Medical mystery: What did the pharmacist know?
A small but critical detail that had been withheld from the physician out of embarrassment made all the difference.
For the second visit in the last month, the patient’s high blood pressure was uncontrolled, and her primary-care physician was concerned.
They had tried two medication adjustments with no significant change in the reading, and the patient said she had no side effects from the medicine. At age 56, and with diabetes and a strong family history of hypertension and stroke, blood pressure control for this patient was a high priority, and the sooner the better. Thorough laboratory testing was ordered and revealed no abnormalities that might explain resistance to her current blood pressure medicine.
At this juncture, the physician might ordinarily consult with a specialist in managing high blood pressure that persists despite first-line efforts at control. A nephrologist (kidney specialist) or cardiologist would be ideal.
But this time, the doctor decided first to confer with the newest member of the primary-care team — the clinical pharmacist — for a thorough medication review and suggestions she might have for dosage adjustments.
The clinical pharmacist made a pivotal discovery. When she asked the patient about the cost of her medication, the patient admitted she couldn’t afford her medications and was too upset and ashamed to tell her doctor when he asked. She had medical insurance, but no prescription plan, and had been using a combination of discount cards to cover the monthly cost of $220. She had to choose between food, transportation, and medications each month, and medications came in last place.
The pharmacist began to review the patient’s chart, looking at her current prescriptions, her last few office visits, and pharmacy fill history. At first glance, the medication list was unremarkable — all were generic medications, which might typically be affordable. Experience, though, had taught the pharmacist that generic doesn’t always mean cheap.
The pharmacist began reviewing the patient’s medication list to look for less expensive alternatives that were equally or more effective in treating high blood pressure. She also looked for nonessential medications on her list for other prescriptions that could be discontinued, or “de-prescribed." Sure enough, there was one diabetes medication she had been taking that made little impact on her sugar control.
The pharmacist researched additional patient assistance programs, special pricing offered at other community pharmacies, and drug discounts. The physician accepted all of the pharmacist’s recommendations, and together they were able to save the patient enough money to bring her prescription drug cost into an affordable range. Her blood pressure was nearly normal by the next office visit.
The primary-care doctor was surprised at what the pharmacist had uncovered, and pleased with the creative solution. It was a vivid reminder of how primary care is, now more than ever, a team-based practice. Embedded clinical pharmacists are doctorate-level practitioners who can apply their deep knowledge of medication chemistry and therapeutics, along with understanding of payment models, on behalf of patients. Their training and skills complement the physician’s, which allows them to work together to provide optimal care.
Pharmacists are part of a growing team of care management professionals, including nurse care managers, social workers, behavioral health counselors and nutritionists, who can help you manage illness and stay well. Next time you visit your primary-care doctor, ask what services have joined the care team roster.
Jeffrey Millstein is a primary-care physician and medical director for patient experience-regional practices at Penn Medicine. Michelle L. Patterson is a clinical pharmacy specialist focusing on transitions of care and primary care at Penn Medicine.