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December 18, 2009

The Politics of Healthcare Reform

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Henri R. Manasse, Jr., Ph.D., Sc.D.

Henri R. Manasse, Jr., Ph.D., Sc.D.

NOW THAT THE BRUISING PRESIDENTIAL CAMPAIGN is finally behind us, Americans are wondering how the new realities in Washington, D.C., might affect their daily lives.

Whatever your personal political leanings might be, it’s clear that President Obama’s sweeping healthcare reform proposals are some of the most ambitious in decades.

His plan focuses on access and affordability as well as promoting public health via prevention and chronic disease state management. The latter is especially good news for hospital and health-system pharmacists. That’s because we are uniquely positioned to provide the kind of medication therapy management that would save money and dramatically increase quality.

In this new legislative reality, ASHP has a number of priorities, including adding annual medication therapy review and assessment by a pharmacist to all Medicare Part D plans and including pharmacists as providers under Medicare Part B.

We are also moving forward with legislation drafted late last year to restore Medicare funding for postgraduate year two (PGY2) pharmacy residency programs. As you’ll read in the cover story in this issue of InterSections, ASHP has a long history of supporting and cultivating residency training for pharmacists.

When the Centers for Medicaid & Medicare Services (CMS) cut funding for PGY2 programs in 2004, it was a real blow to pharmacists everywhere who wish to pursue this important specialty training. The new “Medicare Specialized Pharmacy and Health Care Improvement Act” seeks to restore this funding. Sen. Tim Johnson (D.-S.D.) has signed on as the bill’s chief sponsor.

Of course, given the current global economic crisis, we know that securing new Congressional appropriations will be a challenge and that we will be just one of many organizations seeking Congressional support in this move toward universal health care. But we are very excited about the possibilities for patient care and pharmacy’s future. And we are more committed than ever to moving pharmacy’s agenda forward in this new political environment.

Henri R. Manasse, Jr., Ph.D., Sc.D.

The Need for C-Suite Pharmacists

THE INCREASING COMPLEXITY and rapidly rising costs of today’s drug therapies require new levels of expertise to ensure positive patient outcomes. And pharmacists are in a unique position to provide that leadership, according to the new ASHP Statement on the Roles and Responsibilities of the Pharmacy Executive.

The statement, which supports the development of a pharmacy executive position within hospitals and health systems to oversee the design, operation, and improvement of the medication-use process, was recently approved by the ASHP Board of Directors and House of Delegates.

Pharmacists who currently serve in “C-Suite” roles serve as powerful examples of a pharmacy executive’s ability to ensure safe and effective medication use.

Mark Todd, Pharm.D., FASHP, assistant vice president and chief pharmacy officer, University of Alabama Hospital at Birmingham, said that the key difference between his current position and his previous role as director of pharmacy is the ability to influence medication-use policies.

“I now report directly to the CEO and serve as a member of his executive team. I have a significant voice in the decision-making process, which has elevated the profession of pharmacy within our entire health system,” Todd said.

William Greene, Pharm.D., BCPS, FASHP, chief pharmacy officer, St. Jude Children’s Research Hospital, Memphis, directs and oversees all pharmaceutical services for the hospital. St. Jude’s research mission and academic structure helped facilitate the addition of a pharmacy executive to the staff, according to Greene. The fact that a pharmacist, William Evans, serves as St. Jude’s chief executive officer also helped make the case.

Regardless of setting, Greene feels that every institution can benefit from the skills and insights of a pharmacy executive, adding that he or she must possess initiative and vision.

“If you’re not at the table, I guarantee that you’ll be left out,” he said. “Don’t wait to be invited to meetings or to serve on committees. Make sure that everyone who needs to know understands that the presence of a pharmacist will ensure optimal drug therapy outcomes.”

The ASHP statement highlights the importance of a pharmacy executive’s ability to effectively communicate and collaborate with peers. Pharmacy executives should:

• Be involved in the organization’s strategic planning related to the medication-use process,
• Report directly to the organization’s principal executive,
• Have a title internally consistent with others reporting at that organizational  level (i.e., chief financial officer or chief nursing officer), and
• Be a member of the medical executive committee or its equivalent.

Because many hospitals or health systems may not yet be ready—politically, financially, or culturally—to create a pharmacy executive position, Todd suggests developing the role over time.

“I recommend working to have the existing director of pharmacy report directly to the chief executive officer or chief operating officer, a change that doesn’t cost a dime,” he said.

Additionally, when proposing a pharmacy executive position to hospital administration, Todd believes that patient safety should be the primary message.

“Medications touch every patient who comes into the hospital,” he said. “To be a safe, cost-effective organization, medication-management issues must be at the top of any CEO’s list.”

Greene agreed, saying that pharmacy leaders must be “assertive; identify the roles that they need to be involved in; and have a vision and make sure that that vision gets carried out.”

