With the changing times, and pharmacy gaining more exposure and traction as a revenue generating department, rather than a cost center, it is important we, as pharmacy leaders, continue to evolve and evaluate new opportunities to continue to be business savvy. This may mean we will be pushed beyond our comfort zones, but we should find comfort that we have a network of pharmacy executives and leaders who will work collaboratively together. We are in a unique position, as we must always balance cost savings, revenue opportunities with clinical and professional judgement, which includes limiting risk and predicting the downstream impact of certain decisions. 

As we get out of Covid-19, with a whirlwind of new expectations, including rising costs and shrinking margins have put us in a unique position to be innovative and think differently. One opportunity that may not be novel, in nature, but gaining more attention in the inpatient space is inpatient rebates. When I first heard of the concept years ago, I shut it down immediately; however, with the growing need to find every penny, this has moved from a hard pass and gone beyond exploratory to being a real option. 

As you consider the concept of inpatient rebates, including the vendor you decide to partner with, there are several things you should consider before making a decision to 1) even entertain this concept, and 2) selecting a vendor.

Understand that the business model has been around for a while, particularly in long term care facilities and the retail pharmacy space (particularly between manufacturers and PBMs). As you begin your journey and perform your due diligence, ensure you speak with your colleagues across your network to see if they’re comfortable and how they got comfortable. Equally as important, ensure you work internally with your counsel and other stakeholders, so you do not accidentally cause a negative impact at your organization.

Evaluate the data requirements: Get into the details about what the third party wants vs. what they need to process the rebate, and if that is acceptable for your organization. In a world where data and data sharing is a hot topic, it’s best to know the position of your organization when it comes to data. 

Eligibility: Ask about which medications are eligible and compare that to your inpatient operations. Pay attention to payor mix and 340B eligibility and how that may complicate and impact the potential pro forma. 

Legal: Although your legal counsel will play a significant role in going through the contract and protecting the organization with certain boiler plates and mitigate liability whenever possible, you should take care to understand the process between all parties and see where you and your organization may be vulnerable or at risk. 

Timeline: Be sure to understand the timeline on how and when the data is to be transferred and when to expect the rebate back to the organization. It’s important to set clear expectations for all parties. 

As we embark in new territory and asked to evaluate new ideas, be sure to take a step back and take a 360-lens approach when performing your due diligence.

About medigi - Complexity and fragmentation in the pharmaceutical supply chain can lead to inefficiencies and inflated costs. Ultimately, unstable medication supply has a negative impact on patient care. At medigi, our simple, direct sourcing solution hosts a rapidly expanding community of pharmacies and drug manufacturers motivated to improve the supply chain. Our mission at medigi is to empower pharmacies and manufacturers to access, buy, sell, and distribute pharmaceutical products through an open, streamlined, easy-to-access eCommerce platform. The Results? Lower costs, highly efficient procurement, and improved patient access. 

Neal Dave, Executive Director of Pharmacy at Texas Oncology, has been a pharmacist for 18 years. He says we’re living in the worst drug shortage crisis he’s ever seen.

“I’d rank this as the worst because of the amount of products that have been affected,” Dave says. “The two big shortages that are affecting cancer patients are the platinum compounds: cisplatin and carboplatin. A lot of times, you may be able to substitute one for the other in a treatment regimen, but now, we’re low on both.”

Dave says the current drug shortage is because a pharmaceutical company in India that supplied both carboplatin and cisplatin to pharmacies across the U.S. had quality control issues, causing it to shut down. But it’s not just cancer drugs that are tough to get. He’s also seen supportive care drugs that have been harder to reach, such as: Elitek, Infed, Lidocaine, Retacrit, Soludortef, Solumedrol, Fluorouracil Methotrexate and Docetaxel.

Those of us who have been in healthcare for a long time have seen changes come and go at a breakneck pace. Regulations, practice, lean into clinical, defer to the physician, multidisciplinary practice, silo mentality, more tech, less tech…yada yada yada. With so much energy spent attending to putting out fires every day, I have found it is easy to lose sight of the person behind the profession.

