For Personal Use Only. Any commercial use is …mhpharmacy-hospital-rotation.weebly.com/uploads/4/9/2/4/...of Crowds. According to Surow-iecki, the collective opinions of “wise crowds”—groups

844 AM J HEALTH-SYST PHARM | VOLUME 73 | NUMBER XX | MONTH XX, 2016

PHARMACY FORECAST 2019

For Personal Use Only. Any commercial use is strictly prohibited.

ForewordThe ASHP Research and Education Foundation (“the

Foundation”) is pleased to present the seventh edition of the annual Pharmacy Forecast. We are again pleased to dis-seminate the Pharmacy Forecast through AJHP, providing readers with easy access to the report. The editorial staff of AJHP has provided substantial support for this publication, and we appreciate their assistance.

The Pharmacy Forecast is a vital component of the Foundation’s efforts to advance pharmacy practice lead-ership, and the Foundation appreciates the many phar-macists and others who have contributed to the David A. Zilz Leaders for the Future fund, which provides the resources to develop the report. The Foundation is also grateful to Omnicell for its support of the Zilz fund, which has made the Pharmacy Forecast possible. The Pharmacy Forecast could not be created without the contributions of the report editor, founding editor, members of the Advi-sory Committee, Forecast Panelists who responded to the forecast survey, and chapter authors. The Foundation is indebted to those individuals who have helped make the 2019 edition a success.

Over the past 6 years, the Pharmacy Forecast has pro-vided insight into emerging trends and phenomena that have impacted the practice of pharmacy and the health of patients in health systems. The value of the report, how-ever, is defined by its use by health-system pharmacists and health-system pharmacy leaders as they use the report to inform their strategic planning efforts. The Pharmacy Forecast is not intended to be a quantitatively or even a qualitatively (directionally) accurate prediction of future events. Rather, the report is, at its core, a provocative stimu-lant for the thinking, discussion, and planning that must take place in every hospital and health system in order for those organizations to succeed in their mission of caring for patients and advancing the profession of pharmacy. Some may disagree with the opinions of the Forecast Panelists or the positions taken by individual chapter authors with respect to their vision of future events. That is not only ac-ceptable, it is desirable. If you believe the predictions dis-cussed in the Pharmacy Forecast are not correct, it follows that you have a different opinion of what the future holds or how future events will shape the healthcare system and the care we provide. As long as you articulate those differing opinions in the context of your own organization’s strate-gic planning process and chart a course for your organiza-tion that is consistent with your beliefs, then the Pharmacy Forecast has met its objective of encouraging planning ef-forts of health systems.

We welcome your comments on this new edition of the Pharmacy Forecast. Suggestions for future forecasts can be sent to any of the forecast editors through the Foundation’s Pharmacy Forecast website at www.ashpfoundation.org/pharmacyforecast and will be considered for future editions.

Creation of the Pharmacy Forecast 2019 report was supported by an

unrestricted grant from Omnicell, Inc., to the David A. Zilz Leaders for

the Future Fund of the ASHP Research and Education Foundation.

Strategic Planning Advicefor Pharmacy Departments in Hospitals and Health Systems

Editor: Lee C. Vermeulen, B.S.Pharm., M.S., FCCP, FFIPUniversity of Kentucky, Lexington, Kentucky

Founding Editor: William A. Zellmer, B.S.Pharm., M.P.H., FFIPPharmacy Foresight Consulting, Bethesda, Maryland

Advisory CommitteeStephanie D. Brown, M.Ed.ASHP Research and Education Foundation, Bethesda, MarylandJannet M. Carmichael, Pharm.D., BCPS, FCCP, FAPhAPharm Consult NV LLC, Reno, NevadaDavid Chen, B.S.Pharm., M.B.A.American Society of Health-System Pharmacists, Bethesda, MarylandCharles E. Daniels, B.S.Pharm., Ph.D.UC San Diego Health, San Diego, CaliforniaAllen Flynn, Pharm.D., Ph.D.University of Michigan, Ann Arbor, MichiganErin R. Fox, Pharm.D., BCPS, FASHPUniversity of Utah Health, Salt Lake City, UtahJames M. Hoffman, Pharm.D., M.S., BCPS, FASHPSt. Jude Children’s Research Hospital, Memphis, TennesseeFelicity Homsted, Pharm.D., M.B.A.Turnkey Pharmacy Solutions, Bangor, MaineScott J. Knoer, M.S., Pharm.D., FASHPCleveland Clinic, Cleveland, OhioBarbara B. Nussbaum, B.S.Pharm., Ph.D.ASHP Research and Education Foundation, Bethesda, MarylandPamela L. Stamm, Pharm.D., BCPS, BCACP, CDE, FASHPAuburn University, Auburn, AlabamaRoss W. Thompson, B.S.Pharm., M.S., FASHPTufts Medical Center, Boston, MassachusettsShelly D. Wiest, Pharm.D., BCPS, FASHPUC Health, Cincinnati, OhioStephanie Sollis Bethay, Pharm.D., M.B.A. (Resident Observer)University of Kentucky, Lexington, KentuckyJames Blackmer, Pharm.D., M.P.A. (Resident Observer)Cleveland Clinic, Cleveland, OhioKen Perez (ASHP Foundation Board Observer)OmniCell, Mountain View, California

The bibliographic citation for this report is as follows: Vermeulen LC, Eddington ND, Gourdine MA et al. Pharmacy forecast 2019: strategic planning advice for pharmacy departments in hospitals and health systems. Am J Health-Syst Pharm. 2019; 76:71-100.

Keywords: drug therapy trends, forecasting, healthcare analytics, health-system trends, patient care trends, pharmacy leadership

DOI 10.2146/sp180010

Open access

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PHARMACY FORECAST 2019INTRODUCTION

AM J HEALTH-SYST PHARM | VOLUME 75 | 2018 e845


Introduction: An Environmental Scan to Inform Strategic Planning

Lee C. Vermeulen, B.S.Pharm., M.S., FCCP, FFIP, Chief, Academic Service Lines, UK HealthCare and Professor of Medicine and Pharmacy, University of Kentucky, Lexington, KY.

Address correspondence to Mr. Vermeulen ([email protected]).

Copyright © 2018, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/18/0000-e845.

At 4:50 am on Sunday, September 3, 1967, Sweden implemented a

radical (and dangerous) change. The högertrafikomläggningen, or Right-Hand Traffic Diversion, was imple-mented, changing the entire country from driving automobiles on the left to the right side of Swedish roads to match the traffic pattern in use in neighboring Scandinavian countries. While the traffic jam that occurred at the moment of change was described as “brief but monumental,” acci-dents were rare—perhaps due to the increased care Swedish drivers exer-cised as they became accustomed to the new driving pattern.1 Throughout recent history, necessary changes in the U.S. healthcare delivery models have been affected most successfully by altering healthcare payment mod-els. For example, in the United States in the early 1980s, it was recognized that a great deal of care was being de-livered in the acute care setting when the ambulatory care setting would be more efficient. To affect a change in setting, the prospective payment model of reimbursement (e.g., diag-nosis related group [DRG]-based pay-ment) was developed. The changes that ensued were traumatic, but the new system was thoughtfully coordi-nated and implemented and was ul-timately successful. The intent of the

Affordable Care Act was (and largely remains) to shift our care delivery model from one driven by a fee-for-service model to one driven by value-based incentives where quality (not quantity) is rewarded. Unfortunately, that transformation is now being implemented in an almost random fashion, leaving patients, providers, payers, and regulators alike adrift in uncertainty. Accurately describ-ing the nature of the challenges fac-ing health-system pharmacy leaders today is difficult without sounding melodramatic. It is as though we are now trying to phase in a conversion from driving on one side of the road to the other. One of the most effec-tive means of responding to these challenges requires careful and de-liberate strategic planning. This 2019 Pharmacy Forecast is intended to as-sist with strategic planning efforts by health-system leaders.

FORECAST METHODS

The methods used to develop the 2019 Pharmacy Forecast were similar to those used in the previous editions, drawing on concepts described in James Surowiecki’s2 book, The Wisdom of Crowds. According to Surow-iecki, the collective opinions of “wise crowds”—groups of diverse individu-als in which each participant’s input is provided independently, drawing from his or her own locally informed points of view—can be more informa-tive than the opinion of any individual participant. This process is particular-ly valuable when addressing phenom-ena that are not well suited to quan-titative predictive methods. A critical requirement for successfully creating crowd-based knowledge is establish-ing a systematic method of combin-ing individual beliefs into a collective opinion—the Pharmacy Forecast uses a survey of carefully selected pharma-

cy leaders to derive our environmental scan.

The 2019 Pharmacy Forecast Advi-sory Committee (see membership list in the Foreword) began the develop-ment of survey questions by contrib-uting lists of issues and concerns they believed will influence health-system pharmacy in the coming 5 years. That list was then expanded and refined through an iterative process, resulting in a final set of 8 themes, each with 6 focused topics on which the survey was built. Each of 48 survey items was written to explore the selected topics and was pilot-tested to ensure clarity and face validity.

As in the past, survey respondents—Forecast Panelists (FPs)—were se-lected by ASHP staff after nomination by the leaders of the ASHP sections. Nominations were limited to indi-viduals known to have expertise in health-system pharmacy, knowledge of trends and new developments in the field, and the ability to think ana-lytically about the future. This year, the size of the panel was deliberately increased—nearly doubled in size—in an effort to capture opinions from a wider range of pharmacy leaders.

The survey instructed FPs to read each of the 48 scenarios represented in survey items and consider the like-lihood of those scenarios occurring in the next 5 years. They were asked to base their response on their first-hand knowledge of current conditions in their region, not based on their understanding of national circum-stances. The panel was carefully bal-anced across the census regions of the United States to reflect a representa-tive national picture. They were asked to provide a top-of-mind response re-garding the likelihood of those condi-tions being very likely, somewhat like-ly, somewhat unlikely, or very unlikely to occur.

PHARMACY FORECAST 2019 INTRODUCTION

e846 AM J HEALTH-SYST PHARM | VOLUME 75 | 2018


ACKNOWLEDGMENTSThe editor gratefully acknowl-edges the contributions of many individuals who have made the 2019 Pharmacy Forecast a suc-cess. The members of the Phar-macy Forecast Advisory Com-mittee were instrumental in considering hundreds of factors that may influence the future of health-system pharmacy and distilling those ideas into a co-herent survey. The authors of each Forecast section took the “crowd wisdom” and created impactful messages and recom-mendations. Also acknowledged for assistance with various as-pects of the process are Philip Almeter, Stephanie Brown, David Chen, Daniel Cobaugh, Lynn Hoffman, Anita Lonesome, Maryam Mohassel, Rohit Moghe, Barbara Nussbaum, Antoniette Parris, Abhay Patel, Suzanne Turner, and Yvonne Yirka. The editor also again recognizes the leadership and vision of William A. Zellmer, the Found-ing Editor of the ASHP Founda-tion Pharmacy Forecast series for creating a resource for the pro-fession that continues to have significant value.

