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In conclusion, drug therapy problems for the elderly residing in nursing homes are now well recognized. The cost savings and patient care contribution that the consultant pharmacist can make in helping to minimize these problems has been thoroughly demonstrated.

The society welcomes the opportunity to work with the select committee in maximizing the effectiveness of the shrinking health care dollar through promoting and encouraging the active involvement of pharmacists in monitoring nursing home patient drug regimens.

[The prepared statement of Mr. Abrams follows:)


ON DRUG MIS-USE IN NURSING HOMES I am Mark Abrams, president of the American Society of Consultant Pharmacists.

The American Society of Consultant Pharmacists is the national professional society of pharmacists who specialize in serving the unique needs of residents of long term care facilities and providing non-dispensing pharmacist services to these and other health care settings. Society membership numbers over 1500 and includes the leading practitioners in the field who are responsible for pharmacy and pharmacist services to more than 700,000 or greater than half of the Nation's nursing home patients.

The society applauds the select committee's interest in drug therapy for the elderly. We are pleased to participate in this hearing and your efforts to focus attention on the problems of drug use in nursing homes.

A number of problems relating to drug therapy for nursing home patients are now well recognized. The institutionalized elderly typically suffer from multiple chronic and acute illnesses commonly resulting in a high level of drug use. Our estimates indicate that the average nursing home patient takes 6 or 7 different drugs consuming 7 or 8 doses of medication daily.

The extensive use of drugs combined with the fact that aging entails physiologic changes leading to alterations in the ways drugs affect the body predisposes the elderly to significant increased risk of complication from drug therapy. That the elderly are much more likely to experience adverse drug reactions than younger patients is extensively documented in the literature. However, substantial progress toward eliminating or minimizing drug therapy problems in nursing homes has been made since the 1974 adoption of the requirement for pharmacist drug regimen review in skilled nursing facilities. The patient care and economic value of the drug therapy assessment activities of pharmacists in this health care setting has been demonstrated in numerous studies and reports.

Unfortunately, the knowledge pharmacists have of adverse drug reactions, drug interactions, pharmacokinetics, and appropriate therapy is not being utilized to its full potential. This is highlighted by the fact that drug regimen review by pharmacists is not part of the patient care plan in all nursing homes.

In some facilities, drug regimen reviews, although completed to meet the letter of the regulation, are performed in a totally lackadaisical manner. In these cases, the nursing home is simply satisfied with paper compliance.

Non-compliance with the drug regimen review requirement or less that adequate performance of these reviews stems from a number of causes.

The widespread lack of understanding or mis-understanding of exactly what constitutes drug regimen review contributes significantly to the problem. All too many nursing home administrators, nurses, physicians, nursing home surveyors, and yes, pharmacists have little knowledge of what the drug regimen review requirement means. To some, it's reviewing a drug regimen to check for potential drug interactions. To others, it may simply mean verifying that the drug name on prescription containers matches with the nursing homes medication records.

Pharmacists doing good drug regimen reviews, however, will tell you that the entire contents of the patient's medical record including physicians and nurses progress notes, occupational and physical therapist notes, dietary and laboratory records, past medical and drug history, as well as medication orders and administration records must be thoroughly reviewed and the information integrated to reach a sound conclusion as to the appropriateness of a drug regimen. Many pharmacists find it necessary to physically examine or talk to a patient to finally determine if the rash the patient has developed is a drug allergy or something else.

To foster a better understanding of the meaning of drug regimen review, the society is pursuing a number of avenues. First, the society is developing practice guidelines for consultant pharmacists in long term care facilities which will elaborate on the drug regimen review process. These guidelines are currently in draft stage but should be finalized and adopted by the association in the near future. Publication of these guidelines will be accompanied by the society's on-going educational programming and publication activities to gain a universal understanding of their drug regimen review activities by practicing consultant pharmacists.

On another front, the society will continue to push for more emphasis on the drug regimen review regulations in the upcoming skilled and intermediate care facility proposals. We are encouraging the Department of Health and Human Services to make the distinction between pharmacy services and pharmacist services very clear in the regulations. We feel strongly that two distinct sections, pharmacy and pharmacist, are needed to eliminate the present confusion associated with differentiating between services typically provided by a pharmacy (i.e. dispensing drugs to patients in the facility) and those services provided by a pharmacist (i.e. administrative and clinical responsibilities, such as supervising pharmaceutical services and performing drug regimen reviews).

The society has also endorsed and participated in the departments initial efforts to develop guidelines that nursing home surveyors can use to determine facility compliance with the drug regimen review requirement. Although we have some fear that these “drug regimen review indicators" may be mis-applied by inadequately trained surveyors, we view adoption of these guidelines as a positive step by government to increase emphasis and understanding of the patient care opportunities presented by effective drug regimen review.