School taught us the Krebs cycle and anatomy. We learned the “lock and key” theory as drugs do their thing. We spent hours memorizing every written word and nugget of wisdom from our professors. As I now have a lifetime of experience in this chosen profession of ours, I find that the most valuable lessons are the ones life has taught me and unlike the tenets of practice back and forth, these lessons hold true throughout. Secret weapon: the intangibles. Here I share a few thoughts on pharmacy leadership that I have gathered over years of being in the trenches at every level.

Find your value and lean into it. You know how to do the job, but do you know how to lean into your strengths? The things that make you a good leader also make you a good follower. Managing goes both up and down. Learn from everyone around you, and then take that and create your strongest path. Tell a joke in a tense situation. Offer a creative idea from the cheap seats. This will be hit and miss, but you don’t know if you don’t try. Find your best voice and sing from the rooftops.

Learn your surroundings and adapt to how the organization works. No matter how good you are, how smart you are, how high your GPA was, none of that matters if you can’t operationalize your big brain so be sure to read the room. This includes the people you are working with which can be hit and miss. I offer this: taking a swing and missing at times, and knowing when to make a change, is as important as sticking with it at all costs. You may lose a little of yourself if you don’t take time to identify the moment. Learn the “politics” of your organization and work within that framework to show the immense power of what you bring, and how pharmacy can be transformative to an organization.

Think of things you can do to make strides. Real strides, things that propel you and your practice forward in a different way. Ruth Bader Ginsburg said, “Fight for the things that you care about, but do it in a way that will lead others to join you”. This will get you noticed for all the right reasons.

You can’t do it alone. None of us does it alone. We may think we do, but if you dig a little deeper you will realize that whatever success you have or wish to have does not happen in a vacuum. Think about key turning points in your professional life and there will always be someone or something that helped you get there. Never forget that and remember to pay it forward. Maybe take that call you would normally screen. Set that meeting that you think you don’t need. I have always said that you never know whose hand you will eventually shake, be open to it.

Of course, we should be talking about Specialty, 340B, staffing, budgets, etc., but we should also talk about and share how we take our profession to new heights outside of the daily grind and look a little deeper at our success as highly trained professionals in a rapidly changing world.

PharmEcology® is the exclusive company that can provide your organization with specialized solutions for USP 800 Assessment of Risk requirements and pharmaceutical waste management programs.

PharmEcology®’s Pharmaceutical Waste Program is not dependent on a particular waste disposal vendor or waste collection container. The savings you will realize are driven by PharmEcology’s optimization of the waste streams your organization generates for disposal. This is particularly important today given the capacity shortages and inflating costs for pharmaceutical waste disposal.

The University of Florida (UF) Health Precision Medicine Program (PMP) launched in 2012 with an initial focus on pharmacogenetic testing. The first gene-drug pair implemented into practice was CYP2C19-clopidogrel in the setting of percutaneous coronary intervention. Since then, the program has expanded to support implementation of the following gene-drug pairs: TPMT/NUDT15-thiopurines, CYP2D6/CYP2C19-antidepressants, CYP2D6-opioids, CYP2C19-proton pump inhibitors (PPIs), and CYP2C9-nonsteriodal anti-inflammatory drugs. Each implementation occurred in response to a physician request for pharmacogenetic testing to help inform prescribing decisions. Panel-based testing became available in 2019 and covers nine pharmacogenes, including those listed above.

With each implementation, several key best practices are followed. First, it is critical that there is strong evidence to support genetic associations with drug effectiveness and/or safety. Importantly, it is not necessary for there to be evidence of improved clinical outcomes with the use of genotype information in prescribing decisions. Rather, genotype is considered to be another important factor, similar to age or serum creatinine, to consider when optimizing drug therapy for a given patient. The Clinical Pharmacogenetics Implementation Consortium (CPIC) evaluates and summarizes the pharmacogenetic evidence.¹ For gene-drug pairs with a high-level of evidence, CPIC provides recommendations for how to integrate genotype results into prescribing decisions. Thus, for institutions newly implementing pharmacogenetic testing, CPIC guidelines are a great resource for evidence evaluation.