FORECAST SURVEY RESULTS The strength (and possibly valid-

ity) of predictions generated using the “wisdom of the crowd” method is largely dependent on the nature of the panelists responding to the fore-cast survey; therefore, it is important to understand the composition and characteristics of the panel. A total of 335 FPs were recruited to complete the survey (up from 165 FPs recruit-ed in 2018). Responses were received from 286 (an 85.4% response rate). While total responses increased from 146 in 2018, response rate fell only slightly from 88.5% seen last year. Most of the FPs (87%) had been in practice for more than 10 years, and 58% had been in practice for more than 20 years (up from 50% of FPs in 2018). Most FPs (56%) described their practice setting as a teaching hospital or health system, while 14% of FPs were from nonteaching hos-pitals or health systems. FPs in aca-demia represented 13% of respon-dents (down from 18% in 2018). FPs reported that their primary organi-zations offered very diverse services including home health or infusion care (52% of FPs), specialty phar-macy (57% of FPs), ambulatory care (78% of FPs), pediatric care (61% of FPs), and hospice care (43% of FPs). The mix of services did not differ substantially from that reported in the 2018 Pharmacy Forecast.

Many of the FPs hold the title of chief pharmacy officer or director of pharmacy (15% and 16% of FPs, re-spectively). Another large group of FPs (16%) listed their primary position as faculty. The remainder of FPs included leaders and practitioners at varying levels and titles. Again, this distribu-tion was not substantially different from the 2018 panel. While 24% of FPs indicated that their primary organi-zation was not a hospital (unchanged from 2018), 58% of FPs were employed by hospitals with 400 or more beds (down from 61% in 2018), and 18% of respondents were from hospitals with fewer than 400 beds (up from 15% in 2018).

The size of the panel in 2018 was increased in the hope of obtaining a more representative geographic dis-tribution, and increasing response rates from some regions that had not been well represented in the past. This year, we obtained at least 1 response from every state with the exception of 7 (Delaware, Hawaii, Idaho, Maine, Nevada, Vermont, and West Virgin-ia). As shown in the table, response rates per million population in each U.S. region ranged from 0.4 in the Middle South (Arkansas, Louisiana, Oklahoma, and Texas) to 1.9 in the Southeast (Kentucky, Tennessee, Ala-

bama, and Mississippi), and greater numbers of responses were received from many regions that were under-represented last year. A large propor-tion of responses, nearly 26%, were received from the Great Lakes region (Ohio, Indiana, Illinois, Michigan, and Wisconsin). Every region was represented by a minimum of 16 FP respondents.

CONTENTS OF THE 2019 PHARMACY FORECAST

Within each section of this report, the results of each survey question are summarized in detail. The results are discussed and key strategic recom-mendations are provided to stimu-late strategic planning by pharmacy leaders.

In a section on pharmacy educa-tion and workforce, Natalie Eddington and Michelle Gourdine describe the impact of a number of trends on the preparation of pharmacists and the continued evolution of the technical workforce in pharmacy. As many new schools and colleges of pharmacy have opened over the past few years, the ca-pacity of our pharmacy education sys-tem has increased to the point where, nationally, we have nearly as many slots for incoming students as we have applicants interested in pharmacy training (regardless of whether they are as qualified for admission as past applicants). Whether new graduates in the future will have the ability to take on the advancing professional roles increasingly demanded of health-sys-tem pharmacists is in doubt, and our response to that concern is something we must plan to address.

Jim Jorgenson and David Kvancz provide a section exploring financial challenges facing health-system phar-macy leaders and the phenomenon that will make those challenges more acute in the coming year. In particular, while continued changes to the 340B Drug Pricing Program seem inevita-ble, the impact that those changes will have on our ability to care for under-served patients is less clear. Another issue with profound financial, clinical,

2019

72 AM J HEALTH-SYST PHARM | VOLUME 76 | NUMBER 2 | JANUARY 15, 2019

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Introduction: An Environmental Scan to Inform Strategic Planning

Lee C. Vermeulen, B.S.Pharm., M.S., FCCP, FFIP, Chief, Academic Service Lines, UK HealthCare and Professor of Medicine and Pharmacy, University of Kentucky, Lexington, KY.

Address correspondence to Mr. Vermeulen ([email protected]).


At 4:50 am on Sunday, September 3, 1967, Sweden implemented a

radical (and dangerous) change. The högertrafikomläggningen, or Right-Hand Traffic Diversion, was imple-mented, changing the entire country from driving automobiles on the left to the right side of Swedish roads to match the traffic pattern in use in neighboring Scandinavian countries. While the traffic jam that occurred at the moment of change was described as “brief but monumental,” acci-dents were rare—perhaps due to the increased care Swedish drivers exer-cised as they became accustomed to the new driving pattern.1 Throughout recent history, necessary changes in the U.S. healthcare delivery models have been affected most successfully by altering healthcare payment mod-els. For example, in the United States in the early 1980s, it was recognized that a great deal of care was being de-livered in the acute care setting when the ambulatory care setting would be more efficient. To affect a change in setting, the prospective payment model of reimbursement (e.g., diag-nosis related group [DRG]-based pay-ment) was developed. The changes that ensued were traumatic, but the new system was thoughtfully coordi-nated and implemented and was ul-timately successful. The intent of the

Affordable Care Act was (and largely remains) to shift our care delivery model from one driven by a fee-for-service model to one driven by value-based incentives where quality (not quantity) is rewarded. Unfortunately, that transformation is now being implemented in an almost random fashion, leaving patients, providers, payers, and regulators alike adrift in uncertainty. Accurately describ-ing the nature of the challenges fac-ing health-system pharmacy leaders today is difficult without sounding melodramatic. It is as though we are now trying to phase in a conversion from driving on one side of the road to the other. One of the most effec-tive means of responding to these challenges requires careful and de-liberate strategic planning. This 2019 Pharmacy Forecast is intended to as-sist with strategic planning efforts by health-system leaders.

FORECAST METHODS

The methods used to develop the 2019 Pharmacy Forecast were similar to those used in the previous editions, drawing on concepts described in James Surowiecki’s2 book, The Wisdom of Crowds. According to Surow-iecki, the collective opinions of “wise crowds”—groups of diverse individu-als in which each participant’s input is provided independently, drawing from his or her own locally informed points of view—can be more informa-tive than the opinion of any individual participant. This process is particular-ly valuable when addressing phenom-ena that are not well suited to quan-titative predictive methods. A critical requirement for successfully creating crowd-based knowledge is establish-ing a systematic method of combin-ing individual beliefs into a collective opinion—the Pharmacy Forecast uses a survey of carefully selected pharma-

cy leaders to derive our environmental scan.

The 2019 Pharmacy Forecast Advi-sory Committee (see membership list in the Foreword) began the develop-ment of survey questions by contrib-uting lists of issues and concerns they believed will influence health-system pharmacy in the coming 5 years. That list was then expanded and refined through an iterative process, resulting in a final set of 8 themes, each with 6 focused topics on which the survey was built. Each of 48 survey items was written to explore the selected topics and was pilot-tested to ensure clarity and face validity.

As in the past, survey respondents—Forecast Panelists (FPs)—were se-lected by ASHP staff after nomination by the leaders of the ASHP sections. Nominations were limited to indi-viduals known to have expertise in health-system pharmacy, knowledge of trends and new developments in the field, and the ability to think ana-lytically about the future. This year, the size of the panel was deliberately increased—nearly doubled in size—in an effort to capture opinions from a wider range of pharmacy leaders.

The survey instructed FPs to read each of the 48 scenarios represented in survey items and consider the like-lihood of those scenarios occurring in the next 5 years. They were asked to base their response on their first-hand knowledge of current conditions in their region, not based on their understanding of national circum-stances. The panel was carefully bal-anced across the census regions of the United States to reflect a representa-tive national picture. They were asked to provide a top-of-mind response re-garding the likelihood of those condi-tions being very likely, somewhat like-ly, somewhat unlikely, or very unlikely to occur.




ACKNOWLEDGMENTSThe editor gratefully acknowl-edges the contributions of many individuals who have made the 2019 Pharmacy Forecast a suc-cess. The members of the Phar-macy Forecast Advisory Com-mittee were instrumental in considering hundreds of factors that may influence the future of health-system pharmacy and distilling those ideas into a co-herent survey. The authors of each Forecast section took the “crowd wisdom” and created impactful messages and recom-mendations. Also acknowledged for assistance with various as-pects of the process are Philip Almeter, Stephanie Brown, David Chen, Daniel Cobaugh, Lynn Hoffman, Anita Lonesome, Maryam Mohassel, Rohit Moghe, Barbara Nussbaum, Antoniette Parris, Abhay Patel, Suzanne Turner, and Yvonne Yirka. The editor also again recognizes the leadership and vision of William A. Zellmer, the Found-ing Editor of the ASHP Founda-tion Pharmacy Forecast series for creating a resource for the pro-fession that continues to have significant value.

FORECAST SURVEY RESULTS The strength (and possibly valid-

ity) of predictions generated using the “wisdom of the crowd” method is largely dependent on the nature of the panelists responding to the fore-cast survey; therefore, it is important to understand the composition and characteristics of the panel. A total of 335 FPs were recruited to complete the survey (up from 165 FPs recruit-ed in 2018). Responses were received from 286 (an 85.4% response rate). While total responses increased from 146 in 2018, response rate fell only slightly from 88.5% seen last year. Most of the FPs (87%) had been in practice for more than 10 years, and 58% had been in practice for more than 20 years (up from 50% of FPs in 2018). Most FPs (56%) described their practice setting as a teaching hospital or health system, while 14% of FPs were from nonteaching hos-pitals or health systems. FPs in aca-demia represented 13% of respon-dents (down from 18% in 2018). FPs reported that their primary organi-zations offered very diverse services including home health or infusion care (52% of FPs), specialty phar-macy (57% of FPs), ambulatory care (78% of FPs), pediatric care (61% of FPs), and hospice care (43% of FPs). The mix of services did not differ substantially from that reported in the 2018 Pharmacy Forecast.

Many of the FPs hold the title of chief pharmacy officer or director of pharmacy (15% and 16% of FPs, re-spectively). Another large group of FPs (16%) listed their primary position as faculty. The remainder of FPs included leaders and practitioners at varying levels and titles. Again, this distribu-tion was not substantially different from the 2018 panel. While 24% of FPs indicated that their primary organi-zation was not a hospital (unchanged from 2018), 58% of FPs were employed by hospitals with 400 or more beds (down from 61% in 2018), and 18% of respondents were from hospitals with fewer than 400 beds (up from 15% in 2018).

The size of the panel in 2018 was increased in the hope of obtaining a more representative geographic dis-tribution, and increasing response rates from some regions that had not been well represented in the past. This year, we obtained at least 1 response from every state with the exception of 7 (Delaware, Hawaii, Idaho, Maine, Nevada, Vermont, and West Virgin-ia). As shown in the table, response rates per million population in each U.S. region ranged from 0.4 in the Middle South (Arkansas, Louisiana, Oklahoma, and Texas) to 1.9 in the Southeast (Kentucky, Tennessee, Ala-

bama, and Mississippi), and greater numbers of responses were received from many regions that were under-represented last year. A large propor-tion of responses, nearly 26%, were received from the Great Lakes region (Ohio, Indiana, Illinois, Michigan, and Wisconsin). Every region was represented by a minimum of 16 FP respondents.

CONTENTS OF THE 2019 PHARMACY FORECAST

Within each section of this report, the results of each survey question are summarized in detail. The results are discussed and key strategic recom-mendations are provided to stimu-late strategic planning by pharmacy leaders.

In a section on pharmacy educa-tion and workforce, Natalie Eddington and Michelle Gourdine describe the impact of a number of trends on the preparation of pharmacists and the continued evolution of the technical workforce in pharmacy. As many new schools and colleges of pharmacy have opened over the past few years, the ca-pacity of our pharmacy education sys-tem has increased to the point where, nationally, we have nearly as many slots for incoming students as we have applicants interested in pharmacy training (regardless of whether they are as qualified for admission as past applicants). Whether new graduates in the future will have the ability to take on the advancing professional roles increasingly demanded of health-sys-tem pharmacists is in doubt, and our response to that concern is something we must plan to address.

