THE FUTURE OF HEALTH

SYSTEMS PHARMACY

HANNAH COOPER & MORGAN SCHAFFER

PGY1 PHARMACY RESIDENTS
PHARMACY STRATEGIC PLANNING DAY
FRIDAY SEPTEMBER 6, 2019
 OBJECTIVES:

1. Summarize the strategic planning advice outlined in the ASHP Foundation’s 2019
Pharmacy Forecast
2. Identify and evaluate external healthcare trends that will affect health system pharmacies
3. Evaluate recommendations provided by the Pharmacy Forecast and the Advisory Board
Executive Forum to guide strategic planning within the Deaconess Health System
 SECTION 1:
THE FUTURE OF PHARMACY
EDUCATION & WORKFORCE
 PGY1 RESIDENCY REQUIREMENTS:

 The American College of Clinical Pharmacy has

called for all pharmacists involved in direct patient
care activities to be residency trained by 2020
 61% of panelists agree that graduates will NOT be prepared
for frontline health-system pharmacy practice
 PharmD curriculum prepares for general patient care
 Pharmacy leadership must ensure sufficient number of
programs & positions available
 Estimated 4,839 positions will be needed
 EXECUTIVE LEADERSHIP POSITIONS FOR PHARMACISTS:

 52% of panelists believe it is unlikely pharmacists will hold

an executive leadership position outside of pharmacy
 Recognition of expertise that pharmacy can bring to:
 Innovative care models
 Medication services
 Management of business profitability

 Medications = one of the major contributors in healthcare

expenditures
 REMOTE OVERSIGHT OF TECHNICIANS:

 Existing deficit of pharmacists in rural & underserved

areas
 Use of telepharmacy for remote oversight
 >50% of panelists believe health systems will use these
applications
 Oversee operations
 Provide clinical, analytic, and managerial services

 Need to consider other incentives to meet these

demands
 TELEPHARMACY FOR REMOTE OVERSIGHT:

 Pharmacy technicians
on-site at certain clinic
locations
 Pharmacist supervision
via telepharmacy from
off-site hubs/other
locations
 TELEPHARMACY (CONT.):

Care
Financial Growth
Delivery
Offer at-home
prescription Offer
Market
monitoring telepharmacy to
telepharmacy
support support patients
services more
between
Use of apps and widely in the
physician office
text-based community
visits
reminders
 TECHNICIANS IN DIRECT PATIENT CARE:

 Competency-assured technicians allowed to perform

patient care activities
 Transitions of care
 Medication histories
 Medication reconciliation

 Requirement for certificates that validate skills/ability

 PHARMACY STUDENT SUPPLY VS. DEMAND:

 60% believe the number of graduates will decrease by ≥10%

 Expansion of pharmacy academia over the past 10 years:

Year # of Schools # of Grads

2007 100 9,800
2016 128 14,556
2018 143 …
 Result = supply > demand
 Need = reduce class sizes to align with workforce
 BURNOUT IN ADVANCED PRACTICE ROLES:
 Burnout = psychological process whereby human service
professionals attempting to influence the lives of others
become overwhelmed and frustrated by unforeseen job
stressors
 Existing research largely focuses on physicians and
nursing
 Expected increase in annual turnover expected by ≥15%

↓Quality of
Burnout ↑Turnover Care &
Patient Safety
 SECTION 2:
MEDICATIONS AS THE KEY DRIVER OF
HEALTHCARE FINANCE AND CARE DELIVERY
 VERTICAL INTEGRATION:

 Split on whether acquisitions and alignments will slow

expenditure growth
 Expected market strategy for the foreseeable future
 Example: expansion of retailers into diagnostic and
clinical care services
 Need for development of new models that will take
advantage of this shift in healthcare
EXAMPLE: VERTICAL INTEGRATION
 INDEPENDENT HOSPITALS:

 Continued alignments, merges, and acquisitions

 Majority felt the number of independent hospitals
will continue to decrease
 Pharmacy programs will need to be involved to
support the organization in these acquisitions
 Ex: Formulary Management
 PRIOR AUTHORIZATION PROCESS:

 17-22% spending growth per year for specialty drugs

 Expected to comprise 50% of US drug expenditures next
year
 Prior authorization process is a distraction to most
clinicians
 Opportunity to centralize the process and increase
efficiency
 BIOSIMILARS:

 Medicare B: reimbursement linked to average sale

of the branded product
 Felt to be unfair for innovator biologic
manufacturers
 Trump Administration (2018): reimbursement will
be based on specific biosimilar product price
 Result = pricing may increase to increase
reimbursement
 340B DRUG PRICING PROGRAMS:

 340b programs allow opportunities to stretch scarce

resources
 ~75% of panelists believe savings from 340b will be
reduced by up to 50%
 CMS will continue to reduce payment for
medications purchased through 340b programs
 COMMUNITY HEALTH PROGRAMS:

 Movement to a value-based care payment model

 CMS goal to deliver 90% of payments to these models in
the next 10 years
 Emphasis on:
 Disease prevention
 Wellness management

 Expansion into more community-based programs

 SECTION 3:
THE OPIOID CRISIS
OPIOID STEWARDSHIP:
 OPIOID STEWARDSHIP (CONT.):

 Integrated multidisciplinary pain consultation

 Input from physicians, pharmacists, etc.
 Optimize non-opioid pain therapy
 Evidence-based use of opioids where necessary

 Telepharmacy to provide this service in rural areas

 Ex: Project ECHO

 Facilitate disposal of leftover opioids, promote

awareness of CDC guidelines, etc.
 PATIENT CARE:

 Government coverage for addiction

treatment must increase/expand
 Health systems need to do more to care for
those with opioid use disorders
 Pharmacy role in managing
 Medication assisted therapy
 Relief of withdrawal symptoms
 Identification of at-risk patients
 PATIENT CARE (CONT.):

Ensure a
Take part in
Emphasis on balance
shared
non- between
decision
pharmacologi stewardship
making with
c pain & optimal
patients &
treatments pain
care teams
management
Partner with
Remove pain
community-
management
based
questions from
pharmacists for
patient
comprehensive
satisfaction
pain
surveys
management
 SECTION 4:
ETHICAL ISSUES
 RIGHT TO TRY:

 Right-to-try legislation passed in May 2018

 Increased requests for diagnostics or therapies that lack
evidence of safety and/or efficacy
 Policies are needed that address these requests
 Pharmacists may be challenged to justify evidence-based
policies
 HARVESTING PATIENT DATA:

 Risk vs. benefit for use of personal non-health data

 Social media
 Web searches
 Fitness trackers
 Commercial genetic testing
 Consumer purchases

 Must consider what we have to gain from such

information
 Patients right to privacy
 Ensure good intentions and full disclosure of use
CONFLICTS OF INTEREST:
 SECTION 5:
TECHNOLOGY INNOVATIONS &
INVOLVEMENT BY PHARMACY LEADERS
 INFORMATICS PHARMACISTS & DEVELOPMENT OF
TECHNOLOGIES:

 Informatics pharmacists should be involved at the leadership level

 63% of panelists believe the use of artificial intelligence would reduce pharmacist time
spent on routine clinical tasks (such as selection and dosing)
 Primary responsibility for evaluating and supporting clinical decision making tools will fall to informaticists

 Interoperability between software systems

 Involvement in patient care through:
 Apps
 Patient portals
 Pharmacogenomics
 PHARMACOGENOMICS:

 Current implications for:

 Oncology
 Psychology
 Cardiovascular

 Pharmacy can provide consultative support by:

 Providing testing
 Providing results
 Implications of results
 PHARMACOGENOMICS:

Education Sessions for

P&T Subcommittee: Clinical Support:
Providers:
• Basics of PGx • Identify testing with • Certifying
• Health system best evidence pharmacists as PGx
offerings • Identifying drug-gene consultants
• Pharmacy support pairs that could • Manage hospital-
cause ADE’s based PGx
• Build EHR flags work/support
• Negotiate test
reimbursements
 SECTION 6:
EMPOWERING PATIENTS TO OPTIMIZE
MEDICATION USE
 PATIENT ENGAGEMENT:
Structures for Engagement:
 Patient and family advisory councils
(PFAC’s)
 Patient and family perspectives on health
system issues
 Improved quality performance measures
 Involvement on initiatives and committees
throughout the organization
 Including P & T committees
The Health System’s Brand:
 Weighing patient engagement with
protecting the brand
 Majority expect health systems to have a
set process for responding to negative
social media comments (~90%)
 75% believe health systems will highlight
pharmacy involvement in clinics in their
marketing strategies
 PARTNERSHIP AT THE POINT OF CARE:

 Enhance collaboration with patients and family

 Share in decision making to achieve best outcomes
 Patients will be better served by medications that they
are willing to take
 Patient preference vs. guideline-based therapies
 Must also consider socioeconomic determinants
 Avoid paternalistic models!
 SECTION 7:
PHARMACISTS IN PATIENT CARE
 PRESCRIBING AUTHORITY:

 Nearly 70% of panelists believe ≥75% of states will grant

pharmacists independent prescribing authority
 Independent prescribing is needed to meet full potential
 Move toward value-based financial system

Improved patient ↑ Productivity

↓Costs
care outcomes & Quality

 ~75% believe pharmacists will be subject to credentialing

and privileging requirements
 AMBULATORY CARE & SPECIALTY CLINICS:

 Pharmacy value in ambulatory and specialty clinics is

well documented

Improved patient ↑ Productivity

↓Costs
care outcomes & Quality

 Recommends aggressive expansion into new areas of

clinic practice
 Pain management
 Endocrinology
 Neurology
 Cardiology
 Geriatrics
 GERIATRICS:

 Medicare population continues to grow and

age
 There is a shift as “Boomers” reach the “old-
old” patient population (≥85 y.o.)
 Area of unmet needs by pharmacy
 GERIATRICS:

Care
Financ Growt
Delive
Risk stratify ial h
ry high-risk MTM Accessible and
patients easy-to-use
De-prescribing Use of generics specialty
efforts and biosimilars pharmacy
Med when possible Market clinical
synchronization pharmacist
Adherence access
packaging
 GERIATRICS:

 How do we get involved?

Consult Provide Pharmacist ability

Advocate for a full-
agreements to comprehensive to add, modify, or
time geriatric
allow physician medication reviews remove
board-certified
referral for and assess for medications as
clinical pharmacist
polypharmacy to ongoing or long- necessary (under
within outpatient
geriatric term medication consult
clinics
pharmacist needs agreement)
 SECTION 8:
DISRUPTIVE FORCES IN HEALTHCARE
 DRUG PRICING & MANUFACTURING:
Transparency of Pricing:
 Mixed results on whether a federal law will
be passed to limit pricing of
pharmaceuticals
 Vocalize the impact of high drug costs on
patients
 Partner with non-traditional participants in
healthcare to control costs
 Support transparency of drug pricing for
better patient and caregiver
understanding
Manufacturing by Health
Systems:
 In response to the growing number of
drug shortages
 Majority of panelists believe it is unlikely
health systems will go in this direction
 Likely due to overwhelming number of
shortages being experienced
NON-TRADITIONAL PARTICIPANTS IN HEALTHCARE DELIVERY:

 Ex: Amazon, Apple, Google, JP Morgan, etc.

 ~6o% of panelists believe this activity will reduce the role of fiscal and supply chain
intermediaries
 ~75% of panelists believe health systems will partner with these companies to reduce
costs and increase quality of services

Reduction in Partnering
fiscal & supply with non- ↓Cost &
chain traditional ↑Quality
intermediaries participants
 SUMMARY OF RECOMMENDATIONS:

1. Discuss Deaconess’ response to the entry level requirement for PGY1 training and the need
for increased residency positions
2. Examine opportunities for pharmacy involvement in outpatient services in the following
areas:
• Telepharmacy
• Opioid stewardship
• Geriatrics
THE FUTURE OF HEALTH
SYSTEMS PHARMACY

QUESTIONS?