I want it for FREE!!....Wait....I don't???

Currently in the Johns Hopkins Hospital there is a "sample prohibition" on the way. What is a "sample"? In health care, it refers to those free drug samples you get from your physician, or that discount card you receive to get a free medication from your community pharmacist. From a consumer and patient perspective, it's hard to see the any drawbacks to receiving free drugs. I have to admit, I was puzzled when I attended meetings discussing how Johns Hopkins was going to get rid of all the free drug samples in the hospital, and prevent vendors from donating products to any of the health system's satellite hospitals and clinics.

As a future pharmacist, I want all of my patients to have access to necessary medication. If companies are willing to give away their brand-name drugs for free, who am I to stand in their way? I finally had to ask for an explanation. The response I received was somewhat surprising.

Samples come from a manufacturer trying to promote its product, but not all manufacturers supply free samples to hospitals. Let's say a patient comes into a hospital/clinic and is diagnosed with mild form of asthma. The physician knows that the patient lacks prescription drug coverage and believes that the cost of medication therapy would deter the patient from getting his/her medication. So the physician decides to give the patient a free sample of Advair, because that's what he has on hand. But is Advair the right drug to give this patient? Not according to the physician's initial diagnosis. Advair is reserved for moderate to severe asthmatic symptoms, which is not the diagnosis.

So what happens if the patient runs out of the free Advair sample? If the patient is responding well to the drug therapy, standard protocol is to keep the patient on the drug. But Advair is one of the most expensive inhalers on the market. What now? The patient may have had difficulty paying for an albuterol inhaler or nebulizer, but a single cycle of Advair can exceed $350. So how will the patient pay for prescription refills?

Well I will tell you how they get their refills, the hospital pharmacy gives it to them for free, or the patient gets Medical Assistance which will then pay for the drug. Both option cause the health system and the hospital time, money and stress. All of this from one sample of a drug, now multiply that by the nearly 100,000 samples given out by the Hopkins hospital alone last year and the picture becomes a little less hazy. Samples aren't only restricted to drugs, when new moms and their babies leave the hospital companies give them free cases of their formula for the baby. It's a way to hook them on their product from day one, a lot of times the free product is the most expensive product and not necessarily the best product.

I know a lot of you may be thinking, well if we get rid of samples how can we ensure that the patient gets the medication they need. Well that all comes full circle back to one of my previous postings when I talked about 340B. We can offer patients drugs at our 340B pricing which is more than free but usually less than a dollar or give away generic drugs for pennies. Either way it saves the system and hospital in the long run. All very interesting when you change your perspective.

A little help

I have a small dilemma. At the end of the internship each intern is required to make a presentation to the directors, managers, residents and remaining interns. Mine is of course the last one...because you save the best for last. Unfortunately I have no idea which of my dozens of projects I should actually present on that will also engage the crowd. One of my favorite projects happen to be my simplest project in which I know I could bring it to life and have tons of fun with it. On the other hand it borders on un-professionalism, but should I really worry about that?
I have about 15 different projects that I am involved with out of those 15 none of them are actually completed. This is due to no fault of my own here a simple project can span into a year-long headache. I knew this before coming and accepted that things I started would most likely be finished by someone else and maybe within a year I will see the fruits of my labor. The biggest project that I will try to get updates on during the school year is the Creative Alternatives packaging. I found alternative packaging for this program through a product called DisPill. It's actually really innovative and all signs point to them moving forward with the packaging in the coming months. More than just finding it through a google search I had to work with our IT department to ensure that the programing would integrate with our current computer system. Discussing the operational impact of packaging change and the costs per patient associated with the new packaging. I also had the opportunity to work with producers of DisPill to change their software to benefit our target population. I have a problem presenting this as my final presentation as it only has application here at Johns Hopkins. I want to present something that no matter where their career takes them they can think back and remember the presentation. It looks as though I will have to search through my projects and find the one...

