The Pharmacist’s Role in Managing Autoimmune Blistering Disease Patients’ Medication Needs
By Michael Rigas, Pharm.D.
The first video in our new series, Pass the Mic with Dr. Mike, the Pharmacist is available.
Patients with Autoimmune Blistering Diseases (AIBD) may require multiple oral, topical, and intravenous drugs to obtain the best clinical outcomes. Obtaining this drug therapy requires the patient to interact with multiple physicians, pharmacists, pharmacies, drug wholesalers, and insurance companies. What is the pharmacists’ role in this process?
In many respects, the pharmacist acts as the coordinator of this process since they function at the intersection of the physician’s prescription, the drug makers’ FDA-approved product, the drug wholesaler, the insurance company’s authorization and payment for the medication, and the patient, for whom all these actions are taken.
Relative to the patient experience, the pharmacist’s main duties can be categorized into five main areas. Let’s discuss each separately to see how it impacts the patient’s experience and clinical outcome.
- Prescription processing: This is the main coordinating function the pharmacist manages for the patient. When the prescription is received (usually electronically nowadays), the pharmacist compares the drug ordered to the patient’s diagnosis, history, and physical to see that there is a match and that there are no major issues such as the patient’s allergies, the inventory in the pharmacy or the drug wholesaler at that time, the insurance companies formulary and approved diagnosis that would allow coverage for the drug for the patient that is for their disease. The pharmacist also verifies what the patient’s coverage would be and what the patient’s out-of-pocket costs would be, and verifies that the prescriber is licensed to prescribe in the patient’s state of residence. They also check to verify that the physician is not on any state or federal list of prescribers who are barred from prescribing for many reasons. Finally, the pharmacist tabulates the time needed to accomplish all of these events to assure the availability of the drug and how rapidly the patient needs the drug to match.
In some instances, for oral generic drugs, this whole process may be accomplished in 15 minutes or less. But, in other more complex cases that involve costly oral, topical, or intravenous medications, this process may take days or weeks. This may depend on the availability of the drug, the possible need for more patient clinical data to be submitted, additional laboratory testing, etc., that may be required to obtain authorization for the ordered therapy from the insurance company. This protracted process may involve written appeals by the physician/pharmacy or a telephone consultation with the prescribing doctor and the insurance company’s doctors.
- Patient support and safety: During the many steps in the above process, the pharmacist analyzes multiple issues and data points to assure that the likelihood of clinical, temporal, logistical, and financial harm to the patient is minimized. This may involve checking for allergic responses to ordered medications based on their history, or checking to see that the time needed to complete the above process is consistent with the acuity of the patient’s needs and other planned activities ( i.e., other medical procedures or tests, vacations, etc.), and that the out-of-pocket costs that the patient will be facing as a result of the ordered medications are minimized.
- Patient education: This is an important function where the pharmacist compiles information from various sources and shares with the patient details about drug dosage and dose frequency, expected rapidity of drug effect, drug storage, expected drug side effects, and whom to call if an issue occurs. Education may also include issues surrounding home safety, fall prevention, and tips to better manage the other diseases the patient may have relative to the newly ordered drug therapy.
- Billing and associated actions with the insurance company: One of the most important functions of the pharmacy and pharmacist is their “customer service” functions which mostly surround the insurance company’s billing on behalf of the patient and adjudicating the patient’s out-of-pocket costs. On the one hand, this function may be completely managed electronically in a few minutes for inexpensive oral medications. Alternatively, this function may take days or weeks for more expensive, infused medications. Interaction between the pharmacy, the payor, and the ordering physician is typically required initially, and maybe in an ongoing fashion if the authorization is denied and an appeal is needed, to obtain the payor’s authorization for payment.
While this is happening, the pharmacist is evaluating the out-of-pocket exposure to the patient for the drug(s) ordered to see if there is anything clinically equivalent that is available that may result in a lesser out-of-pocket cost to the patient. Suppose there is a less costly, clinically equivalent product available. In that case, the pharmacist calls the ordering physician to discuss it with them, get the order changed, and then reaches out to the payor for authorization reflecting the new lowered out-of-pocket costs.
Finally, suppose the patient cannot afford their out-of-pocket costs. At the patient’s request, the pharmacy may explore drug company-based and non-profit foundation-based financial assistance programs for which the patient may qualify. The sum of these programs may make the drug affordable to the patient.
- Regulatory compliance: This is a complex concept. It ensures that all the data collected from each patient’s prescription processing and dispensing is properly collected, stored, and reported to the inquiring party. These parties include:
- The state board of pharmacy
- The patient’s insurance company
- Medicare
- Medicaid
The pharmacist must also assure that the prescriber is licensed to prescribe the exact products ordered in the patient’s state and is not on any lists of suspended or disbarred prescribers.
These audits may be known and planned for or may be a surprise in nature. Poor performance in these audits may result in the pharmacy being sanctioned, removed from the payor contract, fined, or closed down.
As you can see, there are a lot of actions behind the scenes that make the pharmacist a key player in the healthcare team. Pharmacists are extremely knowledgeable about the medications you have been prescribed and are traditionally underutilized by patients, and their role is often misunderstood. I hope this information has helped you better understand the pharmacist’s important role in your healthcare and well-being.