Unfortunately, other elements of the government have yet to understand drug regimen review, particularly the economic and patient care value of the activity. Many state medicaid programs still do not recognize the cost for pharmacists of providing this professional service. Consequently, payment to pharmacists continues to be inadequate. In the final analysis, inadequate payment for the drug regimen review and other non-dispensing services of the consultant pharmacist remains as the primary roadblock to universal and effective drug therapy assessment in nursing homes.

Currently, most state medicaid programs have chosen to ignore, soft-pedal, or even refuse the demands of consultant pharmacists and nursing home operators for recognition of the need for payment for consultant pharmacists' services. In those few states that have taken action on the issue, the upper limit of “reasonable" payment has been set an "unreasonable" low level.

A recent "Survey of Long Term Care Operations” conducted by the society indicates that pharmacists spend an average of 3 hours per 100 patients per week performing drug regimen review and other clinical and administrative consultant services in nursing homes. This same survey reports that the pharmacist's cost of providing these consultant services is from $12.00 to $14.21 per hour. In a 100 patient facility, the monthly cost to the consultant pharmacist is over $180 in time alone.

The Maine medicaid program policy limiting reimbursement for consultant pharmacist services to $.75 per patient per month highlights the fact that lack of adequate payment is a strong disincentive to good drug regimen review. Based on a 3 hour per week time commitment and costs of $14.21 per hour, the pharmacist would lose over $100 per month in providing consultant services to a 100 bed facility.

Amazingly, the situation in Maine is not unique. Most States have yet to publicly acknowledge in their reimbursement manuals the fact that the charges of consultant pharmacist are a reimbursable cost under their cost-related reimbursement formulas for nursing homes.

Another factor contributing to consultant pharmacists difficulty in effectively performing drug regimen reviews is their current minimal level of authority to take action to gather information necessary to the review or to correct an “irregularity" in the drug regimen when one is observed. For example, determining whether or not a potassium supplement should be recommended for a patient taking a potassium depleting diuretic is impossible if a recent laboratory test report indicating the patients' body potassium levels are not available. In cases such as this, the pharmacist should have the authority to order the appropriate lab test. The same applies to lab tests to determine hemoglobin levels for patients taking anti-anemia medications as well as other lab tests that are necessary to determine the need to institute or continue therapy with a certain drug.

In the case of potassium levels it seems logical that the pharmacist should be able to go the next step and order a potassium supplement if the lab test reports a lower than normal potassium level for the patient. This prescribing role for pharmacists is a natural outgrowth of their expertise in drug therapy. Although novel, prescribing by pharmacists after diagnosis by the physician is currently being evaluated in a California project. Early reports are the project indicates that pharmacists are doing an effective job in establishing rational patient drug regimens.

State medicaid programs can do more to promote appropriate drug therapy for nursing home patients. Implementing a capitation payment system for drugs dispensed to nursing home patients would effectively remove any incentive for a pharmacy to dispense more prescriptions to these patients. Currently, all State medicaid programs except New Jersey, pay pharmacies based on the number of prescriptions they dispense. This method essentially amounts to a “bounty system” which is at cross purposes with the drug regimen reduction intent of reviews.

Capitation of the dispensing fee for nursing home prescriptions would in contrast to the current payment system, encourage pharmacists to help the consultant pharmacist in reducing drug regimens. It would also facilitate the extra benefit of prospective or before-the-fact reviews of patient drug therapy. In this situation, the dispensing pharmacy has more incentive to review new drug orders prior to dispensing thus preventing potential adverse drug reactions that may occur prior to the consultant pharmacist's monthly review of the patient's drug regimen.

Drug therapy problems for the elderly residing in nursing homes are now well recognized. The cost saving and patient care contribution that the consultant pharmacist can make in helping to minimize these problems has been thoroughly demonstrated. The society welcomes the opportunity to work with the select committee in maximizing the effectiveness of the shrinking health care dollar through promoting and encouraging the active involvement of pharmacists in monitoring nursing home patient drug regimens.

The CHAIRMAN. Thank you very much, Mr. Abrams, for an excellent statement.

Now, Mrs. Cane? Mrs. CANE. No, nothing additional. Mr. WEBSTER. No, Mr. Chairman. The CHAIRMAN. Well, I have always had a high regard for the pharmacists. We call them doctor a lot of times down home. But you have enhanced my appreciation of the importance of the pharmacist and also of the attitudes that you have taken, Dr. Schlegel and Dr. Lamy, the role of the pharmacist.