It's all about the people

I just wanted to spotlight some of the great people I have had the opportunity to work with as this will be the last week we are all together. This year there were 24 interns accepted into the Johns Hopkins Internship program and I am grateful for the opportunity to meet each and every one of them. I won't go through all of them but I did want to talk about a few people who have made my experience incredible.
The preceptors are the people that make it possible for us to have this program. My preceptor is Nathan Thompson the Director of Outpatient Pharmacy. Other notable preceptors include: Yvonne LeBlanc (Clinical Applications Manager), Jim DiPaula (Operations Manager), Bridgette Thomas (PharmIS Manager), Krista Decker (Quality & Safety Manager), Brendan Reichert (PharmIS Director), Brian Pinto (Drug Use and Policy Director), and Edina Avdic (Pharmacoeconomics Manager). I was able to spend at least one full day with each of these preceptors and want to thank them for their time. A lot of other people have acted as a reference and guide this summer and hopefully mentors as my career progress these people include; John Hopkins (that's his real name, no relation) and Jim Van Daniker who both serve as the business managers for the outpatient pharmacy and Dan Ashby (Director of Pharmacy) I have to send a special thanks to Luis Simbala who is not a pharmacist but taught me so much the summer about Microsoft programs that Bill Gates himself should write this guy a check.
The interns helped me keep my sanity and made me laugh every day. First up is Abbie Shallop who we all know since she goes to school with us. It was great to get to know Abbie more of the summer we had some great laughs together and I want to wish the best of luck on her marriage and hopes that she enjoys it before classes begin again. Then there is Rami Beiram who is like the big brother I always wanted. He is a third-year student at Harding University by way of Atlanta, Georgia, he and I share the same humor and make quite the comedic duo. Then there's Tamara Fawall, the little sister I never wanted. Actually she's great her and I have the same exact birthday so you can imagine what a female version of me is like to deal with. Tamara is also a third-year student at Rutger's University, I finally found my Jersey girl. Without the three of them I would not have enjoyed myself nearly as much and I will keep in contact with all of them as we go forward, Abbie has no choice since I'll sit right next to her in class but the other two I will bother them through other media. This Monday will be our last day together as Rami heads back to Atlanta before heading back to school at Harding University. I swear... I'm not going to cry...

The New Era of 340B

It's been a bit since my last update. I know that my blog contains no pictures so I seem boring but I completely planned to upload pics soon. Then I had a serious disagreement with my iPhone and it decided to reset itself and delete everything that was in the phone over the past 5 months. Meaning that I lost all the pics I took this summer, I'll try to get some pics from the other interns and take more pics before the end of the internship, which is only a month away.
Enough complaining this Monday I was invited to the annual 340B Coalition Summit held in Washington, D.C. The conference attracts pharmacist, physicians, nurses and business managers from all over the country to discuss the future of 340B. The Affordable Care Act (ACA) or Health Care Reform is the first change to the 340B change since it's creation in 1992. To give a brief rundown on what exactly 340B is and how it relates to hospitals I will attempt to make it as painless as possible.
Almost every hospital participates in a form of charity. As health care professionals it is not in the nature of our job to turn away patients in need. When a hospital services a disproportionate number of patients who neither qualify for Medicare or Medicaid assistance that hospital outpatient pharmacy can now apply for the 340B program. The official percentage is 11.75% of your population must fit in this description of need. So now what? Say normally I purchase a bottle of Drug A for $1.00 and I normally sell that bottle of Drug A for $1.75, well my profit margin for that drug is $0.75. Now I am part of the 340B program and under this program I can purchase drugs for a deeply discounted price. For the same bottle of Drug A I can now buy it at a price of $0.75, well I am still going to sell it for normal price of $1.75. What changed? Well now my margin on the same product is now $1.00 compared to $0.75. The goal of this increased margin however is not to pocket the savings but put the savings back into the charity fund. This allows the hospital to either increase the number of patients they serve or close the gap in the dollar value of drugs given to patients without insurance. Also a few things to note 340B is that it is only used for outpatient drugs, not inpatient and only a few clinic drugs. 340B is important because like I said most hospitals have a form a charity it is beneficial to be part of the 340B program to increase your margins and close the gap in charitable funds and revenue collected.
Back to business the summit was actually over three days but I was only able to go to the first day. The two big questions that were going to be debated over the conference were: 1) if everyone is now covered in some form or another with insurance will their be a need for 340B? and 2) if manufactures can afford to offer 15-30% discounts on the drugs currently under the program than what kind of prices are they charging? Two great questions without solid answers. As health care providers it is in our best interest to serve our population any way possible without going broke and that's what 340B allows. What about the millions of Americans that health care reform leaves out, who still wont have insurance? All valid questions and this is just a small portion of the ACA. I bring attention to this because pharmacist play a crucial role in the years moving forward at least when it comes to 340B pharmacist have taken the leadership role and advocated for their patients which is great. When law is finally signed there could be substantial changes to 340B like getting is extended into the inpatient setting, it could disappear all together. I guess only time will tell...
P.S. - Love walking through the conference with my Johns Hopkins badge on, they treat you like a freakin rock star. No joke