Jim Jorgenson and David Kvancz provide a section exploring financial challenges facing health-system phar-macy leaders and the phenomenon that will make those challenges more acute in the coming year. In particular, while continued changes to the 340B Drug Pricing Program seem inevita-ble, the impact that those changes will have on our ability to care for under-served patients is less clear. Another issue with profound financial, clinical,


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and societal implications—the opioid crisis—is addressed by Suzanne Nesbit and Mark Bicket in a specific section devoted to how that crisis will affect health-system pharmacy and the rest of the healthcare system. Few of the current challenges facing healthcare leaders are unaffected by our ability to impact substance-use disorder, and many critical objectives are depen-dent on our success in that fight. We turn to Bill Zellmer and Amanda Hine for a discussion of emerging ethical concerns in healthcare. It is an unfor-tunate reality that as our challenges become acute, it becomes easier to rationalize ethical compromises that we would never have accepted under more stable circumstances. Our ability to reconcile ethical dilemmas in a civil fashion, despite unstable conditions, is essential, and this section provides important guidance on those issues.

Sylvia Belford and Steve Peters contribute a section on technologi-cal innovation and the likely future of informatics in healthcare. This is a topic that frequently appears in the Pharmacy Forecast, and this year’s edition focuses on continued evolu-tion of advanced analytics and the im-pact on patients and health systems, particularly how the investment we make in our information systems may soon pay significant dividends. James Hoffman and Bill Schwab delve into patient empowerment in a section dedicated to the increasing need for patient-centered care. Adopting the construct of “nothing about me, with-out me”—including patient and fam-ily advisors in every aspect of health-system governance—may require cultural changes within organizations, but it clearly provides a mechanism to address challenging issues that are important to those for whom we care.

Scott Knoer and Toby Cosgrove contribute a section on emerging roles for pharmacists in patient care. While previous editions of the Pharmacy Forecast have touched on practice models, the current healthcare en-vironment makes it imperative that pharmacists broaden their scope of

Table. Forecast Survey Responses by Region

Region

% ResponsesResponses/1,000,000

Populationa

2018 2019 2018 2019

New England (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut) 5 6.6 0.6 1.5

Mid-Atlantic (Delaware, New York, New Jersey, Pennsylvania) 7 8.4 0.2 0.6

South Atlantic (Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida) 21 15.0 0.5 0.8

Southeast (Kentucky, Tennessee, Alabama, Mississippi) 11 9.4 1.1 1.9

Great Lakes (Ohio, Indiana, Illinois, Michigan, Wisconsin) 24 25.9 0.8 1.6

Western Plains (Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas) 11 12.9 0.8 1.8

Middle South (Arkansas, Louisiana, Oklahoma, Texas) 5 5.6 0.2 0.4

Mountain (Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada) 9 5.9 0.9 1.2

Pacific (Washington, Oregon, California, Alaska, Hawaii) 8 10.1 0.2 0.6

aBased on 2010 U.S. Census population data.

practice. This may require a shift in self-perception—what pharmacists believe their role can and should be—and bold action is needed to take on new responsibilities in direct patient care. Finally, a section from Stan Kent and John Clark continues a series of topics included in the past 2 Pharmacy Forecast reports focused on the impact of political, economic, and commercial disrupters in healthcare. Uncertainty causes many leaders to become risk averse and more unwill-ing to attempt innovative strategies, despite the possibility that those strat-egies may produce positive outcomes. However, some leaders and organi-zations exploit the turbulence that causes competitors to seek cover, and they profit as a result. If healthcare or-ganizations choose to ignore such op-portunities, we must be ready to work with entities that are not traditionally active in our space.

USER’S GUIDE TO THE PHARMACY FORECAST

This advice on using the 2019 Pharmacy Forecast is similar to that provided in the first 6 editions. The purpose of this report is to encourage and support active, deliberate strate-gic planning in hospitals and health systems. It is intended to stimulate thinking and discussion and pro-vide a starting point for individuals and teams who wish to proactively position themselves and their teams and departments for potential future events and trends rather than be re-active to things that occur. This edi-tion of the report differs from the first 6 editions, just as each previous ver-sion differed from earlier versions. When using the Pharmacy Forecast, it is recommended that planners re-view at least 1 or 2 past editions in ad-dition to this new report, as many of the observations and recommenda-




tions that are 1 or 2 years old remain important to consider. All past edi-tions of the Pharmacy Forecast can be found on the ASHP Foundation website at www.ashpfoundation.org/pharmacyforecast.

The process of strategic planning should involve pharmacy staff at all levels—those in formal leadership positions, frontline staff (both phar-macists and pharmacy technicians), as well as others connected to de-partments of pharmacy, such as af-filiated faculty members, key physi-cian and nursing leaders involved in pharmacy activities, and others. The Pharmacy Forecast has been devel-oped to provide guidance to anyone participating in strategic planning activities, and it is recommended that the report be reviewed by all involved.

Importantly, the process of stra-tegic planning should not be limited to an annual process, producing a strategic plan that is then largely ig-nored until the following year when a revised plan is created. Given the complexity, uncertainty, and pace of change in healthcare today, stra-tegic planning must be a continu-ous process. Strategic plans should be reviewed frequently, allowing for tactical adjustments in course over time as trends (those discussed in

this report and others that were not predicted) emerge. It is only through a continuous process that organiza-tions can be responsive to changes that are sure to affect our profession, organizations, and patients.

During the strategic planning process, the Pharmacy Forecast can be used as a provocative springboard for brainstorming and discussion; however, those leading strategic planning discussions should be open to opinions that differ from those expressed by the FP members and the chapter authors. Unique charac-teristics of each hospital and health system may suggest important dif-ferences in the potential impact of emerging trends, or individuals may simply disagree with the predictions made in this report. As a stimulant for thought and discussion, dissent-ing opinions can be constructive and valuable, provided those who express disagreement are willing to offer al-ternative views and recommenda-tions for action that go along with their perspectives.

Those organizations involved in education or training should consid-er the use of the Pharmacy Forecast as a teaching tool. Many educators and residency preceptors use the report as part of coursework, seminars, or journal club sessions to help engage

pharmacy trainees in thinking about the future of the profession they are preparing to enter.

Finally, as pharmacists are in-creasingly relied upon to provide sys-temwide leadership, the Pharmacy Forecast addresses many issues that are relevant well beyond the tradi-tional boundaries of pharmacy and the medication-use process. The content of the report should inform the broadened scope of responsi-bility that many pharmacists now take. The Pharmacy Forecast should be shared with other senior health-system leaders and executives as a resource to help them understand the challenges facing pharmacy and recognize how emerging healthcare trends will affect many other areas of health systems.

DisclosuresThe author has declared no potential con-

flicts of interest.

References1. Hipple AS. This day in history: Swed-

ish traffic switches sides—September 3, 1967. http://realscandinavia.com/this-day-in-history-swedish-traffic-switches-sides-september-3-1967/ (accessed 2018 Aug 14).

2. Surowiecki J. The wisdom of crowds. New York: Anchor; 2005.


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and societal implications—the opioid crisis—is addressed by Suzanne Nesbit and Mark Bicket in a specific section devoted to how that crisis will affect health-system pharmacy and the rest of the healthcare system. Few of the current challenges facing healthcare leaders are unaffected by our ability to impact substance-use disorder, and many critical objectives are depen-dent on our success in that fight. We turn to Bill Zellmer and Amanda Hine for a discussion of emerging ethical concerns in healthcare. It is an unfor-tunate reality that as our challenges become acute, it becomes easier to rationalize ethical compromises that we would never have accepted under more stable circumstances. Our ability to reconcile ethical dilemmas in a civil fashion, despite unstable conditions, is essential, and this section provides important guidance on those issues.

Sylvia Belford and Steve Peters contribute a section on technologi-cal innovation and the likely future of informatics in healthcare. This is a topic that frequently appears in the Pharmacy Forecast, and this year’s edition focuses on continued evolu-tion of advanced analytics and the im-pact on patients and health systems, particularly how the investment we make in our information systems may soon pay significant dividends. James Hoffman and Bill Schwab delve into patient empowerment in a section dedicated to the increasing need for patient-centered care. Adopting the construct of “nothing about me, with-out me”—including patient and fam-ily advisors in every aspect of health-system governance—may require cultural changes within organizations, but it clearly provides a mechanism to address challenging issues that are important to those for whom we care.

Scott Knoer and Toby Cosgrove contribute a section on emerging roles for pharmacists in patient care. While previous editions of the Pharmacy Forecast have touched on practice models, the current healthcare en-vironment makes it imperative that pharmacists broaden their scope of

Table. Forecast Survey Responses by Region

Region

% ResponsesResponses/1,000,000

Populationa

2018 2019 2018 2019

New England (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut) 5 6.6 0.6 1.5

Mid-Atlantic (Delaware, New York, New Jersey, Pennsylvania) 7 8.4 0.2 0.6

South Atlantic (Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida) 21 15.0 0.5 0.8

Southeast (Kentucky, Tennessee, Alabama, Mississippi) 11 9.4 1.1 1.9

Great Lakes (Ohio, Indiana, Illinois, Michigan, Wisconsin) 24 25.9 0.8 1.6

Western Plains (Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas) 11 12.9 0.8 1.8

Middle South (Arkansas, Louisiana, Oklahoma, Texas) 5 5.6 0.2 0.4

Mountain (Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada) 9 5.9 0.9 1.2

Pacific (Washington, Oregon, California, Alaska, Hawaii) 8 10.1 0.2 0.6

aBased on 2010 U.S. Census population data.

practice. This may require a shift in self-perception—what pharmacists believe their role can and should be—and bold action is needed to take on new responsibilities in direct patient care. Finally, a section from Stan Kent and John Clark continues a series of topics included in the past 2 Pharmacy Forecast reports focused on the impact of political, economic, and commercial disrupters in healthcare. Uncertainty causes many leaders to become risk averse and more unwill-ing to attempt innovative strategies, despite the possibility that those strat-egies may produce positive outcomes. However, some leaders and organi-zations exploit the turbulence that causes competitors to seek cover, and they profit as a result. If healthcare or-ganizations choose to ignore such op-portunities, we must be ready to work with entities that are not traditionally active in our space.

USER’S GUIDE TO THE PHARMACY FORECAST

This advice on using the 2019 Pharmacy Forecast is similar to that provided in the first 6 editions. The purpose of this report is to encourage and support active, deliberate strate-gic planning in hospitals and health systems. It is intended to stimulate thinking and discussion and pro-vide a starting point for individuals and teams who wish to proactively position themselves and their teams and departments for potential future events and trends rather than be re-active to things that occur. This edi-tion of the report differs from the first 6 editions, just as each previous ver-sion differed from earlier versions. When using the Pharmacy Forecast, it is recommended that planners re-view at least 1 or 2 past editions in ad-dition to this new report, as many of the observations and recommenda-




tions that are 1 or 2 years old remain important to consider. All past edi-tions of the Pharmacy Forecast can be found on the ASHP Foundation website at www.ashpfoundation.org/pharmacyforecast.

