ASHP InterSections ASHP InterSections

December 22, 2010

Committee on Finance & Audit meeting

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January 21, 2010

Health Care Reform and the Health-System Pharmacist: A Primer

IMPROVED THERAPEUTIC OUTCOMES… reduced medication errors and adverse drug events… enhanced coordination of care… lowered health care costs… decreased rates of hospital re-admissions…

Portions of the new health care legislation being debated in Congress read like a pharmacists’ wish list of sorts. And, as details of the plans under consideration begin to come out, there appears to be real synergy between what Congress is considering and the ways in which pharmacists can improve patient care.

The bills recently passed by the House of Representatives and the Senate both offer “a great opportunity to demonstrate to patients and providers such as doctors, nurses, and dentists the value of pharmacists as a critical medical resource,” said Joseph M. Hill, director of ASHP federal legislative affairs.

“Although there are a lot of ‘moving parts’ in the bills, we’re excited to see that they generally address the issues of work force, quality, and access that directly concern ASHP and our members,” Hill added.

So, how might the different concepts being considered in Congress affect the lives of frontline pharmacists and pharmacy managers alike? And are there unexpected consequences to the legislation?

Improving Quality, Decreasing Costs

“The whole national health care debate has revolved around access and affordability, but we can’t take action on those without improving quality and decreasing costs at the same time,” said former ASHP President Kevin Colgan, M.A., FASHP, corporate director of pharmacy at Rush University Medical Center in Chicago. “So that means we should ask for what pharmacists need to help meet those goals.”

ASHP has done just that, tailoring its top advocacy agenda items to support the goals of improved quality and decreased costs. In written testimony, in visits to Capitol Hill and the White House, in collaboration with other stakeholders, and in assisting members in their own direct advocacy, ASHP has kept a steady drumbeat of pressure around the issues of provider status for pharmacists, support for PGY2 pharmacy residency funding, and a new federal loan-forgiveness program for pharmacy graduates.

Reimbursement for Pharmacists’ Services

As pharmacists increase their patient-care activities, the need for compensation for those services rises, said Thomas Johnson, Pharm.D., M.B.A., BCPS, FASHP, professor of pharmacy practice at South Dakota State University College of Pharmacy and clinical specialist in critical care at Avera McKennan Hospital in Sioux Falls.Achieving recognition for medication management services “would enable pharmacists to get paid for what we know and do rather than just for avoiding costs,” he said.

The bills would implement a new grant program to accomplish just that. Pharmacists in all practice settings and in new care delivery models, including so-called medical homes, could provide medication management services to chronically ill patients. “As this bill opens the door for innovative care delivery models and pilot programs, there should be additional opportunities for pharmacists to ???conduct medication management, which is very exciting,” Hill said.

Reimbursement for pharmacists’ services has long been a contentious issue. ASHP has strongly advocated for years that pharmacists be recognized as health care providers, to enable billing for services. Although some third-party payers have started paying for certain services, pharmacists remain frustrated by the slowness with which payers are embracing this model.

One idea being floated is the implementation of financial incentives such as pay-for-performance measures. These measures, in theory, would make hospitals and other care providers more accountable for ensuring that patients remain healthy.

A pay-for-performance system would demonstrate the value that pharmacists can bring to hospitals as part of a “closed-loop system,” said Roy Guharoy, Pharm.D., FASHP, chief pharmacy officer and professor of medicine at UMass Memorial Health Care, Worchester, Mass.

Hospitals could simultaneously increase the level of care and reduce costs by making pharmacists a more integrated component of a patient’s care.

Gerald Meyer of Pennsylvania was part of a large contingent of ASHP members who fanned out on Capitol Hill last fall.

Guharoy pointed to the example of a patient who had recently been discharged from the hospital and given prescriptions for two blood thinners. The patient failed to pick up the prescriptions at his local pharmacy and was later readmitted to the hospital. In this case, “closing the loop” by having a pharmacist consult the patient at home would have ensured continuity of care and avoided a hospital readmission.

