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IS THE LAW:
> COUNSELING
ROLE OF OMNIBUS BUDGET
RECONCILIATION ACT OF
1990 (OBRA 1990) IN PATIENT
COUNSELING
OBRA 1990 is one of the most important laws affecting patient counseling activities in a pharmacy setting.
OBRA 1990 instituted an important pharmacy-related
provision that went into effect on January 1, 1993. The
key provisions of this legislation were to increase the
pharmacists responsibilities to educate and counsel patients about prescribed drugs, to assure the appropriateness of the prescribed therapies or prospective drug utilization review, and to provide for the collection of
patient information (OBRA, 1990; Perri, Kotzan, Pritchard, Ozburn, & Francisco, 1995). According to this
provision, pharmacists must offer counseling to all
Medicaid patients (Brenner, 1992; OBRA, 1990). Since
then, most state boards of pharmacy (44 out of 50) have
passed legislation mandating that pharmacists should
provide patient counseling to all patients, not just
Medicaid patients (Perri et al., 1995).
OBRA 1990 established increased responsibilities for
the pharmacist, from being only a dispenser of medications to a health professional who helps ensure proper
use of prescribed medications. The passage of OBRA
1990 had specific implications for the practice of pharmacy. First, pharmacists were required to offer counseling to Medicaid patients when a new prescribed medication or a refill for an existing prescription was
dispensed. Second, it required state Medicaid programs
to establish drug use review programs that rely heavily
on pharmacists expertise. Last, OBRA 1990 authorized
demonstration programs to determine the effect of reimbursement of pharmacists for patient counseling
(Christensen et al., 1999). OBRA 1990 has saved the
Medicaid program millions of dollars annually by en-
The Authors
Ashish Chandra, MMS, MBA, PhD, is an associate professor in the Graduate School of Management, Marshall University Graduate College, South Charleston, West Virginia.
Margery Fetters, MBA, MS, is associate professor of marketing and management, North Central College, Naperville,
Illinois, and currently owner of CS Consultants.
Nathaniel Malcolm II, BS, PharmD, is a GlaxoSmithKline
Pharmacoeconomic and Health Outcomes Post Doctoral
Fellow and a candidate for the masters in pharmaceutical
administration at The Ohio State University.
couraging manufacturers to give state Medicaid programs the opportunity to purchase drugs at the lowest
prices available to any health care entity within the
United States (Christensen et al., 1999).
A study conducted at the University of Mississippi
indicated that pharmacists derive professional satisfaction from counseling patients (Meade, 1995). Though
data regarding the success or failure of OBRA 1990 are
scarce, there is anecdotal evidence that this law is having a positive effect on patients and the pharmaceutical
profession (Meade, 1995; Torg, 1992). A study conducted in Georgia indicated that even though the number of patients counseled by pharmacists has increased
in the post-OBRA period, the amount of time spent collecting patient information and patient counseling has
decreased (Perri et al., 1995). The same study also indicated that only 12.4% of consumers surveyed were
aware of the OBRA 1990 legislation. Of those consumers who received prescriptions since the OBRA 1990
legislation took effect in January 1993, only 33% indicated that the pharmacist personally counseled them
about their prescriptions.
In an effort to comply with OBRA 1990 regulations,
many pharmacists often face several barriers. Some of
the factors affecting counseling activities, as determined by pharmacists, include excessive workload,
lack of financial compensation, and patients attitudes.
According to a study by Barnes, Riedlinger, McClosky,
and Montagne (1996), almost half of the responding
pharmacists indicated that OBRA 1990 regulations had
not affected or changed their practice, one quarter of the
pharmacists believed their practice was less rewarding
after implementation of OBRA 1990, and about one fifth
believed it was more rewarding. This demonstrates that
patient interaction cannot be legislated but can be developed through motivation and appropriate reimbursement.