The process of strategic planning should involve pharmacy staff at all levels—those in formal leadership positions, frontline staff (both phar-macists and pharmacy technicians), as well as others connected to de-partments of pharmacy, such as af-filiated faculty members, key physi-cian and nursing leaders involved in pharmacy activities, and others. The Pharmacy Forecast has been devel-oped to provide guidance to anyone participating in strategic planning activities, and it is recommended that the report be reviewed by all involved.

Importantly, the process of stra-tegic planning should not be limited to an annual process, producing a strategic plan that is then largely ig-nored until the following year when a revised plan is created. Given the complexity, uncertainty, and pace of change in healthcare today, stra-tegic planning must be a continu-ous process. Strategic plans should be reviewed frequently, allowing for tactical adjustments in course over time as trends (those discussed in

this report and others that were not predicted) emerge. It is only through a continuous process that organiza-tions can be responsive to changes that are sure to affect our profession, organizations, and patients.

During the strategic planning process, the Pharmacy Forecast can be used as a provocative springboard for brainstorming and discussion; however, those leading strategic planning discussions should be open to opinions that differ from those expressed by the FP members and the chapter authors. Unique charac-teristics of each hospital and health system may suggest important dif-ferences in the potential impact of emerging trends, or individuals may simply disagree with the predictions made in this report. As a stimulant for thought and discussion, dissent-ing opinions can be constructive and valuable, provided those who express disagreement are willing to offer al-ternative views and recommenda-tions for action that go along with their perspectives.

Those organizations involved in education or training should consid-er the use of the Pharmacy Forecast as a teaching tool. Many educators and residency preceptors use the report as part of coursework, seminars, or journal club sessions to help engage

pharmacy trainees in thinking about the future of the profession they are preparing to enter.

Finally, as pharmacists are in-creasingly relied upon to provide sys-temwide leadership, the Pharmacy Forecast addresses many issues that are relevant well beyond the tradi-tional boundaries of pharmacy and the medication-use process. The content of the report should inform the broadened scope of responsi-bility that many pharmacists now take. The Pharmacy Forecast should be shared with other senior health-system leaders and executives as a resource to help them understand the challenges facing pharmacy and recognize how emerging healthcare trends will affect many other areas of health systems.

DisclosuresThe author has declared no potential con-

flicts of interest.

References1. Hipple AS. This day in history: Swed-

ish traffic switches sides—September 3, 1967. http://realscandinavia.com/this-day-in-history-swedish-traffic-switches-sides-september-3-1967/ (accessed 2018 Aug 14).

2. Surowiecki J. The wisdom of crowds. New York: Anchor; 2005.


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PHARMACY FORECAST 2018FUTURE OF PHARMACY



Future of Pharmacy Education and Workforce

Natalie D. Eddington, Ph.D., FAAPS, FCP, Dean and Professor, School of Pharmacy, University of Maryland, Baltimore, MD.

Michelle A. Gourdine, M.D., Senior Vice President, Population Health and Primary Care, University of Maryland Medical System, Baltimore, MD.

Address correspondence to Dr. Eddington ([email protected]).


POSTGRADUATE YEAR 1 RESIDENCY REQUIREMENTS

The American College of Clinical Pharmacy has called for pharma-

cists involved in the provision of “di-rect patient care” to have residency training by 2020.1 Sixty-one percent of Forecast Panelists (FPs) agreed that most Pharm.D. graduates will not be prepared for frontline health-system pharmacy practice, prompting near-ly all health systems to require post-graduate year 1 (PGY1) residency for entry-level pharmacist positions (Figure 1, item 1). Pharm.D. compe-tencies include general patient care, whereas PGY1 residencies focus on medication-use systems and optimal medication outcomes for patients with a broad range of diseases.1,2

In order for PGY1 residencies to be mandatory, pharmacy leadership must ensure that there are sufficient residency programs available for graduating students. Based on prior statistics, a total of 4,839 residency positions will be required in order to meet the needs of students graduat-ing in 2020.3 Health systems must consistently increase slots to ensure that residency training for direct pa-tient care in health systems is attain-able in 2020.

EXECUTIVE LEADERSHIP FOR PHARMACISTS

Fifty-two percent of FPs believed that it was somewhat or very unlikely that in 25% of health systems, at least 1 pharmacist will have an executive leadership role outside of pharmacy (Figure 1, item 2). There is a change emerging regarding pharmacists in executive leadership positions in the C-suite. Informing this change is the recognition of the expertise that phar-macists bring to innovative care mod-els, medication services, and manag-ing business profitability.4

Medications continue to be one of the major drivers in healthcare expen-ditures. Pharmacy executives must manage medication expenditures while adhering to their formulary and minimizing drug shortages and focus-ing on team-based care.5 The Centers for Medicare and Medicaid Services recently implemented the star-quality rating system that includes evalu-ation of medication management, population health, and chronic dis-ease management.6 This approach directly attributes outcomes that align with pharmacy expertise and their readiness for leadership outside of pharmacy.

REMOTE OVERSIGHT OF PHARMACY TECHNICIANS

Increases in the pharmacy work-force have not addressed the signifi-cant deficit of pharmacists in rural areas; hence, certain states have im-plemented telepharmacy for remote oversight of pharmacy technicians.7 In fact, 56% of FPs felt it likely that many health systems will use telepharma-cy applications for remote oversight of pharmacy technicians (Figure 1, item 3). Appropriately trained phar-macists can use telepharmacy to re-motely oversee operations and pro-vide distributive, clinical, analytic, and managerial services.8 It should be

noted that as health systems expand remote oversight, they must continue to proactively engage the expanding pharmacist workforce. Incentives and strategies similar to those employed to recruit physicians (e.g., loan repay-ment) might address the pharmacist shortage in rural and underserved areas.

PHARMACY TECHNICIANS IN PATIENT CARE

FPs were split on the question of whether competency-assured phar-macy technicians will be authorized to independently perform patient care activities (Figure 1, item 4). The op-posing views of the FPs may reflect the diversity in the patient care activities considered and the technician train-ing used to support these activities. It should be noted that physicians and nurses use provider extenders to sup-port the provision of healthcare. With the appropriate training, technicians have provided services including transition of care, medication histo-ries, and medication reconciliation.7 These patient care activities require competency-based training, leading to certificates that validate the requi-site skills and abilities.

PHARMACY STUDENT SUPPLY AND DEMAND

Sixty percent of FPs believed that there will be a decline of graduates by at least 10% (Figure 1, item 5). For the first time in more than 10 years, we are seeing an actual decrease in the num-ber of pharmacy graduates. Nonethe-less, it is informative and alarming to examine the unprecedented expan-sion of academic pharmacy over the past 10 years. In 2007, there were 9,800 graduates from 100 schools; in 2016, there were 14,556 graduates from 128 schools.9 As of the summer of 2018, the number of pharmacy schools has risen to 143.10

PHARMACY FORECAST 2019 FUTURE OF PHARMACY



Figure 1 (Pharmacy Education and Workforce). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

3 At least 50% of health systems will use telepharmacy applications for remote oversight of pharmacy technicians.

1 At least 90% of Pharm.D. graduates will not be prepared for front-line health-system pharmacy practice, prompting nearly all health systems to require PGY-1 residency for entry level pharmacist positions.

6 Burnout from increasing pressure of advanced practice roles and the complexity of healthcare will raise the annual turnover rate for front-line pharmacists to at least 15%. {Note: In 2014, turnover rate was 6.8%, see Pedersen et al., Am J Health-Syst Pharm. 2015; 72:1119-37.}

4 In at least 25% of health systems, competency-assured pharmacy technicians will be authorized to independently perform certain patient-care activities (e.g., manage protocol-based care).

5 The number of graduates of accredited Pharm.D. programs will decline by at least 10%.

2 In 25% of health systems, at least one pharmacist will have an executive leadership role outside of pharmacy (e.g., CEO, COO, CIO).

0%

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21%

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9

2019


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Future of Pharmacy Education and Workforce

Natalie D. Eddington, Ph.D., FAAPS, FCP, Dean and Professor, School of Pharmacy, University of Maryland, Baltimore, MD.

Michelle A. Gourdine, M.D., Senior Vice President, Population Health and Primary Care, University of Maryland Medical System, Baltimore, MD.

Address correspondence to Dr. Eddington ([email protected]).


POSTGRADUATE YEAR 1 RESIDENCY REQUIREMENTS

The American College of Clinical Pharmacy has called for pharma-

cists involved in the provision of “di-rect patient care” to have residency training by 2020.1 Sixty-one percent of Forecast Panelists (FPs) agreed that most Pharm.D. graduates will not be prepared for frontline health-system pharmacy practice, prompting near-ly all health systems to require post-graduate year 1 (PGY1) residency for entry-level pharmacist positions (Figure 1, item 1). Pharm.D. compe-tencies include general patient care, whereas PGY1 residencies focus on medication-use systems and optimal medication outcomes for patients with a broad range of diseases.1,2

In order for PGY1 residencies to be mandatory, pharmacy leadership must ensure that there are sufficient residency programs available for graduating students. Based on prior statistics, a total of 4,839 residency positions will be required in order to meet the needs of students graduat-ing in 2020.3 Health systems must consistently increase slots to ensure that residency training for direct pa-tient care in health systems is attain-able in 2020.

EXECUTIVE LEADERSHIP FOR PHARMACISTS

Fifty-two percent of FPs believed that it was somewhat or very unlikely that in 25% of health systems, at least 1 pharmacist will have an executive leadership role outside of pharmacy (Figure 1, item 2). There is a change emerging regarding pharmacists in executive leadership positions in the C-suite. Informing this change is the recognition of the expertise that phar-macists bring to innovative care mod-els, medication services, and manag-ing business profitability.4

Medications continue to be one of the major drivers in healthcare expen-ditures. Pharmacy executives must manage medication expenditures while adhering to their formulary and minimizing drug shortages and focus-ing on team-based care.5 The Centers for Medicare and Medicaid Services recently implemented the star-quality rating system that includes evalu-ation of medication management, population health, and chronic dis-ease management.6 This approach directly attributes outcomes that align with pharmacy expertise and their readiness for leadership outside of pharmacy.

REMOTE OVERSIGHT OF PHARMACY TECHNICIANS

Increases in the pharmacy work-force have not addressed the signifi-cant deficit of pharmacists in rural areas; hence, certain states have im-plemented telepharmacy for remote oversight of pharmacy technicians.7 In fact, 56% of FPs felt it likely that many health systems will use telepharma-cy applications for remote oversight of pharmacy technicians (Figure 1, item 3). Appropriately trained phar-macists can use telepharmacy to re-motely oversee operations and pro-vide distributive, clinical, analytic, and managerial services.8 It should be

noted that as health systems expand remote oversight, they must continue to proactively engage the expanding pharmacist workforce. Incentives and strategies similar to those employed to recruit physicians (e.g., loan repay-ment) might address the pharmacist shortage in rural and underserved areas.

PHARMACY TECHNICIANS IN PATIENT CARE

FPs were split on the question of whether competency-assured phar-macy technicians will be authorized to independently perform patient care activities (Figure 1, item 4). The op-posing views of the FPs may reflect the diversity in the patient care activities considered and the technician train-ing used to support these activities. It should be noted that physicians and nurses use provider extenders to sup-port the provision of healthcare. With the appropriate training, technicians have provided services including transition of care, medication histo-ries, and medication reconciliation.7 These patient care activities require competency-based training, leading to certificates that validate the requi-site skills and abilities.