Pharmacists and patients alike would seemingly welcome the extension of care beyond the hospital into a patient’s home. But the notion of extending coverage also brings up the question of how to pay for that coverage, said James G. Stevenson, Pharm.D., FASHP, director of pharmacy services and associate dean for clinical services at the University of Michigan Health System and College of Pharmacy, Ann Arbor.

“I’m concerned that reform will dramatically increase the financial pressure on hospital administrators in particular, which could make it more difficult to find the money to invest in the safety of our pharmacy medication systems,” he said.

Renewing PGY2 Funding

Back in 2004, when the Centers for Medicare & Medicaid Services (CMS) eliminated $10 million in annual funding for pharmacy residents in second-year (PGY2) programs, it inadvertently began a process that has contributed to a shortage of qualified pharmacy specialists across the nation. Although ASHP has pushed to restore the dollars since the funding was first revoked, CMS has been reluctant to do so.

If reform efforts are to boost care quality and improve patient outcomes, more well-trained pharmacists who are capable of providing that high level of care will be needed, according to Guharoy. “Without the training and facilities, this will be difficult,” he said. “We need to continue to educate Congress that the potential return-on- investment of funding this program is critical.”

Federal Student-Loan Forgiveness

Health care reform efforts have high- lighted the need to attract medical staff to underserved rural areas, and legislation just passed in the House would include pharmacists along with doctors, nurses, and dentists in the federal loan forgiveness program that eliminates student loan obligations in return for two years of service.

The House version of health-care reform includes provisions for pharmacist involvement in medication management as part of the new “medical home” model.

“The services these new pharmacists could provide underserved communities would be huge,” Colgan noted, pointing to medication reconciliation, anticoagulation services, cholesterol monitoring, diabetes management and education, and case management of high-risk patients.

What’s important to remember is that pharmacists can play a leading rolein improving quality while reducing the costs of providing exceptional health care services, said Guharoy.

“Medication therapy management will be the cornerstone of the success of any health care reform plan,” he said.

From Grassroots to Grasstops: Getting Involved in the Debate

So, how can you begin to shape the future of health care? Simple: Get involved. The national conversation that is happening around health care reform offers pharmacists a unique chance to play a larger and more integrated patient-care role within their own institutions, according to Joseph M. Hill, director of ASHP’s federal legislative affairs. “It’s important to work proactively on shaping the reform agenda rather than waiting to be impacted by it,” he said. A number of ASHP members have been working on their own grassroots campaigns to educate their representatives in Washington, D.C., about the critical role pharmacists already play in the health care system— and how that role should be expanded.

JAMES G. STEVENSON, PHARM.D., FASHP, has been in constant touch on the phone and via e-mail with the senators and representatives from his state. He also participated in ASHP’s Legislative Day, meeting with congressional staff members to discuss the inclusion of medication therapy management by pharmacists in any health care reform legislation. While Stevenson said that he doesn’t know what will result from his diligent efforts, “it’s critically important that we keep our representatives and senators up-to-date on the impact pharmacists can have,” he said.
ROY GUHAROY, PHARM.D., FASHP, met with Rep. James McGovern, (D-Mass.) during ASHP’s Legislative Day and discussed the urgent need for restoration of PGY2 residency funding.
THOMAS JOHNSON, PHARM.D., M.B.A., BCPS, FASHP, stays in touch with the two senators and one representative from his state. “All three of them understand the points I’m trying to get across,” he said. He, too, has been pushing for the reinstatement of PGY2 funds. “But there’s always the ‘but’ of how do we pay for it,” he said. “That’s where I’m trying to show them we can pay for it by improving patient care.”
KEVIN COLGAN, M.A., FASHP, has gone one step further by actually getting Rep. Judy Biggert, (R-Ill.), to visit a hospital where all patients receiving anticoagulation medications were managed by pharmacists. “I was able to show the congresswoman the lack of handoff that existed when those patients reentered the community,” he said


December 18, 2009

Stamp of Approval: ASHP Residency Accreditation Assures Quality

AS PART OF THEIR QUEST for ASHP accreditation in 2007, pharmacy leaders at Deaconess Health System in Evansville, Indiana, decided they needed to do something bold and innovative. They sent residents to the poverty-stricken community of Annotto Bay, Jamaica, to work with a team of pharmacists, physicians, and others on an international mission that many pharmacists might never experience.