Another best practice followed at UF Health is related to the selection of pharmacogenetic variants for testing. There is significant variability in allele frequencies across ancestry groups, and many clinically relevant alleles are common in one ancestry group but rare in others. Our program strives to include any functional variant with appreciable frequency (e.g., ≥1%) in at least one population. For example, for the CYP2D6 gene, the decreased-function *17 and *29 alleles occur frequently in those of African ancestry. Therefore, even though they are uncommon in other populations, *17 and *29 are included on the UF Health CYP2D6 genotype assay. A helpful resource for selecting pharmacogenetic variants for testing comes from the Association of Molecular Pathology, which publishes recommendations for which alleles to include on clinical testing panels.^2-4

A third best practice is that genotype results are entered into the electronic health record (EHR) as discrete data. This allows for building automated alerts within the EHR to guide prescribing decisions at the point of care. In the event that a provider orders a drug for a patient, and the patient has a genotype associated with reduced effectiveness or increased risk of adverse effects to the drug ordered, an alert will automatically appear to notify the provider of such. For example, if a provider orders tramadol for a patient with a CYP2D6 genotype associated with reduced tramadol effectiveness, an alert will appear to warn the prescriber that the patient may get little to no pain relief with tramadol.

A final best practice is that clear clinical decision support is provided to assist prescribers with applying genotype results to drug selection and dosing. Genotype-guided recommendations are provided through the automated alerts described above and are consistent with CPIC guideline recommendations. Referring to the example above, the alert would include recommendations to avoid tramadol and either consider a non-opioid analgesic or an opioid that is not affected by CYP2D6 metabolizer status, with specific examples provided. Clinical pharmacists are available for consultation as needed. 

It is said that with challenges come opportunity. Well, as most every hospital CEO and CFO knows, hospital finances certainly are laden with challenges. Some economists described 2022 as the worst financial year for U.S. hospitals in decades, as expense increases continued to exceed revenue growth. According to data from healthcare data and consulting firm Syntellis Performance Solutions, cumulative hospital expense growth from 2019 to 2022 was 17.5%, while reimbursement by the Medicare Inpatient Prospective Payment System (IPPS) grew only 7.5%. 

Labor shortages fueled explosive growth in contract labor expenses, which contributed to overall hospital labor expense growth of 20.8% over the same period. Even after accounting for increased patient acuity, labor expenses per patient jumped 24.7%. 

Not surprisingly, over half of U.S. hospitals ended 2022 operating at a financial loss. Also not surprisingly, in December 2022 credit rating firm Moody’s concluded that more healthcare organizations were at risk of credit downgrades or default—which turned out to be prophetic, as the first quarter of 2023 saw eight hospitals default, according to research firm Municipal Market Analytics. That figure represented the most hospital bond defaults since 2011, and only one hospital defaulted in the first quarter of 2022. Perhaps most concerning, some of the defaults came from large, highly rated systems. 

Moreover, Kaufman Hall predicts expense pressures will continue through the remainder of this year. The firm’s May 2023 National Hospital Flash Report concluded that: 1) the median operating margin for U.S. hospitals was 0%--meaning just breakeven--in April, leaving most hospitals with little or no financial wiggle room; 2) inpatient volumes declined while lengths of stay rose, and outpatient volumes also dropped; 3) the effects of Medicaid disenrollment could be materializing, as reflected in increases in bad debt and charity care in April, and this trend could continue as substantial disenrollment from Medicaid is projected as a result of the end of the COVID-19 public health emergency on May 11; and 4) inflation continued to impair hospital finances, as labor costs jumped in April and the costs of goods and services continued to be significantly above pre-pandemic levels.

With no quick fix to the labor shortages, hospitals and health systems are scrambling to find other areas to reduce costs and/or increase revenue profitably. Therein lie opportunities for pharmacy leaders to help bolster hospital finances. 

