Mid Term Hospital Systems

What are the domains of HVPE?

Patient Care Services

Business Services

Ambulatory and Specialty Pharmacy Services

Inpatient Operations

Safety and Quality

Pharmacy Workforce

Information Technology, Data and Information Management

Leadership

What does Patient Care Services domain include?

pharmacy services

continuity of healthcare

stewardship of resources and programs

clinical data analytics

Pharmacy Services

comprehensive pharmacy patient care services as providers on the interprofessional team in all care settings, accountable for all medication-use needs to support safe and effective drug use, ensure appropriate use of pharmacogenomic info and biomarkers to optimize drug therapy selective, prevent adverse events and reduce total cost of care

What does the Business Services domain include?

medication cost management

medication access

revenue integrity

business growth

What does the domain of Ambulatory and Specialty Pharmacy Services include?

pharmacy services that benefit population health and improve access to care

retail pharmacy services

specialty pharmacy and infusion care services

employer funded health plans

What does the Inpatient Operation domain include?

medication use systems and operation pharmacists

drug shortage management

drug diversion prevention

safety of medication storage, preparation, distribution, administration, and disposal

efficiency within a multihospital system

What does the Safety and Quality domain include?

cultural and organizational characteristics that define safety and quality

role of pharmacy and therapeutics committees in ensuring evidence-based care

accountability and monitoring of patient safety and quality and value

special considerations for patient and healthcare work safety

What does the domain Pharmacy Workforce include?

pharmacy education

pharmacist scope of practice, staffing, and practice model

pharmacy technicians

scholarship

professional development

What does the domain of Information technology, data and information management include?

fundamental medication management supporting technologies

pharmacy workforce competency

data, information, and analytic platform management

What does the Leadership domain include?

attributes of the pharmacy leadership team

organizing for maximum effectiveness

strategy and innovation

leading for results

developing future leaders

What are the goals of healthcare reform?

expand health insurance coverage for Americans lacking it

Constrain rising costs of care

Improve security of coverage for persons with chronic disease

Medicare Part A

hospital insurance

covers inpatient hospital, skilled nursing facility, home health and hospice

Who is entitled to receiving part A insurance?

individuals (and spouses) after paying payroll taxes for 10+ years

Medicare Part B

supplementary medical insurance

covers physician visits, outpatient, preventive services, home health

Copays for Part B

higher for beneficiaries with higher incomes

20% coinsurance for physician visits and outpatient hospital services (no co-insurance or deductible for annual wellness or preventative services)

Medicare Part C

medicare advantage plan

includes HMOs, PPOs and other private health plans

OR can enroll in regular fee-for service

Medicare Part D

drug benefit

administered solely through private plans (not under fee-for service program)

What is the maximum deductible for Part D?

$505

What is the prescription cost for those under Medicaid and are > 19 years old?

free

What is the prescription cost for those under Medicaid and are < 19 years old?

0

Eligibility Criteria for Medicaid

poor families (children up to 19 in homes up to 200% FPL or parents up to 50-62% FPL)

some elderly at 75% FPL

blind or disabled

What are some optional groups that are eligible for medicaid?

pregnant women and infant up to 194% FPL

elderly, blind or disable NOT otherwise

former foster children (18-26)

Is Medicaid run by state or federal?

state

CHIP 1997 Children Health Insurance Program

provides health coverage to children in families with incomes to high to qualify for Medicaid, but who cant afford coverage (18 year old and younger)

Affordable Care Act

provides states the authority to expand Medicaid eligibility to individuals < 65 in families with income below 133% of the federal poverty level (not all states chose to enroll in this)

Eligibility Criteria for Medicare

65 years old or older younger people with disabilities and people with end stage renal disease

Who is eligible for premium free part A?

age 65 years or older and you or your spouse worked and paid medicare taxes for at least 10 years

What is mandatory to be covered under medicaid?

