Sitting in the waiting room of a Garden Grove doctor's office, 5-year-old Alfonso fiddles with a smartphone while his mother, Rosa Soria, worries about his allergies and a rash.
But Soria's worries are tempered by the knowledge that picking up medicine for her son will be easy and inexpensive. She'll simply have to walk a few steps across the lobby to the pharmacy window, where she’ll benefit from a discounted price and a pharmacist who works directly with her doctor.
“It’s more convenient now,” Soria said. “You get to go straight home,” rather than stopping by a commercial drugstore, which might involve a long wait or delays if the pharmacist has questions for the doctor.
Soria's experience is the result of a decision by AltaMed, Orange County's largest health care provider to uninsured patients, to make the pharmacist a full member of the medical team. Driven by the need to reduce costs and improve health outcomes, the trend likely will grow as federal health reforms take effect.
Getting Patients to Take Their Medicine
The clinic in Garden Grove is the second in-house pharmacy established by AltaMed in the last year, both available onlyto clinic patients. The goal is to address one of the most important issues in health care: persuading patients to fill their prescriptions and take their medicines.
Some 50 percent of patients either fail to take their meds properly or don’t take them at all, according to the World Health Organization and a variety of researchers, resulting in hundreds of billions of dollars annually in avoidable hospitalizations, not to mention shorter lives.
Failure to take medicine is a phenomenon that Dr. Martin Serota, vice president and chief medical officer at AltaMed, knows well. For example, a recent patient with sky-high blood sugar stubbornly refused to take his diabetes medicine. Another patient couldn’t or wouldn’t pay the high cost of malaria medicine despite plans for a trip to Haiti.
“The noncompliance rate for filling prescriptions and taking them is staggering,” Serota said. The problem is especially acute among low-income patients, who are more susceptible to chronic illnesses such as asthma that require complicated medical regimens.
Further, Orange County’s poorer patients often face language barriers and lack transportation to medical services and providers. Most significantly, low-income patients often have no insurance or very limited prescription coverage.
“A lot of times patients can’t get their meds; they cost too much,” said Duane Saikami, chief operations officer at PharMedQuest, the company staffing AltaMed’s pharmacy in Garden Grove.
One result is that doctors can lose valuable time talking to patients about what drugs they can afford rather than the patient’s health, Serota said. In other cases, doctors write a prescription without finding out whether the patient can afford it, leaving the pharmacist to try to scramble for an alternative.
Matching discounts at the big-box stores, AltaMed’s pharmacy charges $4 for a month’s worth of generic drugs. Brand-name medicines go for $10 at the AltaMed pharmacy, including pricey items such as Qvar, a daily asthma inhaler that can otherwise cost almost $200, as well as glucose monitoring strips and insulin vials.
The Changing Health Care Team
Beyond alleviating cost and transportation issues, a pharmacist working with the doctor's office has full access to a patient's medical history and can more easily spot duplication or potentially harmful drug combinations.
Pharmacists working with medical teams can also keep tabs on potential abuses such as attempts to procure painkiller prescriptions from different doctors, Saikami said.
Pharmacists aren’t the only professionals playing a larger role in health care. Physician assistants, nurses and nurse practitioners are increasingly providing medical services as well, said Serota, who supports the expanded role for such providers as long as they are working closely with doctors. Cost savings are an obvious cause of this trend, but data show medical results are better as well, he said.
“Health care is becoming more team-based,” Serota said.
Gerald Kominski, director of the UCLA Center for Health Policy Research, said pharmacists have been moving toward a more active role in health care for some time, with more people getting flu shots and vaccinations at their local drug stores.
“The roles of pharmacies are changing. It was already underway, and it’s going to be accelerated by health care reform,” Kominski said, referring to the Patient Protection and Affordable Care Act, which was enacted in 2010. One reason is that millions of patients will gain medical insurance in 2014, increasing the demands on doctors and pharmacies, according to Kominski.
The reforms reforms will reward medical practices called “accountable care organizations,” which offer coordinated, team-based care based on shared access to medical records, Kominski said.
“This is not new; this is what Kaiser does, for example,” he said, referring to the cost-saving approaches used by the medical provider Kaiser Permanente.
Following a Model From Down Under
This new trend is nothing new to Michelle Sherman, who runs an HIV-AIDS pharmacy practice at Laguna Drug. There she works closely with local doctors, educates patients on the powerful medicines that suppress the virus, warns them about side effects, reconciles competing prescriptions and remains available to patients by phone after hours should they encounter a problem.
In HIV-AIDS care, “Drugs are the focal point of everything. The pharmacist is a pivotal person in taking care of HIV patients,” she said.
In a few key ways, Sherman is functioning more as a pharmacist in countries such as Australia and France, where druggists not only fill prescriptions but in some cases treat patients . Drawing at least partially on this model, AltaMed has a pilot project in Huntington Beach in which a clinical pharmacist follows up with patients after their doctor visits.
“Pharmacists can play a more active role in diagnosing minor illnesses. If you’re having cold or flu symptoms, a pharmacist can identify which it is and prescribe appropriate medicines for symptoms without going to the doctor first,” Kominski said.
Back at the AltaMed in Garden Grove on a recent morning, patients waited for their prescriptions after seeing their doctors across the lobby. Pharmacist Tam Nguyen chatted with patients about proper use of their medicatons, cheerfully telling customers to “have a great day and call if you have any questions.” Nguyen is fluent in English and Vietnamese, and her technicians speak Spanish and English.
Nguyen said she enjoys her role as part of a medical team after working for years in commercial pharmacies.
“I can’t say enough how convenient it is to have doctors next to me. … It used to take days to get a refill approved.” Further, Nguyen can review a patient’s history so that “if there’s a change in dose, we catch that. … The common goal is patient care.”
Amy DePaul is a Voice of OC contributing writer and lecturer in the UC Irvine literary journalism program. You can reach her directly at firstname.lastname@example.org.