In a study by Scott and Miller (1999), it was determined that pharmacists spend 13% of their day on patient counseling. These respondents reported that there
was an increase in the time spent by them on counseling, which was a direct result of OBRA 1990. The average increase was 2.8 minutes at an estimated cost of
$4.63 per prescription filled. As mentioned earlier,
OBRA 1990 requires the pharmacist to offer counseling
Chandra et al. / PHARMACY COUNSELING ACTIVITIES
65
PROMOTION BY
> HEALTH
WAY OF COUNSELING
A well-accepted definition of health promotion is the
science and art of helping people change their lifestyle
to move toward a state of optimal health (ODonnell,
1986, p. 4). Over the years, it has been observed that
health care professionals have changed the way they
provide health care services to their patients. The patient care model of practice has changed from being a
practitioner-centered model, in which the patient was
acted upon, to being a patient-centered model in which
the patient is considered an active participant in the
treatment regimen (Tindall, Beardsley, & Kimberlin,
1994). In the practitioner-centered model, the patients
opinion was not considered paramount. It was thought
that the health care providers opinion superceded any
opinion expressed by the patient. However, with the increasing adoption of the patient-centered model, health
care professionals have started paying more attention to
the opinions expressed by patients. Patients are also being encouraged to take a more active role in their health
care, and, as a result, counseling is now considered an
invaluable aspect of any patient care services. This includes pharmaceutical care provided by health care
professionals such as doctors and pharmacists.
Currently, pharmacists are in an excellent position to
actively promote good health through patient counseling activities. Pharmacists are considered one of the
most respected health care professional groups. In a
Gallup poll ranking 25 different professions for honesty
and ethics among its practitioners, two thirds of the respondents rated pharmacists as the most respected of all
professionals (Haddad, 1990). A study titled Patients
Perceptions of Increased Pharmacy Contact found that
patients desired and appreciated greater contact with
pharmacists because they sensed that pharmacists were
approachable and were highly regarded for their ability
to communicate useful health-related information
66
best product available and not the one that will make
the most profit (Tindall, Beardsley, Kimberlin 1994).
Scenario 2
A man with high blood pressure comes into the
pharmacy to have his prescription for an antihypertensive drug refilled. Before filling the prescription
the pharmacist may ask him if he has had his blood
pressure checked. He replies that he has not checked
his blood pressure in a while and wonders about his
blood pressure level. The pharmacist may ask the
patient if he has consumed meals high in sodium,
and he replies yes. The pharmacist tells the man that
food high in sodium may elevate blood pressure, that
it would benefit him to reduce his intake, and that he
should go back to see his physician. At this point, the
patient may realize the importance of the pharmacists advice and take appropriate action to prevent
any further complications associated with high
blood pressure.
TECHNIQUES AND
> ALTERNATIVE
CHANNELS OF COMMUNICATION
FOR COUNSELING ACTIVITIES
In the concept of pharmaceutical care, one of the
most important services that a pharmacist offers is
counseling a patient on the appropriate use of pharmaceutical products (Hepler & Strand, 1989). Patients
should have a good understanding of the nature of their
drug therapies. For example, the patient should know
Chandra et al. / PHARMACY COUNSELING ACTIVITIES
67
PATIENT
PHARMACIST
68
Because patients will be at varying stages of behavioral changes to improve their health and maximize
therapeutic outcomes, the pharmacists counseling
techniques need to adapt to change. Pharmacists may
need to be more sensitive to the damage that illness can
do to a patients self-image. Lambert, Street, and Cegala
(1997) suggested that staying healthy is a matter of
maintaining a balance between self-image and performance. Self-image is a persons understanding of his or
her own identity and performance of activities of daily
living (Lambert et al., 1997).
Pharmacists communicate effectively when they
keep in mind each patients need to balance self-image
and performance. New medications and new adverse
drug reactions may upset this balance, with serious consequences for the patients quality of life (Lambert et al.,
1997). For instance, a man who has hair loss may perceive himself as a healthy, sexually active male with a
full head of hair. When this patient becomes impotent
as a result of a medication to treat hair loss, the balance
between self-image and performance is upset, and he
begins to feel unhealthy. He may then change his selfimage and see himself as a bald, sexually active male instead of a sexually active male with a full head of hair.
Also, he may alter his performance by stopping the
medication or asking the doctor to prescribe a different
medication to treat his hair loss.
The option chosen by the patient may be at least partially dependent on his relationship with his pharmacist. That example points out the concept of balance, because it shows that patient counseling often requires the
pharmacist to raise issues that may not be comfortable
for the patient or the pharmacist to discuss. These discussions are sometimes necessary to enable the pharmacist to ensure appropriate drug therapy outcome.
Pharmacist-Patient
Communication Models
Many patient counseling models are currently in
place, and some of them are extremely valuable. Two of
these models are the pharmacy consultation program by
Pfizer (1995) and the health communication model by
Svarstad (1986). The pharmacy consultation program
was developed for pharmacists, whereas the health
communication model was developed primarily for
physicians but is often used by pharmacists. Irrespective of whom these models were created for, both had a
common purpose to improve patient health through
various promotional activities.