PHARMACY STUDENT SUPPLY AND DEMAND

Sixty percent of FPs believed that there will be a decline of graduates by at least 10% (Figure 1, item 5). For the first time in more than 10 years, we are seeing an actual decrease in the num-ber of pharmacy graduates. Nonethe-less, it is informative and alarming to examine the unprecedented expan-sion of academic pharmacy over the past 10 years. In 2007, there were 9,800 graduates from 100 schools; in 2016, there were 14,556 graduates from 128 schools.9 As of the summer of 2018, the number of pharmacy schools has risen to 143.10




Figure 1 (Pharmacy Education and Workforce). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

3 At least 50% of health systems will use telepharmacy applications for remote oversight of pharmacy technicians.

1 At least 90% of Pharm.D. graduates will not be prepared for front-line health-system pharmacy practice, prompting nearly all health systems to require PGY-1 residency for entry level pharmacist positions.

6 Burnout from increasing pressure of advanced practice roles and the complexity of healthcare will raise the annual turnover rate for front-line pharmacists to at least 15%. {Note: In 2014, turnover rate was 6.8%, see Pedersen et al., Am J Health-Syst Pharm. 2015; 72:1119-37.}

4 In at least 25% of health systems, competency-assured pharmacy technicians will be authorized to independently perform certain patient-care activities (e.g., manage protocol-based care).

5 The number of graduates of accredited Pharm.D. programs will decline by at least 10%.

2 In 25% of health systems, at least one pharmacist will have an executive leadership role outside of pharmacy (e.g., CEO, COO, CIO).

0%

20%

40%

60%

80%

24%

37%27%

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STRATEGIC RECOMMENDATIONS FOR PRACTICE LEADERS

1. Completion of a PGY1 resi-dency must be the standard for entry into health-system pharmacy practice; ASHP along with health systems must continue the trend of increasing the number of PGY1 residency programs available.

2. Health systems must capital-ize on the strategic business and patient care strengths of pharmacists by proactively recruiting them into C-suite positions.

3. Certificate training is critical to the effective use of pharmacy technicians, and remote over-sight of pharmacy technicians and other incentives may ad-dress the pharmacist shortage in rural and underserved areas.

4. Pharmacy leadership should define advance practice roles

for pharmacy technicians, establish appropriate training and competency standards for these activities, and provide incentives to technicians who perform expanded patient care roles.

5. Schools and colleges of phar-macy must reduce class size to align with workforce needs, and the pharmacy community needs to redouble efforts to push forward federal provider status.

6. ASHP must immediately invest in research on burnout among clinical pharmacists to educate pharmacists about this issue and provide solutions while minimizing any negative im-pact on patient care.

Pharmacist supply is rapidly ex-ceeding demand as retail chains are consolidating and new schools continue to open. The original call (in 2001) to increase the number of schools was based on the projected need for pharmacists determined by the Bureau of Labor and Statistics (BLS). Specifically, BLS noted that the employment outlook may be negatively affected by decreases in retail pharmacies and growth in the number of schools.11 Projections of declining growth are also noted in the Pharmacist Demand Indicator, which has reported a supply of phar-macists much less than demand in 2018.11

BURNOUT IN ADVANCED PRACTICE PHARMACY ROLES

Burnout has been defined as a psy-chological process whereby human service professionals attempting to positively influence the lives of others become overwhelmed and frustrated by unforeseen job stressors. The ma-jority of research on burnout has fo-cused on physicians and nurses. The physician suicide rate was recently reported at 28 to 40 per 100,000, while in the general population, the overall rate was 12.3 per 100,000.

A large majority of FPs believed that burnout from increasing pres-sure of advanced practice roles and the complexity of healthcare will raise the annual turnover rate for frontline pharmacists to at least 15% (Figure 1, item 6). Reports indicate that burn-out can directly affect the quality of care provided and patient safety and increase the rate of medical er-rors and malpractice.13 The National Academy of Medicine Action Collab-orative on Clinician Well-Being and Resilience is a consortium of health-care professional organizations that aims to improve clinician well-being, raise the visibility of clinician stress, and elevate solutions that will im-prove patient care by caring for the caregiver.13

DisclosuresThe authors have declared no potential conflicts of interest.

References 1. Knapp KK, Shah BM, Kim HB et al. Vi-

sions for required postgraduate year 1 residency training by 2020: a com-parison of actual versus projected expansion. Pharmacotherapy. 2009; 29:1030-8.

2. Murphy JE, Nappi JM, Bosso JA et al. American College of Clinical Phar-macy’s vision of the future: postgrad-uate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006; 26:722-33.

3. National Matching Services. ASHP match statistics. The 2018 match. https://natmatch.com/ashprmp/stats.html (accessed 2018 Aug 2).

4. Schumock GT, Stubbings J, Wiest MD et al. National trends in prescription drug expenditures and projections for 2018. Am J Health-Syst Pharm. 2018; 75:1023-38.

5. American Hospital Association. Trends in hospital inpatient drug

costs: issues and challenges. www.aha.org/guidesreports/2018-01-24-trends-hospital-inpatient-drug-costs-issues-and-challenges (accessed 2018 Aug 2).

6. Traynor K. CMS releases medication review performance data as part of Medicare star ratings. Am J Health-Syst Pharm. 2017; 74:2027-8.

7. Mattingly AN, Mattingly TJ 2nd. Advancing the role of the pharmacy technician: a systematic review. J Am Pharm Assoc. 2018; 58:94-108.

8. Casey MM, Sorensen TD, Elias W et al. Current practices and state regula-tions regarding telepharmacy in rural hospitals. Am J Health-Syst Pharm. 2010; 67:1085-92.

9. American Association of Colleges of Pharmacy. Pharmacy workforce center 2018. https://pharmacyman-power.com/ (accessed 2018 Aug 2).

10. American Association of Colleges of Pharmacy. Academic pharmacy’s vital statistics. www.aacp.org/article/academic-pharmacys-vital-statistics (accessed 2018 Oct 15).

11. Bureau of Labor Statistics. Occupa-tional outlook handbook, healthcare occupations, pharmacists, job out-




look. www.bls.gov/ooh/healthcare/pharmacists.htm (accessed 2018 Aug 2).

12. Anderson P. Physicians experi-ence highest suicide rate of any profession. www.medscape.com/viewarticle/896257#vp_1 (accessed 2018 Oct 15).

13. Dyrbye LN, Shanafelt TD, Sinsky CA et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care (July 5, 2017). https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care (accessed 2018 Sep 25).

9


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1. Completion of a PGY1 resi-dency must be the standard for entry into health-system pharmacy practice; ASHP along with health systems must continue the trend of increasing the number of PGY1 residency programs available.

2. Health systems must capital-ize on the strategic business and patient care strengths of pharmacists by proactively recruiting them into C-suite positions.

3. Certificate training is critical to the effective use of pharmacy technicians, and remote over-sight of pharmacy technicians and other incentives may ad-dress the pharmacist shortage in rural and underserved areas.

4. Pharmacy leadership should define advance practice roles

for pharmacy technicians, establish appropriate training and competency standards for these activities, and provide incentives to technicians who perform expanded patient care roles.

5. Schools and colleges of phar-macy must reduce class size to align with workforce needs, and the pharmacy community needs to redouble efforts to push forward federal provider status.

6. ASHP must immediately invest in research on burnout among clinical pharmacists to educate pharmacists about this issue and provide solutions while minimizing any negative im-pact on patient care.

Pharmacist supply is rapidly ex-ceeding demand as retail chains are consolidating and new schools continue to open. The original call (in 2001) to increase the number of schools was based on the projected need for pharmacists determined by the Bureau of Labor and Statistics (BLS). Specifically, BLS noted that the employment outlook may be negatively affected by decreases in retail pharmacies and growth in the number of schools.11 Projections of declining growth are also noted in the Pharmacist Demand Indicator, which has reported a supply of phar-macists much less than demand in 2018.11

BURNOUT IN ADVANCED PRACTICE PHARMACY ROLES

Burnout has been defined as a psy-chological process whereby human service professionals attempting to positively influence the lives of others become overwhelmed and frustrated by unforeseen job stressors. The ma-jority of research on burnout has fo-cused on physicians and nurses. The physician suicide rate was recently reported at 28 to 40 per 100,000, while in the general population, the overall rate was 12.3 per 100,000.

A large majority of FPs believed that burnout from increasing pres-sure of advanced practice roles and the complexity of healthcare will raise the annual turnover rate for frontline pharmacists to at least 15% (Figure 1, item 6). Reports indicate that burn-out can directly affect the quality of care provided and patient safety and increase the rate of medical er-rors and malpractice.13 The National Academy of Medicine Action Collab-orative on Clinician Well-Being and Resilience is a consortium of health-care professional organizations that aims to improve clinician well-being, raise the visibility of clinician stress, and elevate solutions that will im-prove patient care by caring for the caregiver.13


References 1. Knapp KK, Shah BM, Kim HB et al. Vi-

sions for required postgraduate year 1 residency training by 2020: a com-parison of actual versus projected expansion. Pharmacotherapy. 2009; 29:1030-8.

2. Murphy JE, Nappi JM, Bosso JA et al. American College of Clinical Phar-macy’s vision of the future: postgrad-uate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006; 26:722-33.

3. National Matching Services. ASHP match statistics. The 2018 match. https://natmatch.com/ashprmp/stats.html (accessed 2018 Aug 2).

4. Schumock GT, Stubbings J, Wiest MD et al. National trends in prescription drug expenditures and projections for 2018. Am J Health-Syst Pharm. 2018; 75:1023-38.

5. American Hospital Association. Trends in hospital inpatient drug

costs: issues and challenges. www.aha.org/guidesreports/2018-01-24-trends-hospital-inpatient-drug-costs-issues-and-challenges (accessed 2018 Aug 2).

6. Traynor K. CMS releases medication review performance data as part of Medicare star ratings. Am J Health-Syst Pharm. 2017; 74:2027-8.

7. Mattingly AN, Mattingly TJ 2nd. Advancing the role of the pharmacy technician: a systematic review. J Am Pharm Assoc. 2018; 58:94-108.

8. Casey MM, Sorensen TD, Elias W et al. Current practices and state regula-tions regarding telepharmacy in rural hospitals. Am J Health-Syst Pharm. 2010; 67:1085-92.

9. American Association of Colleges of Pharmacy. Pharmacy workforce center 2018. https://pharmacyman-power.com/ (accessed 2018 Aug 2).

10. American Association of Colleges of Pharmacy. Academic pharmacy’s vital statistics. www.aacp.org/article/academic-pharmacys-vital-statistics (accessed 2018 Oct 15).

11. Bureau of Labor Statistics. Occupa-tional outlook handbook, healthcare occupations, pharmacists, job out-




look. www.bls.gov/ooh/healthcare/pharmacists.htm (accessed 2018 Aug 2).

12. Anderson P. Physicians experi-ence highest suicide rate of any profession. www.medscape.com/viewarticle/896257#vp_1 (accessed 2018 Oct 15).

13. Dyrbye LN, Shanafelt TD, Sinsky CA et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care (July 5, 2017). https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care (accessed 2018 Sep 25).


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PHARMACY FORECAST 2018KEY DRIVERS



Medications Are Key Drivers of Healthcare Finance and Care Delivery

James Jorgenson, B.S.Pharm., M.S., FASHP, Chief Executive Officer, Visante Inc. and Visante Ltd., St. Paul, MN.

David A. Kvancz, B.S.Pharm., M.S., FASHP, Senior Vice President Strategic Client Relationships, Visante Inc. and Visante Ltd., St. Paul, MN.