Since prescription drugs are the fourth-largest category of non-capital expenses for hospitals, pharmacy departments can support cost reduction through the deployment of automation to generate labor savings and by leveraging insights gleaned from medication use evaluation, preferably in an automated manner, given the continued widespread shortage of pharmacy technicians, which has required many pharmacists to perform pharmacy technician tasks. 

Furthermore, financial information and analytics firm S&P Global has advised hospitals to diversify beyond acute care and generate new, often more profitable, revenue streams, and the list of promising areas includes an outpatient pharmacy and other pharmacy services. Similarly, McKinsey & Company has identified specialty pharmacy and home infusion as attractive areas for growth and profitability during the next two years.

The shortage of pharmacy technicians is straining pharmacies across the nation, with seemingly no end in sight to the dearth of qualified workers. In fact, vacancy rates have climbed to over 20% from 6% on average, with 10% of hospital pharmacies reporting they’ve lost up to 40% of their techs. 

We’ve previously covered how the pharmacy technician shortage leaves crucial tasks without a clear owner, straining existing staff and resources. Unfortunately, the void of workers continues, exacerbating the pains felt by pharmacies and their teams. Pharmacy leaders worry not just about filling open roles, but about burnout of current employees increasing the risk of errors. 

This shortage is especially straining on hospital-based teams, which tend to take on more responsibilities and patient interaction than retail pharmacies. 

Why are pharmacy techs in short supply?

You likely already know why it’s hard to find and keep hospital-based pharmacy technicians. The job can be chaotic and unforgiving, with long hours and massive accountability to patient health. But the COVID-19 pandemic incited fear of exposure and infection by working in a pharmacy setting, which didn’t do the workforce any favors, either. 

Overall interest in the career of pharmacy technician is evident in decreasing enrollment rates at training programs. And as those programs lose money, the quality of education decreases. Then it’s a compounding effect of fewer techs with less impressive skill sets. 

What else makes the job tough and contributes to turnover rates as high as 41%?

• Inadequate compensation — ¾ of techs say they want higher pay if they’re expected to stick around
• Career dead-ends — pharmacy techs often lack a clear career growth path, leading to disinterest and disillusionment
• Overworked and under pressure — even though the pandemic has passed, the lingering effects have made the job harder
• Unmanageable schedules — working overtime, covering vacant shifts, and doing their best to care for their customers while keeping a modicum of work-life balance

The same research shows that not only are techs overworked and understaffed, but that much of this extra workload ends up on the pharmacists themselves. That means the highest-paid employees with the most important responsibilities in the pharmacy are being saddled with work that detracts from their core duties. 

Pharmacists having to step into tech duties has resulted in 53% reducing services and 48% delaying new services. 

Here’s how you can flip the script on the pharmacy technician shortage and take your hospital operations from surviving to thriving.

Expand pharmacy tech training and duties

While fewer and less educated techs might be coming through the door, the opportunity for on-the-job training remains — and can take mediocre talent to invaluable operational assets. Upskilled pharmacy techs can take on compounding and specialize in certain fields of drugs to expand the pharmacy’s overall capabilities. They can grow into hazardous material handlers, medication therapy managers, pharmacy buyers, insurance specialists, and more. 

They might even be eager to become a pharmacist themself, one day. Nearly ¾ of technicians contribute their job longevity to the leadership and mentorship of their supervising pharmacist. 

Empower career progression to encourage longevity

Many techs report unclear paths to promotions and higher wages as their reason for leaving their jobs. From the time they’re hired, these employees should have a firm grasp on what, when, and how they can progress within the pharmacy or hospital to encourage dedication to their duties. The hospital or pharmacy can also sponsor conferences, training, certifications, and other opportunities for techs to grow their skills. 

This opportunity can increase motivation and accuracy while improving overall job satisfaction. Happier techs stick around longer, refer their friends, and become the best future managers and pharmacists.

Increase pay

Of course, the simplest answer in this case also tends to be the most difficult. More money seems to be the consensus solution for bringing in more techs and keeping them longer. Whether that’s wage increases, sign-on bonuses, retention pay, or other financial rewards, the message is clear.