The pharmacy-consulting program by Pfizer (1995) is
based on open-ended questions that help determine the
patients knowledge of his or her disease and medications. This ensures that by the end of the counseling session the patient understands how to use medications
and what to expect from the medications. Open-ended
questions usually start with words like how, why, what,
or when. An example of an open-ended question is
What did the doctor tell you that your medication is
OF HEALTH EDUCATOR
> ROLE
IN PREPARING PHARMACIST
Now that patients are becoming active participants in
their health care, it is extremely vital for pharmacists to
be promoters of good health to consumers. The pharmacist must have a good understanding of the various social and behavioral aspects as well as the physiological
aspects of the consumer. Though pharmacists are provided some understanding of these aspects in most
pharmacy programs, there is now an increasing need to
pay greater attention to these issues during their professional education. Health promotion educators often
spend a great deal of time in understanding and analyzing the social and behavioral aspects of consumers
health. Pharmacists, on the other hand, spend more
time in understanding the physiological and other scientific aspects as they relate to consumers health.
Hence, by training and education, health promotion educators may perhaps be the most effective individuals
to educate pharmacists about the various sociobehavioral aspects of the consumer, making pharmacists effective and good health promoters.
In the opinion of the authors, it would be better to
have a nonpharmacist individual involved in health
promotion training for pharmacists. We believe that
Chandra et al. / PHARMACY COUNSELING ACTIVITIES
69
these individuals may be able to provide the information in a nonscientific, unbiased manner. Even though
the health promotion educators may not be scientifically trained health care professionals, they have the
ability to provide knowledge and good health promotion strategies utilizing an outsiders perspective. They
can also be contributing members of the health care
team.
Health promotion educators can also assist pharmacists in developing innovative educational tools for
high-risk individual consumers. They can help the
pharmacists in the development of appropriate evaluation tools that can help assess the impact and effectiveness of the patients education efforts. It is highly recommended that these evaluations should be performed
using standardized forms. These forms should be carefully modified, as and when necessary.
> CONCLUSIONS
REFERENCES
Barnes, J., Riedlinger, J. McClosky, W., & Montagne, M. (1996).
Barriers to compliance with OBRA 90 regulations in community
pharmacies. Annals of Pharmacotherapy, 30, 1101-1105.
Brenner, L. (1992). OBRA: Its the law. American Druggist, 207, 2633.
Chandra, A., Blake, S., & Holt, G. A. (1996). Analysis of telephone
calls in a community pharmacy environment. Proceedings of the
1996 Southern Pharmacy Administration Conference (p. 1).
Oxford, MS: University of Mississippi.
Chin J., Muller, R., & Lucarelli, C. (1995). A pharmacy intervention
program: Recognizing pharmacys contribution to improving patient care. Hospital Pharmacy, 30(2), 123-126, 129-130.
Christensen, D., Holmes, G., Fassett, W. E., Neil, N., Andrilla, C.
H., Smith, D. H., Andrews, A., et al. (1999). Influence of financial
70
incentive on cognitive services. Journal of the American Pharmaceutical Association, 39(5), 629-639.
Perri, M., Kotzan, J., Pritchard, L., Ozburn, W., & Francisco, G.
(1995). OBRA 90: The impact on pharmacists and patients. American Pharmacy, NS35, 24-28, 65.
Pfizer, Inc. (1995). Pharmacist-patient consultation program:
Counseling to enhance compliance. New York: National Health
Care Operations.
Procheska, J., DiClemente, C., & Norcross, J. (1992). In search of
how people change: Applications to addictive behaviors. American Psychology, 47, 1102-1114.
Rupp, M. (1992). Value of community pharmacists interventions
to correct prescribing errors. Annals of Pharmacotherapy, 26,
1580-1584.
Scott, D., & Miller, L. (1999). Reimbursement for pharmacy cognitive services: Pharmacists assessment. Journal of Managed Care
Pharmacy, 5(5), 420-24.
Svarstad, B. (1986). Patient-practitioner relationships and compliance with prescribed medical regimens. In L. Aiken & D. Mechanic
(Eds.), Applications of social science to clinical medicine and
health policy (pp 438-459). New Brunswick, NJ: Rutgers University Press.
Tindall, W. N., Beardsley, R. S., & Kimberlin, C. L. (1994). Communication skills in pharmacy practice (3rd ed.). Malvern, PA: Lea &
Febiger.
Torg, E. (1992). Life since OBRA: Roles and responsibilities of consultant pharmacists and physicians in long-term care. The Consultant Pharmacist, 7, 1282-1290.
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