hospital services

early and periodic screening, diagnostic and treatment

nursing home

home health

MD services

lab and radiology

family planning

NMW and NP care

tobacco cessation for pregnant women

transportation to medical care

What is profit and loss?

summary of revenues, costs and expenses of a company during a specified period

provides information about money coming in and the money necessary to obtain that income

"income statement"

Why do we do profit and loss statements?

gives us insight to reimbursement profile, purchasing practice, billing for waste, appropriate utilization, and correctly charging

Limitations to P&L

payment can change within a certain time period, self built report at MUSC health = not externally validated

Diagnosis-related Group method of payment

inpatient

medicare pays a lump sum for the entire hospital admission encounter

Medicare Severity Diagnosis Related Groups (MS-DRG)

inpatient

assigned a unique relative weight which is used to calculate payment to the hospital

What does each DRG weight represent?

average resources required to care for cases in that particular DRG, relative to the average resources used to treat in all DRGs

Drugs < $130 per day

packaged with primary service

no separate payment for medication

outpatient method

What are some examples of drugs < $130?

supplies, lab tests, procedures

no separate payment for medication

Drugs > $130 per day

assigned billing codes

separate payment for medication

outpatient method

What are some drug examples of > $130 per day?

those that utilize J codes

What are the different purchasing accounts?

AWP

WAC

GPO

PHS/340B

AWP

average wholesale price

"sticker price"

WAC

wholesale acquisition cost

price of medication form the manufacturer

PHS/340B

public health services and 340B

acquisition cost for outpatients (ED, clinic, retail)

GPO

group purchasing organization

acquisition cost for admitted inpatients

10-18% cost reduction

Goal of 340B Program

front end drug discounts to "covered entities", provide relief of high drug costs, pharmaceutical pricing agreement (PPA)

outpatient medications only

How does 340B work?

manufacturer provides 340B covered entity with discounted drug, then that entity is able to provide medicines to patients including those with commercial insurance

insurer reimburses at full negotiated rate; entity keeps difference as profit

What does PHS/340B require pharmaceutical manufacturers do?

provide discounts to covered outpatient drugs to covered entities in exchange for having the manufacturers drugs covered by Medicaid and Medicare Part B

Hospital covered entities that qualify for 340B

children's hospitals

sole community hospitals

rural referral centers

critical access hospitals

freestanding cancer hospitals

Non-Hospital covered entities that qualify for 340B

federally qualified health centers

tuberculosis/STDs/black lung/title X family planning/urban indian and native hawaiian clinics

AIDS drug assistance programs

Ryan White

hemophilia treatment centers

What are the goals of a formulary?

safety, outcomes, trust, cost, and financial

Formulary

list of medications and associated support tools to meet the needs of patients

What does a formulary include?

medications and medication related devices

medication use policies

decision support tools

organizational guidelines

Safety Goals of Formulary

reduce errors associated with prescribing

Outcome Goals of Formulary

improve outcomes with evidence based ordering and protocols

Trust Goals of Formulary

guide prescriber decision making to more rational drug therapy

Cost Goals of Formulary

select cost effective therapies when multiple products may exist

Financial Goals of Formulary

protect against decisions driven by marketing claims

Open Formulary

voluntary

unrestrictive with little/no limitations on medication use

cost prohibitive

difficult to manage inventory

Closed Formulary

restricted

helps promote safe, judicious drug therapy

limits the number of available medications

helps contain costs

What are the additional tools that exist that aide providers in therapeutic decision-making?

ATS

IV to PO

Hard Stop

Automatic Therapeutic Substitution (ATS)

interchanging to preferred alternative

limits nonformulary use

does not require prescriber approval

IV to PO tool

switch must meet predefined criteria

Hard Stop

automatic discontinuation in EHR

What is the goal of a P&T committee?

promote rational, clinically appropriate, safe, and cost-effective drug therapy

What are the responsibilities of P&T committee?