Address correspondence to Mr. Jorgenson ([email protected]).


FINANCIAL CHALLENGES

Healthcare currently consumes ap-proximately 18% of the U.S. gross

domestic product, with $3.3 trillion in annual spending.1 Prescription drugs constitute approximately 17% of that total and continue to be among the fastest growing elements of healthcare spending.2 Finances are at the top of virtually every healthcare executive’s list of challenges, making medication cost management a critical concern for pharmacy leaders.3

VERTICAL INTEGRATION

Forecast Panelists (FPs) were split on whether acquisitions and align-ment of business units (i.e., vertical integration) will slow expenditure growth in the future (Figure 2, item 1), and only 10% felt that it would be very likely. Nonetheless, this market strat-egy is expected to continue for the foreseeable future. Examples of this can be seen in the acquisition of phar-macy benefit managers and specialty pharmacy providers by major payers, the expansion of well-known retailers into diagnostic and clinical care ser-vices within their physical locations, and the movement of companies not traditionally in the healthcare space

into supply chain logistics and other healthcare roles. We should expect continued formation of healthcare coalitions to better control the supply chain and costs as investment groups buy providers (e.g., hospitals, physi-cian practices).

INDEPENDENT HOSPITALS

The trend of independent hospi-tals as well as large regional health systems continuing to align, merge, or be acquired by other local, re-gional, or large health systems is also expected to continue for the fore-seeable future. FPs overwhelmingly felt that the number of independent hospitals will decrease dramatically (Figure 2, item 2). The need for pa-tient volume to leverage third-party reimbursement along with opportu-nities to improve the cost structure of healthcare providers (through op-erational efficiencies and improved clinical quality and outcomes) will continue to be driving forces. Clearly, pharmacy programs will be key play-ers in these efforts.

PRIOR-AUTHORIZATION PROCESS

A primary element of payer strat-egies to manage costs is the use of prior authorization to ensure that in-terventions (including medications) are used appropriately. Specialty pharmaceuticals, which have seen 17–22% spending growth per year for many years and are expected to com-prise 50% of U.S. drug expenditures in 2019, are particular targets for prior authorization.4 However, the prior-authorization process is a business function that often distracts clinicians from patient care duties. This presents an opportunity to centralize this func-tion to create a more efficient system. A majority of FPs believed it likely that pharmacy will be responsible for com-

prehensive prior-authorization proc-esses, including medication-related diagnostics and adherence-enabling technology (Figure 2, item 3).

BIOSIMILARS

Fifty-eight percent of FPs felt that the introduction of new biosimilars will reduce national expenditures on biologicals by 25% (Figure 2, item 4); however, only 13% felt this was very likely. The use of biosimilars was a key cost-reduction concept in the Afford-able Care Act. In order to encourage the use of biosimilars, Medicare Part B reimbursement was linked to the aver-age sale price of the branded product. The pharmaceutical industry argued that this was unfair for innovator bio-logicals and potentially discouraged the development of new biotherapeu-tic agents.5 As a result, in May 2018, the Trump administration rescinded this price linkage within Medicare Part B. Going forward, reimbursement will be based on the specific biosimi-lar product pricing. The full impact of this change for individual healthcare organizations will depend on patient and payer mix.

Biosimilars that are priced at a low-er acquisition cost compared to the innovator product are likely to stag-nate or lose market share due to a low reimbursement margin.6 As a result, pricing of biosimilars may increase to make the reimbursement margin competitive with the innovator prod-uct, leaving healthcare organizations in search of other cost reduction opportunities.

340B DRUG PRICING PROGRAM

While all U.S. hospitals are chal-lenged by rising costs and shrinking reimbursement, the 340B program represents a significant opportunity to stretch scarce resources and provide

PHARMACY FORECAST 2019 KEY DRIVERS



Figure 2 (Healthcare Delivery and Financing). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

3 In 75% of health systems, pharmacy departments will be responsible for comprehensive prior authorization programs (e.g., ensuring insurance coverage prior to treatment).

1 Vertical integration in healthcare (i.e., combining two or more entities that have traditionally engaged in different aspects of the healthcare system, such as an insurer with a provider) will slow annual healthcare expenditure growth by 25%.

6 At least 25% of health systems will develop or expand their community-based health programs (e.g., mobile vans for homeless care, food banks) in response to increasing numbers of uninsured and under-insured patients.

4 The introduction of new biosimilars will reduce national expenditures on biologics by 25%.

5 Changes to the 340B program will result in a 50% reduction in savings realized by participating healthcare organizations.

2 The number of independent hospitals (i.e., those that are not part of a multi-hospital system or network) will decrease by at least 75%. {Note: In 2014, there were 487 such hospitals.}

0%

20%

40%

60%

80%

10%

40% 40%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

43% 46%

9%2%

VeryLikely

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VeryUnlikely

0%

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40%

60%

80%

25%

42%

27%

6%

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VeryUnlikely

0%

20%

40%

60%

80%

13%

45%

35%

7%

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VeryUnlikely

0%

20%

40%

60%

80%

27%

52%

19%

2%

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20%

40%

60%

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24%

50%

23%

4%

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VeryUnlikely

9

2019


Dow



P Mem





Medications Are Key Drivers of Healthcare Finance and Care Delivery

James Jorgenson, B.S.Pharm., M.S., FASHP, Chief Executive Officer, Visante Inc. and Visante Ltd., St. Paul, MN.

David A. Kvancz, B.S.Pharm., M.S., FASHP, Senior Vice President Strategic Client Relationships, Visante Inc. and Visante Ltd., St. Paul, MN.

Address correspondence to Mr. Jorgenson ([email protected]).


FINANCIAL CHALLENGES

Healthcare currently consumes ap-proximately 18% of the U.S. gross

domestic product, with $3.3 trillion in annual spending.1 Prescription drugs constitute approximately 17% of that total and continue to be among the fastest growing elements of healthcare spending.2 Finances are at the top of virtually every healthcare executive’s list of challenges, making medication cost management a critical concern for pharmacy leaders.3

VERTICAL INTEGRATION

Forecast Panelists (FPs) were split on whether acquisitions and align-ment of business units (i.e., vertical integration) will slow expenditure growth in the future (Figure 2, item 1), and only 10% felt that it would be very likely. Nonetheless, this market strat-egy is expected to continue for the foreseeable future. Examples of this can be seen in the acquisition of phar-macy benefit managers and specialty pharmacy providers by major payers, the expansion of well-known retailers into diagnostic and clinical care ser-vices within their physical locations, and the movement of companies not traditionally in the healthcare space

into supply chain logistics and other healthcare roles. We should expect continued formation of healthcare coalitions to better control the supply chain and costs as investment groups buy providers (e.g., hospitals, physi-cian practices).

INDEPENDENT HOSPITALS

The trend of independent hospi-tals as well as large regional health systems continuing to align, merge, or be acquired by other local, re-gional, or large health systems is also expected to continue for the fore-seeable future. FPs overwhelmingly felt that the number of independent hospitals will decrease dramatically (Figure 2, item 2). The need for pa-tient volume to leverage third-party reimbursement along with opportu-nities to improve the cost structure of healthcare providers (through op-erational efficiencies and improved clinical quality and outcomes) will continue to be driving forces. Clearly, pharmacy programs will be key play-ers in these efforts.

PRIOR-AUTHORIZATION PROCESS

A primary element of payer strat-egies to manage costs is the use of prior authorization to ensure that in-terventions (including medications) are used appropriately. Specialty pharmaceuticals, which have seen 17–22% spending growth per year for many years and are expected to com-prise 50% of U.S. drug expenditures in 2019, are particular targets for prior authorization.4 However, the prior-authorization process is a business function that often distracts clinicians from patient care duties. This presents an opportunity to centralize this func-tion to create a more efficient system. A majority of FPs believed it likely that pharmacy will be responsible for com-

prehensive prior-authorization proc-esses, including medication-related diagnostics and adherence-enabling technology (Figure 2, item 3).

BIOSIMILARS

Fifty-eight percent of FPs felt that the introduction of new biosimilars will reduce national expenditures on biologicals by 25% (Figure 2, item 4); however, only 13% felt this was very likely. The use of biosimilars was a key cost-reduction concept in the Afford-able Care Act. In order to encourage the use of biosimilars, Medicare Part B reimbursement was linked to the aver-age sale price of the branded product. The pharmaceutical industry argued that this was unfair for innovator bio-logicals and potentially discouraged the development of new biotherapeu-tic agents.5 As a result, in May 2018, the Trump administration rescinded this price linkage within Medicare Part B. Going forward, reimbursement will be based on the specific biosimi-lar product pricing. The full impact of this change for individual healthcare organizations will depend on patient and payer mix.

Biosimilars that are priced at a low-er acquisition cost compared to the innovator product are likely to stag-nate or lose market share due to a low reimbursement margin.6 As a result, pricing of biosimilars may increase to make the reimbursement margin competitive with the innovator prod-uct, leaving healthcare organizations in search of other cost reduction opportunities.

340B DRUG PRICING PROGRAM

While all U.S. hospitals are chal-lenged by rising costs and shrinking reimbursement, the 340B program represents a significant opportunity to stretch scarce resources and provide

PHARMACY FORECAST 2019 KEY DRIVERS



Figure 2 (Healthcare Delivery and Financing). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

3 In 75% of health systems, pharmacy departments will be responsible for comprehensive prior authorization programs (e.g., ensuring insurance coverage prior to treatment).

1 Vertical integration in healthcare (i.e., combining two or more entities that have traditionally engaged in different aspects of the healthcare system, such as an insurer with a provider) will slow annual healthcare expenditure growth by 25%.

6 At least 25% of health systems will develop or expand their community-based health programs (e.g., mobile vans for homeless care, food banks) in response to increasing numbers of uninsured and under-insured patients.

4 The introduction of new biosimilars will reduce national expenditures on biologics by 25%.

5 Changes to the 340B program will result in a 50% reduction in savings realized by participating healthcare organizations.

2 The number of independent hospitals (i.e., those that are not part of a multi-hospital system or network) will decrease by at least 75%. {Note: In 2014, there were 487 such hospitals.}

0%

20%

40%

60%

80%

10%

40% 40%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

43% 46%

9%2%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

25%

42%

27%

6%

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SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

13%

45%

35%

7%

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SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

27%

52%

19%

2%

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SomewhatLikely

SomewhatUnlikely

VeryUnlikely 0%

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60%

80%

24%

50%

23%

4%

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SomewhatLikely

SomewhatUnlikely

VeryUnlikely


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care to their most vulnerable patients. However, the program continues to face escalating criticism from ele-ments of the pharmaceutical and bio-tech industries, community oncology groups, members of Congress, and governmental agencies. The Centers for Medicare and Medicaid Services’s (CMS’s) decision for 2018 to reduce payment for Part B drugs purchased through the 340B program and the re-cent proposal to continue this in 20197 represent a significant financial loss for many 340B covered entities. Addi-tional reductions in the 340B program were also noted in President Trump’s blueprint to reduce drug costs. Almost 80% of FPs felt that savings associated with 340B are likely to be reduced by at least 50% in the coming years (Figure 2, item 5). While a Democratic victory in either house of Congress in the fall 2018 midterm elections may reduce the threat to the 340B program, ad-ditional restrictions on the program from the Health Resources and Servic-es Administration and CMS are likely to increase.