I realize it is a very difficult matter for a pharmacist to tell a doctor, I do not think that medicine you gave Mrs. Jones is doing her any good. As a matter of fact, I think it is hurting her. You can imagine how happy that makes the doctors, they are human beings. There ought to be some way to check.

I know of one instance where my wife was in a hospital, very ill. The nurse got hold of the doctor and said, if you don't do something for Mrs. Pepper before noon today, she is going to be in very serious condition. She got the doctor in there. He gave her some extra treatment and in an hour or two the crisis had passed over.

A nurse—they are supposed to have a confidential relationship with the doctor. I reckon the doctor listens to the nurse more than he would to the pharmacist. Somehow or other we have to find a method by which this sort of second look can be taken at things.

I should have allowed Ms. Oakar to go ahead because we will have to go vote in a very short time. Ms. Oakar.

Ms. OAKAR. Thank you, Mr. Chairman. I will just ask a question or two because we do have a vote.

Which group oversees and monitors the druggists or would be responsible for reprimanding the druggists who are irresponsible? Any of you.

Dr. PENNA. None of our organizations is a regulatory agency. Ms. OAKAR. I know that. But if the druggist belongs to your organization and you know that he or she is irresponsible, what do you do or have you ever?

Dr. Lamy. The State board of pharmacists would handle it.

Dr. PENNA. If the pharmacist has been found guilty of violating a law, and he is a member of our organization, we have a procedure for dismissal and revoking all the privileges that go along with it.

Ms. OAKAR. Have you done that?
Dr. PENNA. Yes.

Ms. OAKAR. I have a lot of respect for pharmacists, especially neighborhood ones which we are seeing fewer and fewer of, because they usually know the community.

But wouldn't you agree, and this is for anyone, that many of these nursing homes have their favorite pharmacists, that in fact there is a little deal between them?

Wouldn't you agree that does happen on occasion and that in fact when you talk about a statute whereby you are mandatorily required to review the records of nursing home patients, that when you are buying medicine en masse that way, filling prescriptions, that there really—that the pharmacist really doesn't review the patient and that a good pharmacist would catch that if he or she had an individual knowledge of that person?

I am sorry that we have to leave now because, boy, I had some questions regarding that, because I do not think we should let the pharmacists off the hook either.

Dr. PENNA. It is not our intention to allow pharmacists to get off the hook. While we disagree with the last recommendation of the GAO report, we also recognize that there are instances where pharmacists do not fulfill their responsibilities as they should.

But we believe that there are current regulations on the books now that will allow those individuals to be detected and if they are violating the law, to be prosecuted.

Ms. OAKAR. Do you think that the average pharmacist who gets a large order from a nursing home really and truly scrutinizes those orders, now really?

Dr. PENNA. You are asking me about the average pharmacist?
Ms. OAKAR. Yes.
Dr. PENNA. I would have to say yes, based on my experience.
Ms. OAKAR. Really?
Dr. PENNA. Yes.

Mr. ABRAMS. In many States they have mandated patient profiles. So no matter if you are walking in off the street or you are in a nursing home, that pharmacist has to review that profile.

Ms. OAKAR. That is right. That is a good point to make because my State of Ohio does not have that mandate which I think is very, very unfortunate, because if you were compelled to review records, even though you probably would have to have some kind of reimbursement formula, I am sure you would say, well, I couldn't afford to do it.

But let's be honest, the drug market is a very profitable business, we are part of the great American drug culture and and you are in the business to sell drugs, right?

Mr. ABRAMS. Can I answer that?

Up until last year we were making $2 to fill a prescription in the State of Delaware. They did a survey to see what it costs to fill a prescription. My site was one of those used by the State to do an onsite inspection. It cost me $3 to fill a prescription. We are filling them for $2. So there isn't the great profit that many people think there is.

The key in this area falls in the consultants' activities in the pharmacy service committee of the facility. Because our policy is that any—this was prior to the mandate of patient profiles—the consultant writes down the regulations for the facility on how that facility will be serviced by any vendor.

So, therefore, what happens, the policy of the facility might be that the pharmacist must have patient profiles for the patients in the facility even though that pharmacy does not do that service. Now a lot of times the pharmacy doesn't want to get involved and turns it away.

Dr. LAMY. May I add something to that?
Ms. OAKAR. We have to go vote.

The CHAIRMAN. You have intrigued our interest here today and we commend you for your excellent interest and your excellent statements. I wish we could stay longer but we have to go vote.

Thank you all very, very much for coming. The hearing is adjourned.

[Whereupon, at 1:35 p.m. the committee adjourned.]

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