Developing drug formulary, monitoring formulary adherence, developing policies and procedures for medication use, performing adverse event review, performing mediation-use evaluations, educating staff on optimal use of medications

GPOs (group purchasing organizations)

purpose is to promote the economic welfare of individual hospitals by utilizing their combined efforts for efficient and economical purchasing of medications

What services do GPOs offer?

contract development

contract and supplier management

enhanced savings programs

online contract management and analytical tools

clinical and information services

Market-Basket

basket of medications to which drug is considered comparable and in direct competition

Market Share

percentage of drug that must be purchased to receive a discount

Tiered pricing

pricing different based on either quantities purchased or market share attained

What are some examples of cost management strategies?

80/20 reports

clinical guidelines/protocols

therapeutic interchange

medication use evaluation

waste monitoring

drug charges

reimbursement strategies

contract negotiations

What are drug companies and reps regulated by?

FDA division of drug marketing, advertising, and communication (DDMAC)

Pharmaceutical Research and Manufacturers of America (PhRMA)

each company is strongly encourage to adherence to this code

Code on Interactions with HealthCare Professionals

A items

high cost or essential medications

C items

less expensive items which only account for a small investment

B items

between A and C items

Visual Inventory Control Method

least effective and least expensive

orderer looks at the shelf and orders based on reorder point and quantity

Periodic Inventory Control Method

stock on hand is counted at intervals and compared to minimum desired levels

Perpetual Inventory Control Method

inventory monitored at all times

best way to control units and investment

most expensive and time consuming

What are some other inventory control methods?

MUSC informatics and formulary subcommittee

Quarterly review of high cost medications

Centralization of drugs

Borrowing systems with area hospitals

Returns and expired meds

Inventory Turnover Rate

average number of times inventory is sold and replaced during a given period

What are the positive predictor risks to supply chain?

IV formulation

antimicrobial agent

analgesic agent

electrolyte

anesthetic

CV agent

What are the negative predictors for shortage risk?

oral formulation only

branded medication

antipsychotic agent

schedule II med

Why do drug shortages occur?

Manufacturer issues (quality, supplies, demand)

Logistical and Operational Issues (workforce, weather, transportation)

Generic drug market

Prescription drug market

Why are drug shortages hard to manage?

not as simple as switching to an alternative

difficult to predict

risk with errors

Who communicate drug shortages?

operations

clinical

resource allocation committee

How can you communicate drug shortages?

how much medication is on hand

how long will the shortage last

where is current supply located

possible alternatives

What is the focus of clinical software?

electronic health record

clinical decision support

Operational Software Focus

software solutions designed with three foci

productivity metrics

quality and safety metrics

finance metrics

Productivity Metrics

medications interventions/day

measures productivity are only as useful as the goals that have been established

What are some examples of productivity metrics?

EHR

pharmacy automation reports

pharmacy operational/safety reports

Quality and Safety Metrics

turnaround times, policy compliance

reduce error lots of patients with same name or medication look alikes

Finance Metrics

payroll reports, invoices, account receivable and account payables reports

Benefits of Technology and Automation

faster data retrieval

improved ordering

quicker billing

early disease detection

speed and precision in medical diagnostics

provision of quality care

improve patient participation and management

minimal errors

safer treatment solutions

enhanced communication

superior and long lasting equipment

affordability of services

Challenges to Technology and Automation in Healthcare and Pharmacy

someone has to aggregate, mine, and interpret the data

Electronic Health Records

digital version of patient specific paper medical chart

Benefits of EHR

maintenance of records

easy collection, review, and transfer of records

incorporation of clinical automation functions

Drawbacks of EHR Order Sets

requires a lot of work

not always intuitive

Benefits of Clinical Decision Support and Alerts

ability to identify various potential causes of patient harm

prevents DDI, duplicate therapy interaction, drug-disease state interaction, pregnancy warnings, allergies

Drawbacks of Clinical Decision Support and Alerts

alert fatigue

HIPPA Purpose

to reform health insurance and increase portability of insurance between jobs and prohibit practices that decreased access to healthcare benefits