20 Year at No. 1

This post is to congratulate Johns Hopkins Hospital for their ranking as the Number 1 Hospital in the Country for the 20th. year in a row. Those of you know who know me know that I have huge pride in my hometown of Baltimore, Maryland and Maryland in general. It's great to be here when the hospital wins their 20th No.1 award because theres a lot of free food and swag. Also to note that the University of Michigan Hospitals and Health Centers, Ann Arbor also are represented again on the Top 15 Hospitals in the country again this year. I will attach the article at the bottom. I will end this blog with a GO BLUE!! And a LOVE MD!!

http://health.yahoo.net/articles/healthcare/best-hospitals-2010-11-honor-roll

When I Grow Up...

About a week ago all of the Johns Hopkins interns made a trip to ASHP headquarters located in Bethesda, Md. It was a great experience and a rare occasion, having all of the interns together at once. We were also accompanied by JH pharmacy residents and pharmacy students from all around the country. It was great to hear the differing perspectives and experiences from those assembled in the room. There were really three discussions/arguments that I was involved in during my time at ASHP. No need to comment about how often I was in the middle of these discussions/arguments.

The issues? First, there is a new ASHP guideline that by the year 2020, all graduates of pharmacy schools will be required to have a one-year residency if they are involved in direct patient care. I strongly disagree with this guideline, yet I can see both sides of this issue have valid points. The first problem with implementing this plan is the limited availability of pharmacy residencies. Last year, for example, there were about 11,000 PharmD graduates while there were about 2,000 available residencies. This doesn't add up. With more pharmacy schools opening and programs expanding (including our own), how will health systems fill the widening gap? Also what does the term "direct patient care" actually mean? Does that mean I have to do a residency if I want to work at Walmart?

Secondly, residencies are one strategy new PharmD graduates use to bolster their career credentials in order to make themselves stand out from their peers. That will disappear when every applicant has to have a residency on his/her resume.

These are my opinions, and, to be sure, there are some compelling arguments in support of this guideline. As I generally oppose this guideline, I'll let someone who agrees with it argue in favor of it.

Contentious issue number two came from a question I asked; namely: Why are so many pharmacy schools opening, and should this trend be curtailed? I perceive this trend as a serious problem for a variety of reasons. Until fairly recently, there was a genuine shortage of pharmacists which benefited our profession because: 1) it allowed pharmacists greater career mobility, and 2) it gave us greater leverage when negotiating salaries, fringes, and career options. (Think supply and demand.)

Now, we are starting to see a systemic decline in job availability and flat or declining salaries. I believe that our profession needs to regulate the growth of pharmacy schools. (ACPE regulates this to some degree through accreditation, but this doesn't address the broader issue of what constitutes too many players in a competitive market.) Because supply-and-demand forces dictate how many pharmacy schools are enough, those of us who have benefited from a seller's market need to deal with it until the balance is restored in our favor.

The final issue of disagreement centered on advocacy. This question I asked the vice president of ASHP and senior director for pharmacy advocacy was what their organization contributed on behalf of pharmacy to the debate on health care reform -- and what they would say to practitioners and students who feel a lack of representation in health care reform. I was informed ASHP apparently fought long and hard to have pharmacy mentioned and represented in the reform. The fact that MTM and tuition forgiveness are now on the table for pharmacy are two areas they are particularly proud of and they have a right to be. Without advocacy there a chance that our profession could have been overlooked entirely.

Now to the title of this blog. For the last 3-4 years my professional goal was to be a director of pharmacy. No one could tell me any different. That's all I ever wanted to be and I felt that it was a great life goal, offering the right level of challenges and perks to keep my satisfied in life.

It took one day at ASHP to change my perspective on things. I realized there was a place in pharmacy that would offer me a greater challenge and reward than I thought possible. Upon leaving ASHP both the vice president and director of advocacy gave me their personal contact information and a book. That's one of the things I love about this profession: There is always more to experience as long as we take the opportunities presented to us.