COMMUNITY HEALTH PROGRAMS

With the shift to value-based care payment models, more health sys-tems are accepting financial risk for larger groups of patients through bun-dled payments or accountable care–type arrangements. CMS has stated a goal of having 90% of payments deliv-ered through these models within 10 years. This approach places increas-ing emphasis on disease prevention and wellness management, which must include strategies for greater community outreach and involve-ment to be successful. A majority of FPs felt that at least 25% of health systems will develop or expand their community-based health programs in response to increasing numbers of uninsured and underinsured pa-tients (Figure 2, item 6).


1. Pharmacists in health sys-tems should take the lead in developing and implementing new models of care that take advantage of emerging vertical integration.

2. In order to achieve the an-ticipated operational, clinical, financial, and risk benefits of disparate healthcare organi-zations coming together as systems, pharmacy leaders must have a formal strategic plan to assist the health system in achieving these goals.

3. Pharmacists should take ownership for the optimal performance of all aspects of the medication-use system, including centralized prior-authorization management.

4. Pharmacists must recognize how the costs and margins of biosimilars drive financial outcomes and respond accord-ingly to protect their institu-tion’s financial performance.

5. Pharmacists should lead their health system’s efforts around the 340B program to not only deliver the desired compli-ance results but also provide a clear delineation of exactly how 340B savings are deployed to provide care to vulnerable patient populations.

6. Pharmacists must move be-yond their traditional focus on disease treatment to become more-active participants in health-system community outreach programs.


References1. Centers for Medicare and Medicaid

Services. National health expenditure data (January 1, 2018). www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html (accessed 2018 Jun 9).

2. Pew Charitable Trusts. A look at drug spending in the U.S. (April 26 2018). www.pewtrusts.org/en/research-and-analysis/fact-sheets/2018/02/a-look-at-drug-spending-in-the-us (accessed 2018 Jun 9).

3. Brown T. What keeps hospital CEOs up at night (April 2018). http://blogs.infor.com/health-care/2018/04/what-keeps-hospital-ceos-up-at-night.html (accessed 2018 Jun 9).

4. McCann D. Specialty drug costs to soar again in 2018 (September 22, 2017). ww2.cfo.com/health-benefits/2017/09/specialty-drug-

costs-soar-2018/ (accessed 2018 Jun 18).

5. Paavola A. Trump policy change could raise price of biosimilars: 7 things to know. www.beckershospitalreview.com/supply-chain/trump-policy-change-could-raise-price-of-biosimilars-7-things-to-know.html (accessed 2018 Jun 20).

6. Mehr S. How will biosimilars be af-fected by Trump’s drug price reform measures? https://biosimilarsrr.com/2018/05/14/will-biosimilars-affected-trumps-drug-price-reform-measures/ (accessed 2018 Jun 20).

7. Centers for Medicare and Medicaid Services. Medicare program: proposed changes to hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs (July 31, 2018). www.federalregister.gov/documents/2018/07/31/2018-15958/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical (accessed 2018 Jul 31).

PHARMACY FORECAST 2019 OPIOID CRISIS



The Opioid Crisis

Suzanne A. Nesbit, Pharm.D., BCPS, CPE, FCCP, Clinical Pharmacy Specialist, Pain Management, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

Mark C. Bicket, M.D., Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Address correspondence to Dr. Nesbit ([email protected]).


OPIOID CRISIS IN PERSPECTIVE

The United States is in the midst of an opioid epidemic, with more

than 350,000 persons dying from an opioid overdose between 1999 and 2016 and more than 47,000 deaths in 2017. As opioid deaths have surged, U.S. life expectancy has fallen for 2 consecutive years in 2016 and 2017, a phenomenon that had not previ-ously occurred since the early 1960s.1 Forecast Panelists (FPs) had mixed opinions about whether or not opioid-related deaths nationally will decline by 25%, with only 59% believ-ing a decline is likely (Figure 3, item 1). Declines in deaths from opioids are unlikely until policymakers enact comprehensive solutions that address opioid use disorder and addiction.

OPIOID STEWARDSHIP

The opioid epidemic underscores the need for leadership from pharma-cists for opioid stewardship to ensure that prescribers remain accountable to evidence-based practices. Phar-macists play a crucial role as key col-laborators within the broader health-care community. Prescription drug monitoring programs (PDMPs), which keep a ledger of controlled substance

prescriptions for each patient, are a significant tool to address inappropri-ate opioid prescribing. While various states mandate the use of these pro-grams by prescribers or pharmacists, the piecemeal nature of PDMPs at the state level leaves significant gaps in interoperability and data sharing that a national program or national standards could address. FPs were equally divided on whether the federal government will develop a national PDMP (Figure 3, item 2).

Integrated multidisciplinary pain consultation services, which ensure input from pharmacists, physicians, and other clinicians, provide a model to optimize nonopioid and nonphar-macologic pain therapies while using opioids in an evidence-based manner. For hospitals in rural settings or other locations that lack such expertise, telemedicine permits input on patient care from pharmacists specializing in pain management and other team members. Project ECHO is an exam-ple of a successful telementoring and professional development program that promotes interprofessional col-laborative patient care.2

Pharmacists have a diverse range of clinical encounters with patients who may benefit from naloxone pro-grams. These patients may include those being discharged from inpatient facilities or those visiting emergency rooms or ambulatory clinics. One key gap in knowledge is whether naloxone is needed for short-term, low-dose opioid therapy at discharge. Promot-ing awareness of evidence-based guidelines such as the CDC Guideline for Prescribing Opioids for Chronic Pain3 represents a key method by which pharmacists may enhance opi-oid stewardship. Most FPs agreed that at least a quarter of health systems will provide structural educational programs to improve pain treatment in primary care (Figure 3, item 3). Pharmacists also have the opportu-

nity to facilitate disposal of leftover opioid products through hosting drug drop boxes in pharmacies, providing patients with drug disposal kits, and publicizing drug take-back events in the community.

PATIENT CARE

One of the primary challenges in patient care is how to stratify the risk of opioid overdose in patients in vari-ous healthcare settings. While effec-tive treatments for opioid use disorder exist, stigma regarding addiction ob-structs many patients from obtaining such treatment. Most FPs believed that states are unlikely to recover the cost of treatment programs for opioid ad-diction through legal actions (Figure 3, item 4). It is clear that government coverage for addiction treatment must expand; yet at the same time, health systems must do more to care for the growing numbers of patients with opi-oid use disorder. States and cities have pushed healthcare systems to follow protocols of care for addiction treat-ment, regardless of whether they are guided by evidence.4

Beyond opioid use disorder, initia-tives focusing on all types of substance use and those at risk of developing these disorders have gained momen-tum. Screening, brief intervention, and referral to treatment (SIRBT)5 works to identify and intervene early in persons with substance use disor-ders and may be implemented in the pharmacy setting. Pharmacists may take a collaborative role in manag-ing patients on medication assisted therapy for opioid use disorder. Pa-tients who desire to taper off opioids may also need help with withdrawal symptoms.

Evidence-based guidelines on pain treatment emphasize nonpharmaco-logic pain treatment such as massage, yoga, and acupuncture as first-line therapy for chronic pain and encour-age its application for acute pain.6-8

9


Dow



P Mem





care to their most vulnerable patients. However, the program continues to face escalating criticism from ele-ments of the pharmaceutical and bio-tech industries, community oncology groups, members of Congress, and governmental agencies. The Centers for Medicare and Medicaid Services’s (CMS’s) decision for 2018 to reduce payment for Part B drugs purchased through the 340B program and the re-cent proposal to continue this in 20197 represent a significant financial loss for many 340B covered entities. Addi-tional reductions in the 340B program were also noted in President Trump’s blueprint to reduce drug costs. Almost 80% of FPs felt that savings associated with 340B are likely to be reduced by at least 50% in the coming years (Figure 2, item 5). While a Democratic victory in either house of Congress in the fall 2018 midterm elections may reduce the threat to the 340B program, ad-ditional restrictions on the program from the Health Resources and Servic-es Administration and CMS are likely to increase.

COMMUNITY HEALTH PROGRAMS

With the shift to value-based care payment models, more health sys-tems are accepting financial risk for larger groups of patients through bun-dled payments or accountable care–type arrangements. CMS has stated a goal of having 90% of payments deliv-ered through these models within 10 years. This approach places increas-ing emphasis on disease prevention and wellness management, which must include strategies for greater community outreach and involve-ment to be successful. A majority of FPs felt that at least 25% of health systems will develop or expand their community-based health programs in response to increasing numbers of uninsured and underinsured pa-tients (Figure 2, item 6).


1. Pharmacists in health sys-tems should take the lead in developing and implementing new models of care that take advantage of emerging vertical integration.

2. In order to achieve the an-ticipated operational, clinical, financial, and risk benefits of disparate healthcare organi-zations coming together as systems, pharmacy leaders must have a formal strategic plan to assist the health system in achieving these goals.

3. Pharmacists should take ownership for the optimal performance of all aspects of the medication-use system, including centralized prior-authorization management.

4. Pharmacists must recognize how the costs and margins of biosimilars drive financial outcomes and respond accord-ingly to protect their institu-tion’s financial performance.

5. Pharmacists should lead their health system’s efforts around the 340B program to not only deliver the desired compli-ance results but also provide a clear delineation of exactly how 340B savings are deployed to provide care to vulnerable patient populations.

6. Pharmacists must move be-yond their traditional focus on disease treatment to become more-active participants in health-system community outreach programs.


References1. Centers for Medicare and Medicaid

Services. National health expenditure data (January 1, 2018). www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html (accessed 2018 Jun 9).

2. Pew Charitable Trusts. A look at drug spending in the U.S. (April 26 2018). www.pewtrusts.org/en/research-and-analysis/fact-sheets/2018/02/a-look-at-drug-spending-in-the-us (accessed 2018 Jun 9).

3. Brown T. What keeps hospital CEOs up at night (April 2018). http://blogs.infor.com/health-care/2018/04/what-keeps-hospital-ceos-up-at-night.html (accessed 2018 Jun 9).

4. McCann D. Specialty drug costs to soar again in 2018 (September 22, 2017). ww2.cfo.com/health-benefits/2017/09/specialty-drug-

costs-soar-2018/ (accessed 2018 Jun 18).

5. Paavola A. Trump policy change could raise price of biosimilars: 7 things to know. www.beckershospitalreview.com/supply-chain/trump-policy-change-could-raise-price-of-biosimilars-7-things-to-know.html (accessed 2018 Jun 20).

6. Mehr S. How will biosimilars be af-fected by Trump’s drug price reform measures? https://biosimilarsrr.com/2018/05/14/will-biosimilars-affected-trumps-drug-price-reform-measures/ (accessed 2018 Jun 20).

7. Centers for Medicare and Medicaid Services. Medicare program: proposed changes to hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs (July 31, 2018). www.federalregister.gov/documents/2018/07/31/2018-15958/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical (accessed 2018 Jul 31).




The Opioid Crisis

Suzanne A. Nesbit, Pharm.D., BCPS, CPE, FCCP, Clinical Pharmacy Specialist, Pain Management, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

Mark C. Bicket, M.D., Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Address correspondence to Dr. Nesbit ([email protected]).


OPIOID CRISIS IN PERSPECTIVE

The United States is in the midst of an opioid epidemic, with more

than 350,000 persons dying from an opioid overdose between 1999 and 2016 and more than 47,000 deaths in 2017. As opioid deaths have surged, U.S. life expectancy has fallen for 2 consecutive years in 2016 and 2017, a phenomenon that had not previ-ously occurred since the early 1960s.1 Forecast Panelists (FPs) had mixed opinions about whether or not opioid-related deaths nationally will decline by 25%, with only 59% believ-ing a decline is likely (Figure 3, item 1). Declines in deaths from opioids are unlikely until policymakers enact comprehensive solutions that address opioid use disorder and addiction.

