By: Amanda Winslow, PharmD, BCPS
As we move into a new decade, it’s natural to contemplate all the changes over the previous 10 years. The healthcare industry vastly transformed throughout that period. The approval of the Affordable Care Act (ACA) in 2010 majorly altered the United States healthcare industry. Coverage for patients was increased by removing restrictions on pre-existing conditions, expanding Medicaid, and mandating coverage for preventative care. The ACA had many provisions to try and shift to a value-based care system. While the idea of paying based on outcomes instead of volume seems appealing, it has potential unintended consequences. Value based care, coupled with increased access to healthcare, has caused several difficulties in the hospital setting.
Below are 5 real issues facing hospital pharmacies today:
1. Drug shortages
Any pharmacist will tell you drug shortages are the number one nuisance in hospital pharmacy. Shortages happen for many reasons, including manufacturing issues, natural disasters, supply issues, raw material issues and discontinuation. Whatever the reason, a shortage has no immediate solution. If the medication is a novel class, there may be no substitutable options. Depending on the cause of the shortage, it can take months to years to resolve. Manufacturers often cannot, or will not, estimate when they will have supply again. Shortages that do have a substitutable medication will then shift the demand to that medication, which will potentially cause other shortages or an increase in price.
2. Sterile compounding
Sterile compounding regulations have been changing significantly every few years. This not only means that pharmacies have to change processes, but may also have to spend a great deal of money to upgrade their ventilation systems, hoods and other equipment. A significant amount of planning would also need to go into these upgrades, such as where the pharmacy will operate during the upgrade. USP 797 and USP 800 have recently been updated, but are not being enforced yet. Once these regulations are enforced, non-compliant pharmacies will face penalties. One of the biggest changes to USP 797 is that Compounding Aseptic Isolators (CAI) and Compounding Aseptic Containment Isolators (CACI) must now be placed in a clean room. Many hospital pharmacies that utilize these types of hoods do so because they don’t have the space for a traditional clean room with a hood. Now, these pharmacies will have to somehow acquire more floorspace to create a cleanroom and spend time and money to ventilate it properly.
3. Workforce issues
The number of pharmacy schools has doubled over the last 30 years, resulting in a surplus of pharmacists in many areas. While the increased number of pharmacists may seem like a benefit to the untrained eye, the increased supply is causing some issues. The competitiveness of pharmacy programs has decreased, which means the candidates are less qualified. Many do not have prior pharmacy experience and it can be difficult to find a job during school because there are so many students. In the past, when there were less pharmacy schools, many students worked as interns or technicians before and/or during their school years. This allowed them extended training time in pharmacies, giving them a better understanding of processes from start to finish. Now, many new pharmacists have 1 or 2 rotations in a hospital setting, where they may or may not be exposed to different aspects of the pharmacy. Now a new pharmacist needs an extended training period to understand the processes fully, or have some on-the-job training and be willing to learn along the way. This may be difficult in smaller pharmacies where pharmacists often work alone.
Although there is a surplus of pharmacists, there is a shortage of good technicians. Unfortunately, many technicians make just above minimum wage and are required to work odd hours and weekends, so it is hard to retain technicians over time. They often return to school to find better long-term job options. Technicians are the backbone of a smoothly running pharmacy, so the turnover makes it difficult.
4. CMS measures
With the passing of the Affordable Care Act, the US healthcare industry started to see a shift towards value-based reimbursement, which is reflected in the reimbursement structure by the Center for Medicare and Medicaid Services (CMS). Hospital reimbursements are being cut due to hospital acquired infections, such as central line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections and Clostridium difficile infections. While pharmacists may not have a role in CLABSIs and CAUTIs, pharmacists do play a role in surgical site infections and Clostridium difficile infections. Hospital pharmacists must walk the line between helping prevent surgical site infections with appropriate antibiotic recommendations and discontinuing antibiotics at an appropriate time to reduce the risk of a Clostridium difficile infection. Assisting the hospital in minimizing the rates of the HAIs ensures that the healthcare system is getting maximum reimbursement and proves that pharmacists are a valuable part of the healthcare team.
5. Opioid epidemic
Hospital pharmacies face a particularly challenging role in the opioid epidemic. Many of our patients have undergone surgeries or are in pain from acute illnesses. Prior to the epidemic, the pharmacist’s job was to ensure the patients were provided with the pain medication(s) needed to make them comfortable. Even this simple job has become more difficult because a few companies cut back on production to “help” with the epidemic, leading to shortages. Pharmacists must also take a more active role in the ordering process of opioids. Pharmacists should be reviewing orders for appropriateness based on procedures done and patient history. They can also be stewards and transition patients to oral pain medications as soon as possible to reduce the “high” patients get from IV medications.