Toyota Motors leads the way in Healthcare

I know I am behind on my posts again, it's been a crazy few weeks so I will attempt to catch up on everything. Last week I had the opportunity to attend the First Annual Johns Hopkins Quality and Safety Improvement Summit. This was an all-day event that had guest speakers from nearly every department in Johns Hopkins with a few special guest speaker with the focus being on of course, Quality and Safety Improvement. The speaker that opened the summit was Peter Pronovost, M.D. he was an incredible speaker and very accomplished Anesthesiologist. Dr. Pronovost was named TIME magazines '100 most influential persons' for the year 2008 in Health care and was also the recipient of the Genius award in 2009. Dr. Pronovost's speech was really thought provoking as he showed us how 15 years ago at Johns Hopkins there were 18 central line infections per 1,000 patients put on a catheter. Granted this number seems really small but the more significant aspect was that about 67% of central line infections resulted in death. To make a long story short, Dr. Pronovost did something drastic he changed the very dynamics of the medical field at Johns Hopkins. First he implemented a 3-step safety check which included: a checklist, independent double checks, and investigation (retrospective). In order to push this process forward Dr. Pronovost and the JHMC staff implemented a system of checks and balances which gave rise to their current interdisciplinary team. No longer were physicians and surgeons the last word on decisions, no longer were they immune to the scrutiny of other health professionals. Under this system physicians, nurses, physician assistants, and pharmacist were required to agree on all decisions concerning patient safety. This system of safety checks and interdisciplinary teams are currently being utilized in the state of Maryland and Michigan with a few hospitals adopting the system in various other states. Dr. Pronovost believed that if all hospitals were to use this system that we could save an additional 20,000 lives per year.
So now lets look at that number in perspective, currently our health care system allows 20,000 preventable deaths per year, just in central line infections. Now taking a step back we all heard in the news a few months ago about the 'Runaway Toyota's' how apparently all of these Camry's and Prius' were accelerating out of control and people were apparently dying left and right. Does anyone know how many people actually died because of the faulty gas pedal? 34. So Toyota Motors is directly responsible for the death of 34 people this year due to poor quality. In fact the government was so upset with Toyota that it slapped the corporation with a $16.4 million dollar fine because of their gross negligence in the area of safety and quality. It almost seems unfair as to how much scrutiny the Toyota Motor representatives went through explaining their lapse in quality yet your local hospital seems somehow immune to the same responsibility.
What's even more ironic is that health systems have been looking at the Toyota model for safety and quality for years to improve their own products. The "Lean" methodology, sometimes called Lean Sigma is an approach to improve quality while reducing costs and it is entirely based on the Toyota Motor Corporations stance on quality improvement. The goal is quite simply, Highest Quality, Lowest Cost, Shortest Lead Time. Amazing how such a simple concept can be applied from the car you drive to the health care you receive.

There can't be two #1's...that's 11

I know how hard it is to be #1, and being the #1 Hospital in the country for the past 18 years means that Johns Hopkins deals with some of the same pressures I go through on a daily basis. The problem is that every hospital in the country paints this massive target on Hopkins in their never-ending goal of toppling the juggernaut of a hospital. Though there are dozens of parameters taken into consideration to determine hospital rankings I was very surprised at how influential the department of pharmacy was in a particular area, customer service. The patient/customer experience at the pharmacy counter is a vital component to the continued success of this hospital. There are three projects that I am working on in conjunction with other interns to monitor and improve customer service in the pharmacy.
The first project is the start of a Secret/Mystery Shopper program for the pharmacy. This project is actually let by another intern Rami, a P3 student from Harding who I work with on a regular basis. We attacked this project from several angles as we decided to not only monitor and evaluate the pharmacy via a physical shopper but also phone calls, fax's, and e-mail directed to the pharmacy. After identifying key components of customer service that we wanted to focus on we then set realistic expectations mainly composed of "Benchmark" projections. Benchmark is an actual company that sets standards in customer service along various venues from fast food to health care. We then consulted the managers of each outpatient pharmacy to their perception of how their pharmacy treats it's clientele. A private company has been contracted to conduct the evaluation and we hope to receive the results before the end of the summer.
The next project is the Wait Time Study, this is actually done by the interns each summer. I will lead the project to determine the customer perception of how long it takes to get a prescription. This is not to be confused with Lead Time which is how long it takes to actually fill a prescription and do the billing, blah blah blah. It's an observational study (nod to Welage/330) as all the interns will get their turn to visit all the pharmacies during various business hours/days to see if we are doing a good job or not. We will compile the data into a presentation that I will present to some rather important people around the end of July.
The third and probably not the last project is the implementation of new technology that should lessen wait time and lead time in the pharmacy. Ok so new technology is a really generous term, essentially is a scanner that links to the pharmacy. This new program asks that when patients check into the hospital for any reason, inpatient, specialist, clinical, or even just a normal check up, that when they take the medical card they also take the patients prescription insurance card. What then happens is that this information is transferred to the pharmacy and the pharmacy can start claims and billing before the patient gets a physical script in their hand. In theory all of the dirty work will be done before the patient makes their way down to the pharmacy. With this project I'm working with the IT department to follow the installation, learn the program, then teach it to the pharmacy staff. How hard can it be, it's really an over-priced scanner but we'll have to see if it makes me lose more hair.
I will update on these projects as more develops. It sounds crazy but I am having a great time.

