A Fix for the Health Decision Bottleneck

May 1, 2013
The decision bottleneck around individual doctors is inefficient, clinically risky and expensive. A fix? Greater clinical specialization among pharmacists.

There are very few industries that would purposefully hinge their success around one decision-maker. Sure, CEOs are often needed to ultimately make the big decisions, but good leaders rely on smart teams to provide recommendations, and they delegate less vital decision-making down to the appropriate level. Having a single point of potential failure – a chokepoint – for all decisions would be seen as both inefficient and risky.

In a sense, however, that’s exactly what the country has done over the last century in healthcare. The decision bottleneck around individual doctors that exists today is operationally inefficient, clinically risky and unnecessarily expensive.

The Physician’s Dilemma

As a practicing physician, I have felt this bottleneck all around me. The real value I provide patients is conducting diagnostic evaluations, interpreting laboratory data, and delivering personalized counseling and treatment – particularly for patients with acute medical problems or ongoing symptoms. Unfortunately, a significant portion of a physician's time is spent on completing more routine follow-up appointments for stable patients, responding to basic medication education questions, and filling out a never-ending pile of forms.  

And with the growing shortage of physicians in primary care and certain specialties, the demands on physicians are becoming even more difficult to manage.

Supporting Healthcare Professionals Need to Operate at the Top of Their Licensure

In the country’s ongoing debate around new models of care, there seems to be consensus around one component: we need to be pushing less critical components of healthcare down to non-physicians. Everyone in healthcare – nurse practitioners, registered nurses, pharmacists, and other supportive personnel on the team – need to be operating at the top of their licensure and expertise.

What that means is this: when a healthcare task can be handled in a clinically appropriate way by a member of the health care delivery team other than the physician, that task and related decisions should be steered to that licensed professional (nurse, pharmacist, physician assistant). The resulting treatment will be more affordable, and it will be conducted by an individual who can specialize in performing that particular task. Meanwhile, the physician will have more time to focus on the decisions that only she has the expertise to handle.

The Need for Clinical Specialization Throughout Healthcare

To make this happen – this broadening of health decision accountability – physicians need to be able to rely on their non-physician counterparts to make as good of decisions, if not better, than the physicians themselves would make. And to instill that level of trust, we must infuse each of these support functions with something many don’t currently have: deep, disease-specific specialization.

The idea of clinical specialization isn’t new – physicians have been doing it for years. If a patient has cancer, he sees an oncologist. If he’s having chest pains, on the other hand, he should see a cardiologist. Now I’m sure there are oncologists capable of diagnosing heart disease, or setting a broken bone for that matter. But when our health is at stake, don’t we all want someone who specializes in treating the particular condition we have? Of course we do.

The real questions might be:

  • Wouldn’t we also value this level of clinical specialization from pharmacists and nurses?
  • And if this clinical specialization existed among these support functions, wouldn’t physicians view these other professionals as trusted collaborators in the decision-making process?

The Value of Clinical Specialization in Pharmacy

At Express Scripts, I lead our disease-specific Therapeutic Resource Centers®. In the TRCs, we have more than 1,500 specialist pharmacists, nurses and support staff whose clinical practices are highly concentrated around patients with specific chronic and/or complex conditions. Day-in and day-out, these specialist pharmacists and nurses focus their expertise to help manage patients within their area of clinical specialization. Unlike a typical retail pharmacist who dispenses medicine for every possible condition, our specialist pharmacists are afforded the training and dedicated professional practice to develop a deep understanding of a particular disease’s therapy nuances, drug-drug interactions, and emerging clinical guidelines. Our specialists better understand the unique needs of their individual patients.

A retail pharmacist may talk with a few dozen cancer patients in a year. An oncology specialist pharmacist at Express Scripts will talk to more than 1,000. The additional focused experience that specialist pharmacists possess empower them to raise critical questions to specialist physicians that otherwise may not have been asked.

For example, an oncology specialist pharmacist knows that certain oral chemotherapy medications require very precise dosing that may vary based on changes in a cancer patient’s total body surface area. Our oncology specialist pharmacists alert physicians to potential safety and efficacy concerns through expert therapy reviews that have led to countless “saves” by our Oncology TRC.

As a result of this heightened level of clinical specialization, our pharmacists are closing gaps in care, increasing patient satisfaction, and improving patient safety and medication adherence. And they’re being viewed by physicians as true collaborators in care.

superior performance results

Dr. Muzina will be discussing the Health Decision Bottleneck today at The Atlantic's Health Care Forum  in Washington DC. 

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