Even as rising drug prices intensify cost pressures, hospital pharmacies are striving to improve care and expand services without breaking the bank.

The biggest change motivator is health reform, with its push toward value-based payment, accountable care and Medicare payment penalties for readmissions. Its emphasis on care throughout a patient's disease state is spurring hospital pharmacists to extend their reach, says Mark Eastham, senior vice president and general manager of McKesson Pharmacy Optimization.

“They want to follow the patients and make sure they’re taking their medication, they’re taking it the right way, and they don’t have any side effects,” he says. “What that does for them and the patient is it really creates more continuity of care versus how the model was before, where it gets handed off to a retail pharmacy and then, all of the sudden, you have this big disconnect.”

That interest in ensuring care continuity has prompted many hospitals to involve pharmacists in patients’ transitions out of the hospital.

At Lifespan, a Rhode Island health system, pharmacists visit patients at risk of readmission while they’re in the hospital. They go over medications with them and describe how the drugs work in the body, says Christine Berard-Collins, director of pharmacy. The pharmacists ask patients to repeat what they’ve heard to make sure they understand their medications before they leave the hospital.

“It’s not just saying, ‘Do you have any questions?’” says Berard-Collins, “It’s explaining to them the whole connection of the medication and what it means to them.”

A clinical pharmacist oversees the transitions-of-care program, offered at Lifespan’s Rhode Island Hospital and The Miriam Hospital. Three pharmacists make the patient visits. After discharge, case-management nurses call patients to follow up on a number of issues, including medication.

Comprehensive Pharmacy Services, which serves more than 550 hospitals and health care facilities, launched a transitions-of-care program in 2014. Under RxTransitions, pharmacists conduct patient discharge teaching, and admission and discharge reconciliation. They follow up with patients 24 and then 48 hours after they’ve been discharged from the hospital to talk through their medications and answer any questions.

Patients can be so overwhelmed at discharge that they don’t absorb medication instructions, says Rod Recor, CPS chief strategy officer. “When we get in touch with that patient a couple of days later, they’re much more receptive to hearing things, and they’re more intently listening.”

The six participating clients, with more than 10,000 patients, have seen readmissions for the conditions they’ve targeted fall between 30 and 50 percent, Recor says.

Instead of sending patients home with a prescription, many hospitals are sending them on their way with their outpatient medicines in hand. These meds-to-beds programs are a way to prevent that patient-provider disconnect that exists in the traditional model of hospital pharmacy services, Berard-Collins says. “We [used to give] them very important, and often lifesaving, prescriptions and hoped they got them filled, hoped they had a ride to the pharmacy, hoped they didn’t run into a co-pay issue, hoped it was covered by their insurance, hoped that they could find a pharmacy that stocked it,” she says. “That did not seem to us to be in the spirit of accountable care.”

Besides meds-to-beds, Lifespans offers free home delivery for patients who might not need their medications at discharge or when drugs need to be specially ordered. While the service has a cost, the patient value is more important, Berard-Collins says.

“Making sure our patients take their medications is the No. 1 priority,” she says. “We’re prescribing [them] for a reason, and that reason is to keep them healthy.”

Growing appeal of retail pharmacy

Interest in maintaining continuity of care into the outpatient setting also is prompting an increasing number of hospitals to create their own retail pharmacies, Eastham says.

Access to patients’ electronic health records means hospital retail pharmacists can check physicians’ notes, what drugs a patient was on in the hospital, lab values, and the last time a patient visited a hospital clinic. “This gives them more data to take care of that patient in a way that a retail pharmacy would not have,” Eastham says.

Hospital-owned retail pharmacies also allow hospitals to capture revenue that otherwise would be lost to pharmacy chains. Careful analysis needs to be made to determine whether a hospital-owned retail pharmacy is financially viable.

Lifespan hired a consultant to conduct a business analysis before entering into the retail pharmacy business. The goal was to make sure the endeavor would at least cover its expenses within five years, so it wouldn’t become a drain on the organization, says Berard-Collins, who is director of pharmacy at Lifespan Pharmacy LLC.

Retail pharmacy has many fixed costs, including space, phones, computers, pharmacists and technicians, so the organization had to determine the baseline number of discharges and specialty services necessary to cover those expenses. The business analysis showed that the threshold was achievable at Lifespan’s two largest hospitals. The organization opened its first retail pharmacy in May 2013 at Rhode Island Hospital and its second in October 2014 at The Miriam Hospital.

Business know-how has to be taken into account when opening a hospital retail pharmacy. “We called it the pharmacy that it took a village to build,” jokes Berard-Collins about Lifespan’s first foray into retail. “It was not a pharmacy project; it was an organization project. It involved marketing, security, information systems, contracting, accounts payable, finance. All the different elements of the organization really came together.”

Lifespan was able to open its pharmacies with existing pharmacists, many of whom had previous retail experience. Each facility has a pharmacist in charge who works only in that location, but other pharmacists alternate between retail and inpatient pharmacy. “We love the fact that we are an integrated service, so our pharmacists in the retail pharmacy are comfortable going into a patient’s room to counsel them,” Berard-Collins says.

Care has to be taken in deciding where to locate a retail pharmacy on a hospital campus, Eastham notes. Places with high foot traffic or near outpatient clinics often work well. “It can’t be your typical hospital pharmacy where it’s in the basement,” Eastham says. “People aren’t going to go down there.”

Some hospitals want to offer patients the convenience and access of on-site retail pharmacy without entering the business themselves. Advocate Health Care in the Chicago area has partnered with Walgreens to provide retail pharmacy in three of its 12 hospitals, with plans to open three more, likely in 2017. “Retail pharmacy is not our core competency, so partnering with someone with expertise makes a lot more sense,” says Rishi Sikka, M.D., Advocate’s senior vice president of clinical operations.

