Communication, confidentiality, and voluntariness among patients, physicians, and pharmacists characterize effective collaborative practice. Based on these values, the Maryland Task Force on the Future of Pharmacy Practice enumerated the following principles for effective collaborative practice:

• Voluntary participation is provided by prescriber, patient, and pharmacist and is not mandated by managed care organizations (MCOs) or other third parties.
• Prescriber must diagnose patient before the pharmacist engages in collaborative practice.
• Pharmacist notifies prescriber when therapy is modified.
• Pharmacist must maintain additional knowledge, skills, and abilities.
• Pharmacist qualifications and collaborative practice agreements are reviewed by the Board of Pharmacy prior to implementation.

In its position statement on collaborative practice, the Academy of Managed Care Pharmacy (AMCP) also recommends that written treatment protocols be evaluated periodically to maintain the highest quality of patient care.

The demands of the managed health care environment have escalated the need for collaborative pharmacy practice. This team approach can alleviate three significant health care problems: escalating costs, insufficient access to medical care, and inconsistent quality of care.

In today's world, the health care industry emphasizes the management of chronic conditions to prevent complications and comorbidities. This focus leads to more reliance on pharmacotherapy.

At the same time, managed formu-laries and preferred drug interchange programs have increased the complexity of pharmaceutical care. Physicians receive more calls than ever from pharmacists, and the trend is escalating.

Formularies differ greatly, and one plan's preferred drug may not even be covered by another. Busy medical personnel are simply unable to keep track of the many different managed formularies, and they may resent having to deal with the proliferating phone calls from pharmacists that these programs generate.

Collaborative pharmacy practice is an effective strategy for maintaining the advantages of managed formularies, while leveraging busy physicians' time.

Advantages of Collaborative Practice
There are many advantages to implementing collaborative pharmacy practice, particularly in the managed care environment. Opinion polls indicate that Americans consistently rank pharmacists as the most trusted professionals.¹

Active pharmacist participation can improve both the quality and availability of patient care. Ready access to care providers is an important component of patient satisfaction. Pharmacists are readily available and can spend the necessary time to listen and respond to a patient's concerns, which enhances the overall quality of care.

Patients with chronic conditions can benefit from the expanded availability of primary care offered by collaborative practice. For example, pharmacists are ideally situated to consult with and coun-sel patients with high blood pressure. After checking the patient's current pressure, the pharmacist can evaluate the medication being taken and discuss other strategies for maintaining optimum health, such as diet and exercise.

"Collaborative practice could jump-start large-scale patient and pharmaceutical care programs," observes Lowell Sterler, AMCP past president. "We need to find creative solutions to the issues of credentialing and ensuring consistency of care." Sterler sees collaborative practice as the logical next step in disease management programs.

Many pharmacists welcome opportunities to practice as part of a managed care team. The work is varied and rewarding; the provider/patient relationships enrich pharmacists' tasks, and the prescribing activities make better use of their extensive training. These broader horizons emphasize the professional aspects of pharmacy practice. In addition, the requirements for additional education imposed in many states provide an avenue for continued learning and even more expanded opportunities.

Finally, collaborative pharmacy practice is tremendously cost-effective for managed care plans and payors. Physi-cians are the pivotal members of any health care team; consequently, they have the most demands on their time. If highly qualified pharmacists can take care of routine testing, prescribing, pa-tient counseling, and follow-up tasks, plans can effectively leverage their expen-sive physician resources.

Cost-effectiveness does not come at the expense of quality, however. The written treatment protocols that are an integral part of the collaborative practice scenario can increase the consistency of treatment for common conditions. When protocols are reviewed and revised periodically, both patients and providers can be assured of treatment that reflects current best practices.

Also of consequence to MCOs is the person-to-person contact afforded by effective collaborative practice. Because patients appreciate individual attention, the services provided through these arrangements can heighten their satisfaction and increase member retention.

Elements of Collaborative Practice
Carmichael et al. have proposed that pharmacists participating in collaborative practice share the responsibility for patient outcomes by solving problems related to drug therapy and by making decisions about the patient's pharmaceutical regimen.² In return, the pharmacist must have access to patients and their health information and be able to conduct ongoing evaluations of the patient's condition and response to medication.

The foundation for effective collaborative pharmacy practice is a written agreement between an individual prescriber and a pharmacist. The goal is to improve the quality and to expedite the delivery of pharmaceutical care.

The usual practice is for the physician to diagnose the patient and prescribe the initial treatment. The pharmacist may then be authorized to monitor the patient's condition, to modify drug therapy as necessary, and to discontinue medications at the end of treatment.

Depending upon state laws, pharmacists may perform some or all of the following tasks:

• Interview patients to obtain information relevant to their pharmacotherapy.
• Request, perform, and interpret laboratory and diagnostic tests.
• Participate in drug therapy decisions, including product selection and dosage.
• Select and administer pharmaceutical therapy to patients according to written protocols.
• Monitor and assess the outcomes of pharmacotherapy.
• Document activities and observations.
• Communicate regularly with the physician in charge of the patient's care.