A Call to Help Elderly Patients

I SPENT MY CHILDHOOD with my grandparents. Watching them age and suffer the limitations of chronic disease made a huge impression on me. Little did I know that this experience was to become invaluable to my career in understanding the medical challenges that geriatric patients face each day.

Demetra Antimisiaris, Pharm.D., CGP, FASCP, is assistant professor, University of Louisville, Department of Family and Geriatric Medicine.

After pharmacy school, I interviewed for an internal medicine residency at a hospital known for its treatment of celebrities as well as a geriatric residency at a Department of Veterans Affairs hospital. Although the internal medicine residency seemed glamorous, the preceptors of the geriatrics program promised me that I would “see everything in internal medicine and more” because the elderly often have multiple chronic diseases.

I owe these preceptors a debtof gratitude because they were spot on. I did see everything and found my true calling along the way. Today, I teach medical students, staff physicians, and others about medication management in the frail elderly. I use my Pharm.D. training to address a critical part of the patient-care equation: detailed medication therapy management (MTM).

Advocating for Pharmacists’ Role

For patients who are taking up to 18 drugs concurrently, medication management is essential. The question is simple: Who on the medical team is best positioned to do this important work?

Physicians can typically spend seven to 15 minutes per patient. If the patient is on multiple medications, how long does that physician have to assess each drug? Likewise, the training nurses, social workers, and pharmacologists undergo focuses on other areas.

This is why it is critical that hospitals and health systems begin to rely more on pharmacists to manage medications.

Educating Patients on Medication Regimens

I recall how my grandparents blithely took their medicines without any knowledge or understanding of what could happen in terms of interactions or other adverse consequences. In retrospect—and with the knowledge that I have now—I’ve come to realize that the number and types of medications they took caused them harm.

So, to help other elderly patients avoid these medication-related problems, I regularly conduct volunteer community seminars to increase awareness. The demand for medication consults after each community session is so immense that I recently opened a medication management clinic. I offer office hours and appointments, and patients pay in cash. My faculty members bill for the consults using their medication management codes.

A New Focus on Patient-Centered Care

The new Medicare Part D codes are the first official recognition that MTM is serious business. I am committed to helping position pharmacists as the medical professionals who are paid to manage drug regimens.

Pharmacists are adept at assessing costs and managing drugs, over-the-counter use, and patient diet. Once a clinical patient-centered focus is added to that mix, it is clear that pharmacists are perfect therapy managers. Regularly studying current medical literature and listening carefully to your patients will foster patient centeredness.

I believe that the ability for pharmacists to practice this kind of high-touch, high-tech approach is the very future of our profession.

MUSC Residency Program Celebrates 50th Anniversary


Margaret Blair Bobo

MARGARET BLAIR BOBO was literally in a class by herself when she enrolled in the inaugural pharmacy residency program at the Medical University of South Carolina (MUSC) Medical Center in Charleston in 1958.Fresh out of the MUSC pharmacy school, where she was the only female in her graduating class, Bobo found being the program’s solo resident an exhilarating learning experience.

“My year there probably was the most monumental in my life,” Bobo said. “I had no pharmacy work experience, so I learned everything. I was a sponge.”

Bobo, who went on to join the MUSC staff as a pharmacist and assistant professor, is joining other alumni this year to celebrate the 50th anniversary of one of the country’s oldest residency programs. More than 450 pharmacists, have completed the ASHP-accredited program, a collaboration between the Medical Center and the South Carolina College of Pharmacy at the MUSC campus.

Over the years, the MUSC residency program has evolved into a multi-faceted program that is nationally known for the advanced practice experiences it offers. More than 40 clinical preceptors oversee the work of an average of 20 post-graduate year 1 (PGY1) and PGY2 pharmacy residents. About 200 pharmacy students apply for the available slots, of which only 60 are chosen for interviews.


MUSC's residency program is one of the most well-known in the country.

MUSC’s residency program is one of the most well-known in the country.

Changing with the Times

William H. Golod, M.S., Ph.D., the program’s pharmacy and residency program director from 1959 to 1965, is credited by many with helping to triple the number of MUSC residents by the 1980s.

That growth in residents has translated into more pharmacy care for more patients and improved patient outcomes, said Wayne Weart, Pharm.D., FASHP, professor of clinical pharmacy and outcome sciences at the South Carolina College of Pharmacy and professor of family medicine at MUSC College of Medicine. He completed a residency at MUSC in 1972.

The growth means that MUSC is “training more residents who go out and apply the high level of care they learn in our program,” said Weart. “We have over 400 alumni who are doing great things all over the country.”

“When I was there, I’m not sure I appreciated how far we had come” from the program’s initial founding in 1958, he noted.

By the time Ray became director, the program had already developed a “strong clinical flavor,” he said. At that time, residents joined daily hospital rounds with medical teams.

