By Todd Sloane

While some forward-looking hospitals and health systems long ago began to realize the value of the inpatient pharmacy department, new trends may be awakening more hospital and health system executives to the opportunities inherent in elevating pharmacists to roles in clinical care and cost control.

The move to value-based care, with its emphases on quality metrics and care efficiency, is one such trend. Another is the need to keep patients from being “frequent flyers,” who keep rebounding into inpatient care. Also triggering executives’ awareness is a host of new regulations related to medication management. And accreditation organizations, such as the Joint Commission, are far more focused these days on the role medicines play in patient safety.

“One of the challenges for the C-suite is to fully understand the full suite of services that the pharmacy provides,” says Edward Choy, PharmD, President of Health Systems Operations for Comprehensive Pharmacy Services (CPS), a national provider of inpatient and outpatient pharmacy management and consulting services to nearly 600 hospitals. “One of the most important things we do at CPS is to educate leadership on what pharmacy can do for the organization, whether it be reducing risk, lowering costs or improving outcomes.”

Some pharmacists are joining multidisciplinary care teams centered on management of patients with chronic conditions, such as hypertension and diabetes. And dashboards with pharmacy data are of growing interest to finance, directors of quality and even CEOs. “This can range from drug costs per patient day to number of adverse drug events to looking at how you are doing on CMS (Centers for Medicare & Medicaid Services) Core Measures to HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, which have many questions related to pharmacy,” says Marcia Gutfeld, PharmD, MBA, CPS Senior Vice President for the East Coast region.

Depending on his or her organization’s patient mix and business outlook, the pain points that drive an executive to either raise the profile of the inpatient pharmacy or engage with a firm such as CPS to help address these issues vary widely. “Everybody wants to do something about drug costs, but these other issues are growing in importance, making them difficult to ignore,” Choy says.

So here (with a nod to David Letterman) is a top 10 list of the leading pharmacy-related pain points experienced by health care leaders today.

No. 10: Adverse drug events (ADEs). It isn’t that these patient safety failures aren’t important; it is that they are old news at this point, says Marvin Finnefrock, PharmD, Divisional President of CPS. “Certainly those on the front lines are pretty focused in on ADEs; they just aren’t top of mind for the C-suite people I talk to.”

No. 9: Compounding pharmacies.Yes, nearly four years after the meningitis outbreak in Massachusetts, it’s still an issue, and newer, tougher regulations on the combining of drugs are on the way. Issues of proper sterility, handling and storing of these compounds are found in every state CPS has looked at.

No. 8: Drug diversion/opioid abuse. The Institute for Safe Medication Practices recently issued a medication alert focused on drug diversion and the U.S. opioid addiction epidemic. More than 19,000 opioid overdose deaths occurred in 2014. The latest data from the U.S. Substance Abuse and Mental Health Services Administration indicate that one in every 10 health professionals is struggling with addiction or abusing drugs that are not prescribed for them. “It is not uncommon that diversion is not identified, but we have an obligation to implement and support programs and processes that will raise the bar in the prevention and identification of these situations,”Gutfeld says.

Finnefrock lists a number of steps toward prevention, starting with an audit of controlled substance data in the hospital organization; maintaining a chain of custody and utilizing witnesses when disposing of controlled substances; establishing education and training across multiple disciplines to educate staff on controlled substance diversion; and placing camera surveillance in high-risk areas.

No. 7: Pharmacy leadership problems.When issues such as high pharmacy department turnover, physician and nurse unhappiness with pharmacy or shortcomings on a Joint Commission survey arise, top executives may need to address current department leadership, Choy says. That might mean simply recruiting a new leader or bringing in a pharmacy management company.

No. 6: Antibiotic stewardship.With the White House backing efforts to stem the tide of drug-resistant superbugs, which sicken 2 million people and cause 23,000 deaths in the United States each year, according to the Centers for Disease Control and Prevention, a number of steps are needed to change this picture. A good starting place is to produce what is known as an antibiogram—a detailed snapshot of what antibiotics your organization as a whole is using, at what cost and with what outcomes. “Without an antibiogram, it is impossible to go to a pharmacy and therapeutics committee meeting or to a physician and realistically seek to change prescribing patterns,”says Finnefrock.

No. 5: Implementing change across a health system. “We’re seeing a lot of mergers in formerly competitive markets, so where you had four competing hospitals, now you have one player,” Choy says. Many, however, are struggling with integration or “systemness” of pharmacy services. One system CPS works with operates more than 100 facilities in 15 states, and it wants to adopt best practices and technology across all of them. “Change is slow, because you need to commit (a) lot of resources to get this done. You need on-site, expert help,” Choy says.

No. 4: The 340B Drug Pricing Program.The program, which allows certain safety-net health care organizations to purchase outpatient drugs at discounted prices, is still a maze,Gutfeld says. “People need a lot of help to get through it. HRSA (the Health Resources and Services Administration) has really stepped up oversight, which is a good thing in terms of limiting fraud and abuse, but there are a lot more audits for everyone, and the rules are getting tighter.”

No. 3: Readmissions.Pharmacy has an opportunity to play an important role in how a patient is managed through all levels of care, including follow-up care at home or a rehabilitation facility. “The whole notion of transitions of care is a huge opportunity for pharmacy,” Gutfeld says. “Starting in the ED (emergency department), we get the history of what meds a patient has been taking and reconcile the list for the hospital stay. We’re there at discharge, informing them about the meds they will bring home, and then we follow up, as many patients don’t fill scripts after they leave without intervention.”

No. 2: Accreditation.CPS has established a large department dedicated to compliance, which maintains a large database of the types of issues surveyors look for, how they interpret the standards and what findings they report.“There has been a sea change over the past 15 years, a significantly greater emphasis on pharmacy and medication use,” Choy says. Two decades ago, the Joint Commission did not publish a separate chapter in its guidelines on medication management. Now the chapter not only exists but is growing, with surveyors looking at sterility of processes, medication reconciliation, patient safety and other areas. “This is creating a lot more pressure on directors of pharmacy, who are becoming much more visible to surveyors and to the C-suite,” Choy adds. “We have a long history of helping clients through this process.”

2015 top Joint Commission noncompliance standards

All-hospital average

CPS-managed hospital average

     

Medication storage

35%

17%

Medication orders

22%

10%

Pharmacist review

16%

0%

Before a procedure, label medicines in syringes
and cups

13%

3%

Medication reconciliation

6%

0%

Medication labeling

5%

5%

Sources: Joint Commission, CPS database

 

And the No. 1 reason the C-suite is taking greater notice of pharmacy is rising drug costs.No surprise, says Finnefrock, “You just can’t get away from it.” “Hyperinflation of drug costs outpaces data on inpatient utilization (and) frankly everything else. It’s now front-page news.”

Adds Gutfeld:“The high cost of prescription drugs is not sustainable for our healthcare institutions and the patients they serve. It is imperative that we develop local, state and national policy that will begin to bring the cost of medications down so the patients who need medications to manage their health can afford them.”