Advocate doesn’t share more patient information with the in-house Walgreens than it would with any other retail pharmacy, says Bill Forslev, Advocate’s vice president of pharmacy. But because the pharmacists are on-site, they have built relationships with physicians and nurses that allow for easy communication.

Specialty pharmacy pros and cons

The explosion of specialty drugs is prompting some hospital systems to create their own specialty pharmacies. Again, the philosophy behind offering the service is to improve care continuity while potentially generating revenue, Eastham says.

In general, specialty drugs are expensive medications that require special handling or careful patient monitoring — traditional cancer chemotherapies are an example. These days, offerings have expanded way beyond infused chemotherapies. In recent years, patient-administered specialty drugs have hit the market, including oral chemotherapies, medications for rheumatoid arthritis and drugs that cure hepatitis C. A promising class of specialty cholesterol-lowering drugs, called PCSK9 inhibitors, are in the drug-development pipeline and could be approved in the next couple of years.

In 2013, Lifespan launched a specialty drug service at its Rhode Island Hospital retail pharmacy after concluding that it made no sense for patients or the organization to hand off those patients to outside pharmacies, Berard-Collins says. “The clinical pharmacists in my clinics are seeing the patients, teaching them about their medications, following up with them to see if they’re having any side effects, checking their lab values,” she says. “They were doing all this work and then sending the prescription out to be filled by some out-of-state pharmacy.”

Complex, sometimes toxic, specialty medications can be managed better by the clinical pharmacists who are working with the rest of the patient’s care team using a shared EHR, Berard-Collins says. “Their patients are our patients, so we have a personal and vested interest in them,” she says. Pharmacists serve in the oncology, renal transplant and hepatitis C clinics.

Lifespan’s retail pharmacy enterprise, including the specialty drug service, is nonprofit. Any revenue gained goes back into the system to pay for new programs, Berard-Collins says. Both retail pharmacy locations are significantly exceeding their revenue targets, and their combined revenues have surpassed the break-even point, she says. As a result, this year they were able to add pharmacist positions in the rheumatology, GI, dermatology and neurology clinics.

Insurance coverage for specialty drugs is tricky, however. Some specialty medicines are covered under the patients’ medical benefits and others under the pharmacy benefit, Eastham says. Pharmacy benefit managers want insurers to move specialty drugs into the pharmacy benefit because that allows them to run them through the PBM’s specialty pharmacies, he says. “But right now, it just depends on how the payer has decided what health benefit to put that in.”

In Rhode Island, the two largest private health insurers have exclusive relationships with outside pharmacies, so patients with their insurance can’t fill their specialty drug prescriptions at Lifespan’s pharmacy. The situation is frustrating because it means Lifespan’s specialty clinic pharmacists can’t keep tabs on those patients as thoroughly, Berard-Collins says.

However, Medicare patients have access to the Lifespan specialty pharmacy through Medicare Part D, Berard-Collins notes. Lifespan is self-insured, and its plan members can fill specialty drug prescriptions at the organization’s retail pharmacy. Another barrier for hospitals is that some specialty drug manufacturers have established limited distribution networks so only certain pharmacy chains can supply their drugs. Lifespan has had some success in working around those deals. “We say, ‘we’re not looking to take over the market for this drug. When it’s our own patient, we’re responsible for them anyway, so can we just fill the drug?’ Some of them have been very open to that,” Berard-Collins says.

Forces Impacting Pharmacy Departments

A number of major trends, from rising drug prices to value-based payment, will affect hospital pharmacy departments in the coming years. “Pharmacy Forecast 2016–2020,” published in December 2015 by the ASHP Foundation, lays out forces impacting pharmacy departments and recommendations for coping with them, including:

-    The pharmacy enterprise can help their organizations to succeed by standardizing processes, implementing best practices that improve patient health, managing the formulary properly and applying business acumen throughout the medication-use process.

-    Because of growth in the use of expensive specialty drugs, health systems should conduct an assessment to determine the best approach to these medications. Options include creating a hospital-owned specialty pharmacy service, establishing such a service with a business partner, completely outsourcing the service, or not providing a specialty drug service while ensuring safe and appropriate care of patients on specialty drugs.

-    The push for quality improvement and payment for value will extend into pharmacy departments. They should design and implement medication therapy-related quality measures and performance metrics that focus on enhancing quality, efficiency and cost management.

-    Consolidation of generic drug manufacturers is posing challenges. The switch from multisource to single-source generics will lead to at least a 25 percent increase in health system expenditures for generics by 2020.

-    In the face of pressure to deal with continual escalation of drug prices, a pharmacy should ensure that the driving force behind its work is patients’ best interests complemented by compliance with evidence-based medication use and waste minimization.

Framing the issue

-    U.S. spending on prescription drugs jumped 12.6 percent in 2014 to $305 billion, compared with 2.5 percent in 2013, largely because of increased spending on new hepatitis C treatments and drugs for cancer and multiple sclerosis, according to the Centers for Medicare & Medicaid Services.

-    Prescription drug prices increased 4.1 percent overall in 2014, up from 2.3 percent in 2013, CMS reports.

-    Annual price increases for prescription drugs are expected to average 3 percent through 2024, CMS states.

-    700 specialty drugs are in the drug development pipeline, according to PricewaterhouseCoopers LLP.

-    The average price of cancer drugs for about a year of therapy increased from $5,000 to $10,000 before 2000 to more than $100,000 by 2012, according to an April 2015 article in Mayo Clinic Proceedings.