Today, the MUSC program boasts an array of disciplines, from psychiatric pharmacy to ambulatory care to adult internal medicine. That variety helps residents find their niches and sharpen the skills that today’s pharmacists need to work on healthcare teams, said Paul W. Bush, Pharm.D., M.B.A., FASHP, director of pharmacy and graduate pharmacy education at MUSC.

“With 23 residency positions, I think our program contributes in a large way to the enhanced role pharmacists enjoy in healthcare today,” Bush said. Today’s residents mentor pharmacy students, educate fellow clinicians and patients about medication therapy, and participate in drug-use review and drug policy development and management.

“It’s important to note that MUSC’s residency program has been ASHP-accredited since 1963. The fact that it has met such rigorous standards for so long speaks to the quality of the programs required of the residents,” said Janet Teeters, M.S., director of ASHP’s accreditation services division.

ASHP has been accrediting pharmacy residency programs to ensure consistent training and improve the level of practice since 1963. The Society will reach its own milestone—1,000 accredited programs—this year.

Current MUSC resident Michael DeCoske, Pharm.D., is thankful he has been able to experience so many facets of pharmacy before choosing his career path.

“It’s a great environment to start off a career in pharmacy,” he said. “You receive a lot of great career guidance. If I had never come here, I might have been off doing a specialty that wasn’t the best fit for me.”

Bridging the Continuity-of-Care Gap

Elaine Ladd cuts the ribbon at the grand opening of the Ladd Family Pharmacy, the only independent ambulatory care pharmacy in Boise, Idaho.

ELAINE LADD, Pharm.D., BCPS, is a busy woman.

As a clinical pharmacy specialist at Saint Alphonsus Regional Medical Center in Boise, Idaho, Ladd rounds with fellow healthcare professionals as part of a medical team.

As a clinical assistant professor of pharmacy practice at Idaho State University (ISU) College of Pharmacy, she educates students on therapeutic options.

And, as owner of Ladd Family Pharmacy, the only independent ambulatory care pharmacy in Boise, she provides medication therapy management (MTM) services to her patients.

Ladd has discovered professional success along the continuum of care.

Educating, Empowering Patients

By counseling patients in both the hospital and in her pharmacy, the new practitioner said she is more effective in ensuring that patients receive the proper medication therapies and that they are educated about the medicines they take.

“My staff and I are cheerleaders, educating patients and empowering them to take control of their disease states,” Ladd said. “It’s a family here, and we want patients to know that we care.”

Ladd Family Pharmacy offers an on-site MTM clinic, compounding services, home delivery of prescriptions by bicycle couriers, and free exercise classes.

Ladd’s mentor of several years, ASHP President Kevin J. Colgan, M.A., FASHP, strongly supports her uncommon endeavor, which he believes provides distinct services to optimize patients’ therapeutic outcomes.

“I think the clincher for me is that Elaine is using this pharmacy to develop sustainable patient programs,” he said. “I think we all can learn a great deal from Elaine’s approach to patient care.”

MTM Clinic a Success

Ladd’s MTM clinic has been a particular success. Customers are asked to schedule a free consultation at the clinic if they take more than two medications for a condition, were prescribed eight medications in a three-month period, or spend more than $4,000 a year on medications.

Staff pharmacists review the patients’ medication histories, screen for needed vaccinations, inquire about drug interactions, monitor medication use, and administer medicines.

The pharmacy also offers rotations for ISU pharmacy students, who learn about compounding, disease management, and other topics. In July, the pharmacy plans to host its first pharmacy resident. Ladd plans to introduce additional MTM clinics for diabetes, hypertension, and lipidemia.

Improving Health with Exercise, Education

Upstairs, customers stretch during free yoga and Pilates classes or attend educational seminars on managing diabetes and weight loss. Nurse practitioners and ISU students conduct health fairs on smoking cessation, heartburn awareness, diabetes, and skincare
screenings. Down the hall, Ladd’s husband, Kip, works in the office as the pharmacy’s business manager.

Patients from Saint Alphonsus Regional Medical Center, where Elaine Ladd works as a clinical specialist, often come to her MTM clinic for follow-up medication counseling.

Staff at the college are impressed with Ladd’s operation.

“There is an urgent need for pharmacist-provided MTM in Boise,” said Barb Mason, Pharm.D., FASHP, professor and chair of the

ISU College of Pharmacy Department of Pharmacy Practice. “Elaine’s sincere passion for patient-centered care and desire to work collaboratively with physicians is sure to bring her success in any endeavor she pursues.”

So far, Ladd’s unique approach is working. The pharmacy has only been open six months, but pharmacists already fill an average of 80 prescriptions on weekdays. And those numbers are trending upward.

Ladd believes that the unique pharmacy services offered by her four pharmacists and six pharmacy technicians are a real benefit to patients. And she is interested in seeing more integration in patient-care services among hospitals and ambulatory care settings as technology improves.

“Every step along the continuity of care matters, and pharmacists are uniquely suited to provide the kind of MTM services that patients need,” she said. “I’m excited to be able to bridge both worlds.”

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.

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