a PC plan. In
many cases, PC is applied in contexts with less complex cases - the average
patient for PC in the community pharmacy setting for example, would
generally be less complex than hospital medical in-patients. So PC in many
instances should be a simpler, more regular process, which would be easier
to price.
Since we know there are difficulties in getting certain aspects of PC
measured and valued we may have to adopt strategy that does not over-promote
PC capability. Basic promotion could, for example, focus on PC as "risk
management" which shows a transparent optimisation of therapeutic activity
while minimising adverse effects/events. On this alone the basic price for
the basic process could be set fairly easily. If other benefits are gained
these can become items of added-value, making the basic price seem better
than ever.
I agree that, of course, measuring improvement in health outcomes from PC is
often a hard thing to do, and the more so if there is no baseline of
comparison, as so often there is not. But here we should consider what we do
. . . Because we are eager to help, too often the patient is not measured
in the current therapeutic strategy, but put immediately into the 'best' one
we can devise. We ought to consider leaving the patient on the existing
strategy (even though we already may feel we know, or at least suspect, how
and why it could be bettered) just so that we can get a proper measure of
their status. When we have that, THEN we can direct them towards improved
therapy via a PC plan. Then we can measure the difference between the two.
Without this difference there is nothing to show the impact of PC. With it,
the results should be unarguable.
If consistently successful we can then argue for improvement of the 'basic'
price. Even more would we be able to negotiate better recognition and reward
if we can show structured comparative trials where randomised groups from a
defined set of patients is given either none, or some, or much PC (or CP)
support. We should expect better results the more PC (or CP) involvement
there is. Results will demonstrate not only the fact of the effect of PC/CP,
but may yield real trends (ie more care = better results). The null
hypothesis would be: pharmacy involvement makes no difference.
As to difference between CP and PC, I think this is becoming a sterile
argument. Let's cut through the debate about terms to the most important
point: we are skilled professionals using various tools to monitor and
manage medication. What we call whatever tools we use to understand the
patient and their medication is not so important as ensuring that we do
provide a true professional service. Our profession does not exist just to
'provide' medications. We do do that, of course, but we have grown way
beyond that. We provide in such as way as to ensure two 'outcomes'
a) The achievement of as much therapeutic good as possible out of the
medications used (a positive quality assurance approach, or "designing for
the best at the start")
b) The minimisation of foresee-able adverse effects/events (risk
management approach)
We do it because we are professionals, and because "it is our duty to care
for health" (that, incidentally, is the motto of the Royal Pharmaceutical
Society GB - did you know?). We take time to do it, and we are justified in
requiring decent rates to cover the time and skills applied. I cannot see
that clinical evaluation of the patient can be separated from the care
planning for the achievement of good medication management. I thus have
considerable doubt that PC and CP are so different. They seem to be to be
just emphases on certain aspects of the overall care. What I like about PC
is that we have a real opportunity to interact with the patient on the
genuine professional-to-client basis. Pharmacists have not been seen this
way (at least not much), and too much of our "advice" has been regarded
(even by ourselves) as incidental to our main task of medicines provision.
So we have given information and advice free. To me PC represents the
opportunity to create a firmer formal relationship in which our professional
knowledge and skills are applied therapeutically in a very deliberate
planned way. Information about medicines is not to be given on a
take-it-or-leave-it basis. Information we give about what medicines are for,
how they work, and the risks they carry is not to be provided such that
patients may or may not use it as they wish. This attitude has to be
replaced by one in which deliberate professional guidance (worked out
co-operatively with the patient) becomes integral to the process of care and
vital to its success.
There are some obvious processes to clinical services, and I would agree
that process-based costing is easier than pricing based on evaluated
cost-benefits. But it seems to me that there is less variation in the
process of PC than there is of CP. There is an obvious difference between
easy-to-do PC cases (especially in the community) that are less complex, and
the clinical evaluation of complex patients which could lead to quite
complex PC plans. This is not, however, going to affect prices because of
different amounts of outcome, it will affect price due to the cost of extra
input! It should not be too hard to judge appropriate PC pricing based on
the likely time required to produce effective care plans. It should be
fairly obvious from a brief review of the disease group(s) and the number of
existing medications whether a particular kind of patient is going to take
longer to deal with. Maybe a crude start can be made based merely on the
number of prescribed medications the patient presents!?
Any thoughts or questions on the above?
Kind regards
Ray.
raymond.skinner@health.wa.gov,au <mailto:raymond.skinner@health.wa.gov,au>
-----Original Message-----
From: B. Futter [mailto:B.Futter@ru.ac.za]
Sent: Thursday, 13 January 2000 21:36
To: PharmCare
Subject: RE: clinical pharmacy
Hi Ray
I have just had the chance to read your comments on this
matter
and support the thesis that you have proposed. I would be
interested in your comments on the differences between
clinical
pharmacy services (CPS) and pharmaceutical care services
(PCS).
I raise this in the context of payment for cognitive
services and
third party reimbusement. My impression is that CPS will be
the
more accepted basis for payment since, as they are mostly
process related, they are easier to define, monitor and
understand
by all concerned. The tendency to ignore outcomes,
commitment
and care because they are more difficult to monitor and be
valued
suggests that PCS will have difficulty getting to first base
on the
payment list.
Cheers
Billy
Billy Futter
Associate Professor
Faculty of Pharmacy
Rhodes University, Grahamstown, South Africa
email B.Futter@ru.ac.za
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