In turn, Society surveyors praised Deaconess for offering residents creative patient-care training that benefited a needy community. ASHP accredited the program in August 2007.

“The surveyors were impressed with the flexibility of our program and the fact that we are able to provide opportunities outside the scope of our hospital,” said Joyce Thomas, Pharm.D., CACP, Deaconess pharmacy director.

The experience in Annotto Bay taught then-resident Andrea Tuma, Pharm.D., the ways in which cultural barriers can affect medication counseling.

“Americans are so used to the idea of seeing a doctor and taking medications, but these patients didn’t have the same access,” Tuma said, recalling her initial struggles. “My experience drove home the point that counseling is a two-way interaction, and that you have to listen as much as you talk.”

Reaching a Milestone

Thomas’s work in enhancing her residency program is an example of how ASHP accreditation helps raise the bar in training pharmacists as they move from pharmacy school to careers in hospitals and health systems.

This year, ASHP will accredit the 1,000th residency program to undergo its rigorous accreditation process since the program’s start in 1963. This important milestone for ASHP—the only organization that accredits pharmacy residency program —reveals how broadly accreditation has spread. It also highlights the far-reaching program improvements that often accompany this process.

ASHP believes so deeply in the value of accredited residencies, in fact, that its House of Delegates passed a resolution on the issue in 2007. The resolution states that by 2020, all new pharmacy graduates who will be providing direct patient care should first complete an ASHP-accredited residency.

“I think ASHP members realize that accreditation has been a huge value for our profession,” said Janet Teeters, M.S., B.S.Pharm., director of ASHP accreditation services, adding that accredited residency programs exist in hospitals, clinics, home health care, community pharmacies, and ?managed care organizations. “Accreditation really pushes the profession forward, making these sites strive to improve their training and clinical pharmacy services.”

ASHP survey reports, for instance, may recommend more diverse pharmacy services to match a diverse patient population, leading health systems to create specialized clinics for anticoagulation, diabetes, heart failure, or asthma.

“We often see reports of people hiring more staff, implementing new clinical services, putting in automation, or redesigning their work areas as a result of our visits,” Teeters said. “The peer review findings or recommendations in the accreditation reports often help pharmacy directors gain the resources they need.”

Those reports start with surveyors like David Warner, Pharm.D., ASHP director of residency program development. Warner travels up to 140 days a year, surveying residency programs and conducting other related work across the U.S. and in Puerto Rico.

ASHP surveyors meet with pharmacy residents, pharmacists, technicians, physicians, nurses, hospital administrators, and many others during the program review. They critique a variety of elements, including the way that residents are trained and evaluated.

ASHP surveyors judge programs using a core set of seven principles, including determining if the program:

• Uses a systems-based approach to train residents,
• Has well-qualified preceptors and program directors,
• Offers comprehensive, safe, and effective pharmacy services, and
• Requires a commitment from its residents to achieve the program’s educational goals and objectives and support the organization’s missions and values.

Warner and other surveyors emphasize the importance of teaching and mentoring residents as well as teamwork within the setting. “We look for the relationship that the pharmacy has with other professions,” he said. “Do physicians and pharmacists collaborate in patient-care decisions?”

In 2008, ASHP conducted more than 230 on-site survey visits. More than 130 of those were new programs. Those figures show the continuous growth in accreditation since the Society bestowed its first accreditation certificate to the program at Jefferson Medical College in Philadelphia in 1963. By 1964, 33 programs had been accredited.

Attracting Future Residents

Thomas sought accreditation after a discussion with a colleague in which she learned that most potential residents are interested in accredited programs.

“When recruiting, I find that residents are looking for accredited programs because they are quality programs backed by ASHP,” she said, adding that the accreditation process led to other inventive learning opportunities. Thomas wanted her residents to teach at a university, so she collaborated with Butler University College of Pharmacy and Health Sciences in Indianapolis to make it happen.