But the challenge is finding that budget. Some pharmacies choose to reduce services or business hours and use those savings to increase compensation. Admittedly, taking such measures merely changes the balance of the staffing shortage, and in the end, patients end up with a lower-quality experience either way. 

Solutions to the pharmacy technician shortage need to free up more of the budget while also reducing the workload, so services need not be reduced. 

Embrace unit-dose drug repackaging to save time and money

Another surefire way to optimize the workload of pharmacy technicians and make the job more appealing is to take the tedious — yet critical — duty of repackaging off their plates. With a responsibility like this handled by a partner like Safecor Health, pharmacy techs can trust medications are properly dosed and devote their time instead to caring for their patients. 

Unit-dose repackaging services save time for techs and pharmacists. It also reduces the labor costs associated with repackaging, and reduces the need for on-site repackaging equipment, saving more money. These medications are accurately packaged in whatever format is needed (solid, liquid, syringes, etc.) and RFID/barcode tracked for inventory streamlining.

Hospital pharmacies utilizing unit-dose repackaging through Safecor Health save $400-700 per patient bed annually, thanks to the increased efficiencies, reduced waste, and freed-up resources. They’re also ensuring patient safety by complying with the latest FDA requirements — which can also put a strain on hospital pharmacies’ operations and people. 

Hospital pharmacies can sign up individually or health systems — with multiple hospitals and pharmacies — can sign up with SafecorLogics. They can also look to prepackaged medications from Safecor that can be purchased through their pharmacy wholesaler with next-business-day delivery. 

Those of us who have been in healthcare for a long time have seen changes come and go at a breakneck pace. Regulations, practice, lean into clinical, defer to the physician, multidisciplinary practice, silo mentality, more tech, less tech…yada yada yada. With so much energy spent attending to putting out fires every day, I have found it is easy to lose sight of the person behind the profession.

School taught us the Krebs cycle and anatomy. We learned the “lock and key” theory as drugs do their thing. We spent hours memorizing every written word and nugget of wisdom from our professors. As I now have a lifetime of experience in this chosen profession of ours, I find that the most valuable lessons are the ones life has taught me and unlike the tenets of practice back and forth, these lessons hold true throughout. Secret weapon: the intangibles. Here I share a few thoughts on pharmacy leadership that I have gathered over years of being in the trenches at every level.

Find your value and lean into it. You know how to do the job, but do you know how to lean into your strengths? The things that make you a good leader also make you a good follower. Managing goes both up and down. learn from everyone around you, and then take that and create your strongest path. Tell a joke in a tense situation. Offer a creative idea from the cheap seats. This will be hit and miss, but you don’t know if you don’t try. Find your best voice and sing from the rooftops. 

No matter how good you are, how smart you are, how high your GPA was, none of that matters if you can’t operationalize your big brain so be sure to read the room. Learn your surroundings and adapt to how the organization works. This includes the people you are working with. This will also be hit and miss, but taking a swing and missing at times, and knowing when to make a change, is as important as sticking with it at all costs. You may lose a little of yourself if you don’t take time to identify the moment. Learn the “politics” of your organization and work within that framework to show the immense power of what you bring, and how pharmacy can be transformative to an organization.

Think of things you can do to make strides. Real strides, things that propel you and your practice forward in a different way. Ruth Bader Ginsburg said, “Fight for the things that you care about, but do it in a way that will lead others to join you”. This will get you noticed for all the right reasons.

You can’t do it alone. None of us does it alone. We may think we do, but if you dig a little deeper you will realize that whatever success you have or wish to have does not happen in a vacuum. Think about key turning points in your professional life and there will always be someone or something that helped you get there. Never forget that and remember to pay it forward. Maybe take that call you would normally screen. Set that meeting that you think you don’t need. I have always said that you never know whose hand you will eventually shake, be open to it. 

Of course, we should be talking about Specialty, 340B, staffing, budgets, etc., but we should also talk about and share how we take our profession to new heights outside of the daily grind and look a little deeper at our success as highly trained professionals in a rapidly changing world.