To the typical consumer, the role of the community pharmacist in the healthcare continuum may seem to be little more than that of a drug dispenser. But what most consumers don’t see behind the scenes (and what pharmaceutical representatives ignore at their own peril) is the enormous influence pharmacists have over a physician’s prescribing habits – influence that goes way beyond the standard request for generic substitutions.

How pharmacists influence doctors

According to the Alexandria, VA-based National Community Pharmacists Association, community pharmacists discussed a patient’s drug therapy with a physician or healthcare professional an average of 7.1 times a day in 2002. Of the recommendations community pharmacists made to physicians regarding therapeutic interchanges, 72% were accepted. These recommendations can take on a variety of forms. “Most likely it would be, first of all, looking at the patient’s therapy in relation to their disease state and identifying, potentially, other medications that the patient needs to be on,” says Anne Burns, group director, practice development and research for the Washington-based American Pharmacists Association. “For instance, if the patient has diabetes, does the patient need to be on aspirin, do they need to be on lipid-lowering medication – some of what we call concomitant conditions that go along with some of the disease states.”

Even though the NCPA estimates that 85% of patients have some sort of third-party insurance, there are still patients who pay for their prescriptions in cash. For these patients, a pharmacist’s recommendation might include cost-related factors.

“Pharmacists are increasingly being called upon to, if a patient can’t afford their medications, look at the medication therapy and make a recommendation to the physician on something that might be affordable for the patient, whether it’s a generic or potentially switching the patient to a different medication that may not be as expensive,” says Burns.

In many cases, a patient may be overmedicated and a pharmacist will, by examining the patient’s overall drug regimen, be able to consolidate prescriptions and save the patient money in that respect. “A retail community pharmacist is in a perfect position to analyze, do a drug regimen review on all the medication a patient is on and then make recommendations to the physician to eliminate (if appropriate) some of those meds,” says Gene Memoli, senior vice president of pharmaceutical care for The Medicine Centre, a large, long-term care pharmacy in Portland, CT. “Many times, because you’re going to multiple pharmacists and multiple physicians, the patient may be on one or two medications to treat the same disease state. By a pharmacist intervening with a drug regimen review, they can possibly get [the patient] off certain medications, decrease the polypharmacy and, in turn, decrease overall healthcare costs. That’s one of the biggest arguments for keeping the medications filled at your local pharmacy.” He estimates that over 90% of these recommendations are accepted.

Pharmacists will make recommendations to physicians based on other factors as well – if a patient doesn’t like the way a drug is delivered, for example. “We’ll call the physician and ask them to change if the patient is allergic to the medication, if the patient can’t take the medication for some reason,” says Douglas Hoey, senior vice president of practice affairs for the NCPA. “That’s rare for that to happen, but occasionally a patient will say, ‘Oh, I can’t swallow pills,’ or ‘I don’t like that flavor, I’m allergic to that flavor, I’m allergic to that dye.’ There are occasions like that where we’ll need to call the physician.”

If the patient is experiencing unwanted side affects that are minor, Hoey says he will write the name of a different drug on a piece of paper so the patient will remember to ask his doctor about it during his next medical appointment.

When pharmacists make recommendations, though, the goal is to collaborate with the physicians, not make them feel like their prescribing is being undermined. “The process is a joint responsibility between the pharmacist and the doctor,” says Memoli. “You don’t want to break that trust and tell people, ‘the doctor should have put you on this.’ We consult with the physician and make recommendations and provide them with the information so they can make the educated choice. Realistically, they call that influential prescribing ‘counter detailing.’ The pharmacist is basically trying to convince the doctor to use another product because of appropriateness to that patient. We’re not making the doctor look bad. Let them think it’s their decision. Because they’ve lost so much in their practice in their ability to prescribe because of HMOs and PBMs and everything, you have to make them buy in that it’s their decision, along with your recommendation.”

Increasing influence?

State and federal government agencies are increasingly recognizing pharmacists’ expertise when it comes to drug therapy. As a result, new factors may guarantee that pharmacist influence on physician prescribing is only going to increase.

As of 2003, more than 75% of states allowed for some kind of collaborative practice agreements or collaborative drug therapy management between physicians and pharmacists. The Kansas City, MO-based American College of Clinical Pharmacy defines collaborative drug therapy as “A collaborative practice agreement between one or more physicians and pharmacists wherein qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility for performing patient assessments; ordering drug therapy-related lab tests; administering drugs; and selecting, initiating, monitoring, continuing and adjusting drug regimens.” In other words, a collaborative practice agreement “delegates drug therapy management authority from a physician to a pharmacist within the terms of a formal agreement.”

Collaborative practice agreements are not meant to substitute the expertise of the pharmacist for that of the physician, but rather to enhance the physician’s skills with those of a pharmacist who has specific drug therapy knowledge.

Collaborative practice agreements will probably evolve as time goes on, but it is unlikely that they will ever extend to the point where pharmacists are diagnosing patients. “The fine line here is the delineation between diagnosing and prescribing,” says Burns. “If you walk in off the street, for instance, and you are exhibiting signs of depression, is it within the realm of the pharmacist’s scope of practice to diagnose that you have depression and then prescribe and then fill a prescription for a medication? Practice is not at that point and I’m not sure that it would ever be at that point.”

The recently passed Medicare drug benefit will also go a long way toward expanding pharmacist influence. The benefit calls for medication management services to be provided to seniors with certain chronic disease states and allows pharmacists to provide some of these services.

Reps can make their mark

Because pharmacists have such influence over prescriptions, pharmaceutical sales representatives can’t afford to neglect pharmacists during their call cycle. So what do pharmacists want? “One thing, and I know this isn’t always a popular thing for them to talk about, is the cost and if theirs is less expensive,” says Hoey. “That’s an important consideration, particularly to the cash-paying patients, and even with the Medicare discount drug cards that are becoming available.”

Adds Hoey, “I like [representatives] to acknowledge their competition. And I know that may be a difficult thing to do, but if someone’s coming in with a new PPI, I know there are four other PPIs on the market, and how does this one compare? Is it a me-too drug, or how is it different? Short, succinct and bulleted. Some of the studies are helpful, but I’m more interested in the dosing and the effectiveness.”

Burns notes that pharmacists are also very receptive to evidence-based medicine. “Pharmacists look for whether or not the patient is in therapy that is consistent with evidence-based guidelines, so beta-blockers for people who have heart attacks and so forth,” she says.

And unlike many physicians who are inundated with sales reps, many pharmacists want to see reps in their practices. “They need to schedule an appointment with the pharmacist, not just come in and throw some pens at ’em,” says Memoli. “Bring them in lunch, make an appointment and then do a brief in-service to provide the information on your drug or your disease state. It’s invaluable to give us that information, because the best way to move market share is to educate the pharmacist so that, when appropriate – and I stress when appropriate – we are going to recommend that drug because we have the appropriate information.”