Sterler suggests that enlisting a blue-ribbon panel of physicians to establish standardized protocols may add credibility to the process. This approach may also encourage other sectors of the health care community to accept and support collaborative pharmacy practice as a positive contribution to patient care.

Ongoing evaluation is an integral part of the process. Before implementing a collaborative practice agreement, the pharmacist's knowledge and competence are assessed, often by the state board of pharmacy. Additional training or continuing medical education may be required if a pharmacist does not have sufficient clinical background.

As time goes on, both pharmacist performance and written protocols should be scrutinized periodically.

The Spread of Collaborative Practice
By mid-1999, 25 states had enacted some form of collaborative pharmacy practice legislation. Most recently, Idaho, Louisiana, Minnesota, Nebraska, Ohio, Tennessee, Virginia, and the U.S. territory of Guam have joined the roster.

States exploring the issue, with legislation in process, include Arizona, Georgia, Illinois, Maine, Utah, and Wyoming. Some jurisdictions with existing collaborative practice laws are considering expanding the scope of their current laws, as in Arkansas, where House Bill 1066, which codifies disease management in the state pharmacy act, is awaiting passage by the Senate.

The Changing Role of Managed Care Pharmacists
The current managed care environment is moving steadily towards the management of chronic disease as a strategy for minimizing and preventing acute epi-sodes, complications, and comorbidities. Because pharmaceutical treatment is an important component of disease management, the next logical step is to grant pharmacists a more prominent place on the medical team. An increasing number of studies affirm that pharmacists can have a positive impact on patient outcomes^{3, 4} and may also lower the cost of treatment.^5-7 Even noncomplex interventions, such as formalized individual pharmacist counseling sessions and callback programs, have improved patient outcomes.^{4, 6, 8}

Drug therapy selection is an increasingly important component in improving patient outcomes and reducing health care expenditures. The next logical step is to grant pharmacists a more formal and pro-mi-nent place in drug therapy decisions.

Pharmaceutical care programs that allow pharmacists to share relevant information with patients can offer significant benefits to physicians as well. By facilitating dialogue between pharmacists and patients, collabora- tive pharmacy practice furthers teamwork among managed health care professionals.

The industry trend of integrating managed care functions and organizations could serve as a natural progression towards broadening the scope of pharmacy practice. By playing a more integral role in patient care, managed care pharmacists can lighten physicians' tasks while enriching their own. The result is improved care for patients, a better workload distribution among health care team members, and more job satisfaction for pharmacists.

The Cost of Collaborative Practice
Managed care pharmacists must take a proactive role in documenting and evaluating the impact of their services -historically a great challenge, and one that has not yet been met successfully.

Collaborative practice presents pharmacists with a prime opportunity to assess the value of their nondispensing roles. The price of avoiding this critical issue may be inadequate compensation for cognitive services. Even more serious, if pharmacists do not take a proactive role in demonstrating the value of their services, payors may transfer drug therapy and monitoring activities to other allied health care professionals.

MCOs and Collaborative Pharmacy Practice
To help reduce double-digit pharmacy benefit cost trends, MCOs have implemented more restrictive formularies with preferred drugs in selected therapeutic classes. Because these formularies differ, physicians may be confused about which drug to prescribe, particularly when they are affiliated with several MCOs.

The advent of collaborative pharmacy practice is an opportunity to reduce this complexity. When designing best-practice treatment protocols for each chronic condition, MCOs can work with each other to align their formularies within high-cost therapeutic classes.

The possibility even exists for regional MCOs to align written drug treatment protocols as they help shape collaborative pharmacy practice legislation. At the same time, MCOs could influence health care integration by categorically endorsing pharmacist participation in drug therapy decisions using these protocols.

This level of consensus building offers several advantages to both patients and members of the health care team. Pharmacists participating more actively in drug selection in retail settings essentially will leverage physician resources and reduce pharmacy benefit costs.

Several important items must be considered as these acts become more mainstream in the health care industry.

As with all professions, pharmacists' knowledge and experiences vary. State legislatures must work with boards of pharmacy and colleges of pharmacy to develop:

• appropriate knowledge and skill assessment tools to objectively evaluate competence, and
• training programs to sharpen clinical and communication skills.

All pharmacists, irrespective of their current capabilities, should be allowed to refine their skills so they can participate in collaborative pharmacy practices.

Conclusion
Collaborative pharmacy practice is truly an idea whose time has come. Pharm-acists are well-positioned to serve an active role in treating and managing many chronic diseases. In fact, many managed care pharmacists are already implementing cost-effective pharmacy benefit strategies.

Collaborative pharmacy practice offers MCOs and payors another way to leverage an underutilized health care resource-the trusted pharmacists within their midst.

  References