Meredith Petty, Pharm.D., clinical supervisor and residency program director at Deaconess, agrees that accreditation makes all the difference in recruiting and retaining residents.

“If I were a resident and taking an extra year to learn and develop myself, I’d want to be in a program that’s accredited,” she said, pointing to the fact that accredited programs are held to a higher standard.

The accreditation process can be done in a year or it can take place across multiple years. This all depends on how fast organizations develop their programs. ASHP will only conduct accreditation site surveys for those programs that have been operating with a resident for at least nine months.

Chris Taylor, Pharm.D., BCPS, clinical pharmacist at the Phoenix VA Healthcare System, believes accreditation can be a boost for program visibility. His accredited post-graduate year two (PGY2) residency program in internal medicine benefits from being listed on the ASHP’s popular online Residency Directory.

“Only accredited programs are included in the directory, so recruitment can be much more difficult if you’re unaccredited,” Taylor said.

Like the program at Deaconess, new training opportunities came with Taylor’s pursuit of accreditation. Taking the advice of surveyors, Taylor now conducts workshops for resident preceptors, including one that is designed to teach preceptors how to complete quality resident evaluations.

ASHP provides preceptors with many resources, including its National Residency Preceptors Con?ference. Held every other year, the conference brings together preceptors, residency program directors, and residents who network and participate in educational sessions.

Searching for Accredited Residencies

After she graduated from The James L. Winkle College of Pharmacy at the University of Cincinnati in 2006, Danielle Patrick, Pharm.D., was only interested in residency programs that had successfully made it through ASHP’s rigorous accreditation process. Patrick graduated from her PGY2 residency in critical care at University Hospital in Cincinnati in 2008.

“The paperwork, reports and evaluations are all part of a continual process in which the program is trying to improve,” Patrick said. “The value of accreditation to me is that I know I’m getting a great education and that I’ll be well-qualified based on the fact that I finished an accredited program.”

Midway through her PGY2 residency in pharmacy administration at Aurora Health Care in Wisconsin, Ashley Feldt, Pharm.D., said she takes real comfort in knowing that her residency program is ASHP-accredited.

“It makes me feel real positive that surveyors are reviewing a program to make sure there are enough preceptors to train residents and that they are committed to the program,” she said. The surveyors also indicated that Aurora’s operations are cutting edge, a plus for Feldt.

“We are in the process of implementing computer prescription order entry and bar-coding, the best practice for patient safety,” she said.

In her exploration of 2010 PGY1 residency programs, Angela Bingham, a student at the South Carolina College of Pharmacy at the Medical University of South Carolina campus in Charleston, is mindful that health systems are on the lookout for future employees who complete accredited residencies.

“When entering the job market, employers want to be confident that new employees can provide direct patient care that comes from accredited residency training,” she said.

No accreditation? No funding, says VA

?If you want to start a pharmacy residency program at any U.S. Department of Veterans Affairs (VA) medical center, you better ensure that it is accredited by ASHP. That’s because the VA requires its residency programs to be accredited in order to receive federal funding.

“There has to be a guarantee that the funding is used correctly and within professional standards, and accreditation is key to ensuring that that will occur,” said Lori Golterman, Pharm.D, clinical specialist in pharmacy benefits management services at the VA Central Office in Washington, D.C. “ASHP has supported our programs a great deal and helped us grow the quality programs that we have.”

The VA has an estimated 120 accredited programs, and trains about 22 percent of all pharmacy residents in the U.S., she said. More than 430 residents were enrolled in VA residencies in 2008.

The VA is assessing its medical centers without pharmacy residency programs to determine how they can implement the programs at those centers, Golterman said. Pharmacy residencies are offered at 89 of the VA’s 155 centers.

All new VA pharmacy residency programs must submit their ASHP accreditation survey reports to Golterman’s office. Report results are shared with all program directors to ensure a continual improvement process.

Golterman’s office has requested VA funding for an additional 80 residency positions over the next five years. She attributes the need for more positions to a rise in both the number of pharmacy schools and actual graduates.

October 9, 2009

Riding out the Economic Storm

Scott Knoer, M.S., Pharm.D., pharmacy director of the University of Minnesota Medical Center, Fairview, Minn.

