The Quality Enterprise: Q & A With the 'Nation's' Chief Pharmacist, Rear Admiral Scott F. Giberson

Meet RADM Giberson

Rear Admiral Scott F. Giberson is Assistant Surgeon General and Chief Pharmacy Officer, US Public Health Service (USPHS) Pharmacy. He advises the Office of the Surgeon General and the US Department of Health and Human Services on recruitment, assignment, deployment, retention, and career development of USPHS pharmacists.

This lead position and other duties give RADM Giberson a national perspective on clinical and public health, and a platform to directly affect the nation’s health.

In addition to serving as Chief Pharmacist, RADM Giberson also serves as the Director of Commissioned Corps Personnel and Readiness. In this role, he leads the operations and responses of all 12 categories of the USPHS.

Q&A

1. What are some current demands for quality within the US healthcare system?

Quality is critical to meet patients’ healthcare needs and expectations and is affected by many variables, including delivery of care. Cost, safety, scope of practice, and access are challenges to delivering quality care.

Chronic diseases continue to grow in prevalence, affecting 45% of the US population (133 million people), and accounting for 81% of all hospital admissions, 91% of prescriptions filled, and 76% of physician visits. Yet, an estimated 56 million Americans, including people with coverage, lack access to primary healthcare for various reasons, including projected shortages of primary care physicians.

2. What is the pharmacist’s role in meeting current quality demands within the healthcare system?

Pharmacists can help reduce the impediments to delivering quality care and positively affect the quality of care itself. Consider this:

• Pharmacists are among the most trusted and accessible healthcare professionals in each community.
• Pharmacists interact with 2 critical elements—patients and their medications—more often than any other provider.
• Pharmacists have extensive education and training in managing chronic conditions for which medications are the primary form of treatment.

Pharmacists occupy a strategic, if not pivotal, space in the healthcare spectrum. They are positioned to positively impact the health of individual patients and the nation’s health overall. The current challenges present significant opportunities for pharmacists to do so.

The need for improved quality care and access to care, combined with the pharmacist’s expertise and strategic position in the health system, suggest that it is both logical and vital to maximize the scope of licensure and many years of education. This includes expanding the pharmacist’s role as an essential member of a healthcare team. As part of this team, pharmacists can positively impact multiple facets of patient and primary care, including:

• Adherence counseling.
• Comprehensive management of chronic conditions that may include:

— Patient assessment.

— Laboratory ordering and interpretation.

— Appropriate prescriptive authority (via approved medical staff privileges).

This is a proven collaborative model, across decades of federal pharmacy, which could promote the overall quality of care if it were more widely adopted.

3. How would provider status change the practice of pharmacy and the role of pharmacists?

Recognizing pharmacists as healthcare providers would:

• Affirm in legislation what already exists in practice—that pharmacists provide healthcare in many practice settings.
• Validate that as healthcare providers, pharmacists can appropriately expand their roles and increase access to care for those vulnerable and underserved populations.
• Reduce legislative barriers to exploring new compensation mechanisms that further expand and improve the quality of care and reduce healthcare costs.

4. How would this practice model change the way pharmacists are compensated? Is it cost-effective?

This model would compensate pharmacists as healthcare providers based on the level of service they provide, similar to the medical model.

Currently, pharmacists receive compensation within Medicare Part D for services provided through Medication Therapy Management (MTM). However, this compensation model presents challenges due to eligibility requirements. For example, in the majority of MTM programs, pharmacists are not allowed to provide MTM services until a patient has multiple medications and at least 2 chronic conditions. Entering the equation this late limits our capacity to help and does not fit a preventive care paradigm.

Also, the current MTM compensation model does not compensate for expanded patient care by pharmacists. Overall, these limitations prevent or discourage pharmacists from practicing to the level of their licensure and education. This can cost the health system more, particularly in the long run.

Ample data, collected over decades (including metaanalyses and systematic reviews), demonstrate that this delivery model can be clinically and financially effective. For example, cost savings and return on investment averages roughly 1:4, meaning that for every dollar spent, a return on investment (healthcare savings) of $4 is realized. The savings can be reinvested elsewhere to further improve overall outcomes. However, that does suggest you must invest the $1 on the front end of care.

5. How would this paradigm affect the quality of patient care as currently measured?

An expanded role for pharmacists aligns with current ideas about improved quality and value of care. Years of data have demonstrated that pharmacy practice is evidence-based, improves overall patient outcomes, and contains costs. Our Pharmacy Report to the US Surgeon General, 2011, cites scores of research studies on this point.

Based on the evidence, as this care model is expanded, the quality of, and access to, patient care can and should improve.

6. How is quality measured in contemporary pharmacy practice? How should it change?

Recent thinking holds that gauging pharmacy practice involves structure, process, and outcome measures, similar to other providers. Traditionally, quality in pharmacy practice has been gauged based on process measures derived from administrative (insurance claims) data, which generally center on medications dispensed.

To better evaluate the quality of pharmacist care and the outcomes of the patient and their overall health, some highly integrated programs (such as the Indian Health Service or the Department of Veterans Affairs) allow pharmacist utilization of the same electronic health record (EHR) as physicians.

These are models we could emulate. EHR systems should further incorporate pharmacy programs and pharmacies. We need to evolve beyond measuring quality based on claims data alone, because they do not necessarily indicate, or [are not] suitable for assessing the value in clinical pharmacy services and the expanded roles of pharmacists.

If given the opportunity to demonstrate pharmacists’ competence and value through the full array of quality and performance measures, I’m confident we can further expand our roles.

Editorial note: In the pharmacy context, structure measures include pharmacist and technician training and certification and product bar coding. Process measures quantify production, such as prescriptions filled, cost of dispensing, percentage of patients counseled, and number of medication errors/incorrect prescription labels. Outcomes include clinical measures such as patient improvement in clinical condition and medication adherence, and humanistic measures, such as patient knowledge of medications or patient satisfaction.

7. What are the next steps?

We need to work more closely with health leadership and other key decision makers toward expanding the pharmacist’s role in patient care. As the Chief Professional Officer of the USPHS Pharmacy, I have the opportunity to discuss this topic with the Surgeon General.

Evolution toward expanded pharmacist practice and quality measurement would advance the profession and can improve patient and health system outcomes, benefitting all healthcare stakeholders.Author affiliation: US Public Health Service, Rockville, MD.

Funding source: This information contained in this publication was sponsored by GlaxoSmithKline (GSK). GSK reviewed the content of this publication for compliance with its own policies; GSK played no role in the selection or content of the material that appears here.

Author disclosures: Rear Admiral Scott F. Giberson reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this supplement.

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