420/330

My summer has boiled down to two courses, 420 and 330. (Makes me wish I actually paid attention in those classes, j/k...) Working with Nathan is like a whirlwind of everything I learned in the last year condensed into 9-10 hours a day. My first major assignment combined all we learned in 420 and 330, John Clark would be so proud Dean Welage not so much.

Johns Hopkins owns their own Managed Care Organization. This hospital also services a disproportionate share of low-income and patients without insurance. Which means the Hopkins Medical Center is authorized to purchase drugs under the 340B pricing guidelines. The hospital is also involved with a high level of charity care in which the hospital takes on all costs of treating a patient without coverage or assists patients with their medical bills. This all seems simple but there is a lot more to it that I don't care to explain at the moment, by the end of my first day I think I had 340B somewhere in all of my sentences. Moving on, the managed care organization wanted to increase their charity work for the Fiscal Year 2011 (which for Hopkins begins in July 2010) and therefore needed to decrease their spending on drugs. Here is where I come in...

In order to save money on prescription drugs I was tasked with reviewing their drug formulary and looking for cost saving options. The only bit of advice I was given by Nathan was to review five classes of drugs: PPI, Statins, Diabetes, ARB's, and Pain Management. The first thing I do is identify each drug for each class, for each class there was at least 6 meds regularly used in their formulary. Next I had to find the price per pill for each drug under the 340B pricing. A side note, 340B pricing is a minimum of 49% discount some brand names were so cheap I couldn't believe it, $0.01 for a bottle of 100 Prevacid 30mg??? So now I have multiple drugs under each category of varying strengths and I have their price per pill under 340B purchasing. Here's where the 330 comes into play, now I need to research the comparative efficacy of each of the drugs in the class. This was a serious headache and I found myself channeling all of my EBM knowledge into this tasks, I had to not only research the task on sites like PubMed, Micromedex and UpToDate, but also appraise the articles for their validity.

Long story short for the five classes: PPI to Omeprazole, Statin's to Simvastatin/Lipitor 80mg, Diabetes to Actos, ARB's to Cozaar, and Pain Management was inconclusive. With the following changes I then had to apply my formulary adjustments to the total spend of the pharmacy for the first three quarters, then annualized for a full year of spending. With this I could show the managed care organization how much money they would have saved this year if they used my proposed formulary. The formulary adjustment equated an 6.5% savings per year which doesn't seem like much, but when compared to an annual spend of $200k in drugs, the costs savings add up.

I then prepared a presentation of my project to be presented today for the Johns Hopkins Charity Committee. The proposed formulary adjustment will be discussed and voted on and could see integration for the second quarter of the 2011 fiscal year. In the last three weeks I have accomplished something of significance that I could not have prior to my first year in pharmacy school. The funny thing is that this is one of 6 projects that I have taken on in the last 3 weeks with more to come. I plan to keep showing the other interns here why they call us the "Leaders and the Best"

Playing Catch Up

So I will preface this blog by saying that I am not a blogger. I actually had to google blog for some examples and I am still a bit confused if I should write it as 'blog' or 'blogg', still trying to work that out. Anyways since I came home to Maryland I was sick as a dog and had a car accident, so uh yeah great. Luckily the accident wasn't too bad my back hurt for a while, but everything is working fine.

Now to what you all came here for, my internship with Johns Hopkins Medical Center. Well there isn't much to contribute just yet, I will be working with the Director of Pharmacy Nathan Thompson. For now I am floating to each of the outpatient pharmacies throughout the hospital shadowing the pharmacists and technicians to get a perspective on their work flow. Each pharmacy in the hospital caters to a slightly different patient population and therefore have a slightly different work flow. Once I have visited all the pharmacies I will meet with Nathan to design a research project for the summer. Throughout the summer I will accompany him to various meetings and even have the opportunity to take his place in certain committees. The summer looks exciting and I will update as things develop.