ASHP MEMBERS are using creative tactics to soften the blow from an economic recession that has reduced revenue and forced

layoffs and loss of staff hours in hospital and health-system pharmacies nationwide.

Pharmacy managers have been struggling to make do with lower budgets and Medicaid reimbursements at the same time that the number of uninsured patients under their care is rising.

According to a recent ASHP survey:

• 37 percent of members have had their staffing budgets reduced,

• 10 percent have laid off personnel, and

• 66 percent have been required to reduce their drug budgets.

Creative Approaches

“It’s like the perfect storm,” said Scott Knoer, M.S., Pharm.D., pharmacy director at the University of Minnesota Medical Center at Fairview, referring to the local and national economic conditions that led to layoffs of pharmacists and pharmacy technicians in his department.

Knoer and his staff have found creative ways to keep costs down, especially in the hospital’s overall drug budget. He believes it is important to communicate those savings to the hospital’s administration.

“My drug budget is a lot bigger than my salary budget, so I’m constantly working to find ways to achieve savings for the hospital through better use of drugs, prescribing, and working with physicians,” Knoer said. “Finding all drug cost savings that your pharmacists produce and articulating those savings to your senior administration is very important. You need to communicate that reducing labor is being penny wise and pound foolish, because pharmacists save more in drug costs than in salaries.”

For example, the pharmacy discourages the use of intravenous (I.V.) medications with short expiration dates, which would have to be thrown out if not used in time. And Knoer makes sure workloads are evenly distributed among pharmacists to increase efficiency. More than ever, pharmacists stress to physicians the important cost savings in prescribing formulary medications.

To avoid laying off any more pharmacists, Knoer reduced the hours of five new pharmacists. “Now, they all work four days instead of five,” he said. “That way, they can keep working and maintain their health insurance coverage.”

Knoer sees a silver lining in the recession in that staff members are staying put in their positions. “We’re not having the turnover we might have had in a good economy,” he said.

Therapeutic Equivalents

Even though Beaumont Hospital in Royal Oak, Michigan, hasn’t lost pharmacy staff to layoffs, it’s still feeling the fallout from the diminishing fortunes of the auto industry.

Kathy Pawlicki, M.S., FASHP, director of Beaumont’s pharmaceutical services, also turned to the drug budget to help reduce expenses. “We look for alternative drugs, therapeutically equivalent, at a better cost,” she said. “We have found some significant savings in wound care products.”

Pawlicki said her staff also uncovered savings by making different operating room product choices. “For example, instead of providing medication with a combination product, we are providing individual components at a lower cost,” she said. “We also consider whether patients can take medication orally rather than through I.V.”

Pawlicki advises pharmacy leaders to engage their staff members in uncovering potential savings. “Your staff sometimes knows where waste is occurring. We discovered unused syringes were being discarded in the operating room,” she said. “You need to get more and more people involved. They look under rocks and behind corners, and they have a lot of great ideas.”

Staying Ahead of the Curve

The pharmacy department at Silver Cross Hospital in Joliet, Illinois, has likewise implemented cost-cutting measures to avoid staffing layoffs.

Kathy Pawlicki, M.S., FASHP, director of pharmaceutical services at Beaumont Hospital in Royal Oak, Mich.

Because the hospital’s daily patient population declined 8 percent over the past year, officials decided not to fill an open technician position. Pharmacy director Frank Butler, Pharm.D., BCPS, acknowledges that other pharmacies are facing more hardships than his has. Yet he continues to look for small ways to shave costs and keep larger financial troubles at bay.

“One thing we’re doing is encouraging staff to use paid time off. It takes expenses out of the books,” Butler said. “If it’s a slow night at the pharmacy, the pharmacists can decide to let other staff members leave early. And we’ve been working real hard to get folks out of here on time so that there is no incremental overtime.”

Butler advises other pharmacies to always keep an eye out for ways to cut costs.

“Make sure you watch for savings opportunities, even if there is no crisis in your hospital,” he said. “You definitely want to stay ahead of the curve.”

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