OPIOID STEWARDSHIP

The opioid epidemic underscores the need for leadership from pharma-cists for opioid stewardship to ensure that prescribers remain accountable to evidence-based practices. Phar-macists play a crucial role as key col-laborators within the broader health-care community. Prescription drug monitoring programs (PDMPs), which keep a ledger of controlled substance

prescriptions for each patient, are a significant tool to address inappropri-ate opioid prescribing. While various states mandate the use of these pro-grams by prescribers or pharmacists, the piecemeal nature of PDMPs at the state level leaves significant gaps in interoperability and data sharing that a national program or national standards could address. FPs were equally divided on whether the federal government will develop a national PDMP (Figure 3, item 2).

Integrated multidisciplinary pain consultation services, which ensure input from pharmacists, physicians, and other clinicians, provide a model to optimize nonopioid and nonphar-macologic pain therapies while using opioids in an evidence-based manner. For hospitals in rural settings or other locations that lack such expertise, telemedicine permits input on patient care from pharmacists specializing in pain management and other team members. Project ECHO is an exam-ple of a successful telementoring and professional development program that promotes interprofessional col-laborative patient care.2

Pharmacists have a diverse range of clinical encounters with patients who may benefit from naloxone pro-grams. These patients may include those being discharged from inpatient facilities or those visiting emergency rooms or ambulatory clinics. One key gap in knowledge is whether naloxone is needed for short-term, low-dose opioid therapy at discharge. Promot-ing awareness of evidence-based guidelines such as the CDC Guideline for Prescribing Opioids for Chronic Pain3 represents a key method by which pharmacists may enhance opi-oid stewardship. Most FPs agreed that at least a quarter of health systems will provide structural educational programs to improve pain treatment in primary care (Figure 3, item 3). Pharmacists also have the opportu-

nity to facilitate disposal of leftover opioid products through hosting drug drop boxes in pharmacies, providing patients with drug disposal kits, and publicizing drug take-back events in the community.

PATIENT CARE

One of the primary challenges in patient care is how to stratify the risk of opioid overdose in patients in vari-ous healthcare settings. While effec-tive treatments for opioid use disorder exist, stigma regarding addiction ob-structs many patients from obtaining such treatment. Most FPs believed that states are unlikely to recover the cost of treatment programs for opioid ad-diction through legal actions (Figure 3, item 4). It is clear that government coverage for addiction treatment must expand; yet at the same time, health systems must do more to care for the growing numbers of patients with opi-oid use disorder. States and cities have pushed healthcare systems to follow protocols of care for addiction treat-ment, regardless of whether they are guided by evidence.4

Beyond opioid use disorder, initia-tives focusing on all types of substance use and those at risk of developing these disorders have gained momen-tum. Screening, brief intervention, and referral to treatment (SIRBT)5 works to identify and intervene early in persons with substance use disor-ders and may be implemented in the pharmacy setting. Pharmacists may take a collaborative role in manag-ing patients on medication assisted therapy for opioid use disorder. Pa-tients who desire to taper off opioids may also need help with withdrawal symptoms.

Evidence-based guidelines on pain treatment emphasize nonpharmaco-logic pain treatment such as massage, yoga, and acupuncture as first-line therapy for chronic pain and encour-age its application for acute pain.6-8

2019


Dow



P Mem


PHARMACY FORECAST 2019OPIOID CRISIS



Figure 3 (The Opioid Crisis). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 Opioid-related deaths nationally will decline by 25%.

6 Pain management questions will be removed from nearly all patient satisfaction surveys used by health systems.

5 The health insurance plan of at least 25% of patients will cover a wide range of non-pharmacologic treatments of pain (e.g., massage therapy, acupuncture, yoga).

0%

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80%

11%

48%

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VeryUnlikely

4 At least 75% of states will successfully recover the cost of treatment programs for opioid addiction through legal actions against opioid manufacturers, large chain drugstore corporations and major drug wholesalers.

0%

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60%

80%

2%

19%

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24%

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VeryUnlikely

3 At least 25% of health systems will provide structured educational programs to improve the treatment of pain by primary care practitioners.

0%

20%

40%

60%

80%

63%

30%

6%1%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 The federal government will develop a standardized national Prescription Drug Monitoring Program that is timely, accurate, and universally accessible by healthcare practitioners.

0%

20%

40%

60%

80%

17%

36% 34%

13%

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VeryUnlikely

0%

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80%

17%

47%

29%

6%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

13%

32%39%

15%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely





1. Pharmacists must assume leadership roles in opioid stewardship initiatives at the local, state, and national levels to ensure implementation of evidence-based practices that balance safety and risk with the need for legitimate access to pain treatment.

2. Pharmacists should participate in shared decision-making with patients, caregivers, and the healthcare team regarding pain treatment strategies in general and opioid prescribing in particular.

3. Pharmacists should take a lead in establishing telehealth pain and addiction consultation services.

4. Health systems should harness the power of the electronic health record to prospectively identify patients at risk from opioids, monitor performance data on opioid prescribing and patient outcomes, identify op-portunities for improvement, and assess the impact of opioid stewardship efforts.

5. Pharmacists should help strike a balance between opioid stewardship and optimal pain management for patients.

6. Health-system pharmacists should partner with commu-nity-based pharmacists to ensure collaboration in com-prehensive pain and opioid management.

Most FPs believed insurance plans will cover a wide range of nonphar-macologic treatments of pain (Figure 3, item 5). Insurance plans have not created pathways to reimburse these nonpharmacologic treatments, except in limited cases. Value-based pay-ers that aim to reduce the total cost of care through reimbursement are more likely to find these nondrug op-tions desirable, given that they avoid increased costs from opioid-related healthcare encounters.

Patient satisfaction surveys, which many believe to have exacerbated the overprescribing of opioids in the early 2000s, remain an ever-present influ-ence on the way healthcare systems measure progress in pain manage-ment.9 The Centers for Medicare and Medicaid Services recently modified the Hospital Consumer Assessment of Healthcare Providers and Systems questions on pain management for hospitals to emphasize communi-cation about pain management in-stead of the treatment of pain itself.10 A slight majority of FPs believed it is unlikely that pain management ques-tions will be removed from nearly all patient satisfaction surveys used by health systems (Figure 3, item 6).

The opioid epidemic has high-lighted the association of opioid pre-scribing with overdose deaths. Opioid prescriptions plateaued in 2014–15, with declines in subsequent years. Is the number of opioid prescriptions an appropriate indicator for optimal pain management? Many clinicians and patients fear that our efforts to reduce opioid prescribing will have unintend-ed consequences, such as restricting access to patients who legitimately need access to opioid analgesics. The concern that the pendulum does not swing too far back is apt.


References1. Dowell D, Arias E, Kochanek K et

al. Contribution of opioid-involved poisoning to the change in life expec-tancy in the United States, 2000–2015. JAMA. 2017; 318:1065-7.

2. Katzman JG, Comerci G Jr, Boyle JF et al. Innovative telementoring for pain management: project ECHO pain. J Contin Educ Health Prof. 2014; 34(1):68-75.

3. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opi-oids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016; 65:1-49.

4. Brooklyn JR, Sigmon SC. Ver-mont hub-and-spoke model of care for opioid use disorder: development, implementation, and impact. J Addict Med. 2017; 11:286-92.

5. SAMHSA-HRSA Center for Integrated Health Solutions. SBIRT: screening, brief intervention, and referral to treatment. www.integration.samhsa.gov/clinical-practice/sbirt (accessed 2018 Sep 25).

6. Herzig SJ, Calcaterra SL, Mosher HJ et al. Safe opioid prescribing for

acute noncancer pain in hospital-ized adults: a systematic review of existing guidelines. J Hosp Med. 2018; 13:256-62.

7. Manchikanti L, Kaye AM, Knezevic NN et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physi-cians (ASIPP) guidelines. Pain Physi-cian. 2017; 20:S3-92.

8. Meghani SH, Vapiwala N. Bridging the critical divide in pain management guidelines from the CDC, NCCN, and ASCO for cancer survivors. JAMA Oncol. Epub ahead of print (DOI 10.1001/jamaoncol.2018.1574).

9. Terfera L, Lehrman WG, Conway P. Measurement of the patient experi-ence. Clarifying facts, myths and approaches. JAMA. 2016; 315:2167-8.

10. Thompson CA. HCAHPS survey to measure pain communication, not management. Am J Health-Syst Pharm. 2017; 74:1924-6.


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PHARMACY FORECAST 2019OPIOID CRISIS



Figure 3 (The Opioid Crisis). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 Opioid-related deaths nationally will decline by 25%.

6 Pain management questions will be removed from nearly all patient satisfaction surveys used by health systems.

5 The health insurance plan of at least 25% of patients will cover a wide range of non-pharmacologic treatments of pain (e.g., massage therapy, acupuncture, yoga).

0%

20%

40%

60%

80%

11%

48%

35%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 At least 75% of states will successfully recover the cost of treatment programs for opioid addiction through legal actions against opioid manufacturers, large chain drugstore corporations and major drug wholesalers.

0%

20%

40%

60%

80%

2%

19%

55%

24%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 At least 25% of health systems will provide structured educational programs to improve the treatment of pain by primary care practitioners.

0%

20%

40%

60%

80%

63%

30%

6%1%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 The federal government will develop a standardized national Prescription Drug Monitoring Program that is timely, accurate, and universally accessible by healthcare practitioners.

0%

20%

40%

60%

80%

17%

36% 34%

13%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

17%

47%

29%

6%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

0%

20%

40%

60%

80%

13%

32%39%

15%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely





1. Pharmacists must assume leadership roles in opioid stewardship initiatives at the local, state, and national levels to ensure implementation of evidence-based practices that balance safety and risk with the need for legitimate access to pain treatment.

2. Pharmacists should participate in shared decision-making with patients, caregivers, and the healthcare team regarding pain treatment strategies in general and opioid prescribing in particular.

3. Pharmacists should take a lead in establishing telehealth pain and addiction consultation services.

4. Health systems should harness the power of the electronic health record to prospectively identify patients at risk from opioids, monitor performance data on opioid prescribing and patient outcomes, identify op-portunities for improvement, and assess the impact of opioid stewardship efforts.

5. Pharmacists should help strike a balance between opioid stewardship and optimal pain management for patients.

6. Health-system pharmacists should partner with commu-nity-based pharmacists to ensure collaboration in com-prehensive pain and opioid management.

Most FPs believed insurance plans will cover a wide range of nonphar-macologic treatments of pain (Figure 3, item 5). Insurance plans have not created pathways to reimburse these nonpharmacologic treatments, except in limited cases. Value-based pay-ers that aim to reduce the total cost of care through reimbursement are more likely to find these nondrug op-tions desirable, given that they avoid increased costs from opioid-related healthcare encounters.

Patient satisfaction surveys, which many believe to have exacerbated the overprescribing of opioids in the early 2000s, remain an ever-present influ-ence on the way healthcare systems measure progress in pain manage-ment.9 The Centers for Medicare and Medicaid Services recently modified the Hospital Consumer Assessment of Healthcare Providers and Systems questions on pain management for hospitals to emphasize communi-cation about pain management in-stead of the treatment of pain itself.10 A slight majority of FPs believed it is unlikely that pain management ques-tions will be removed from nearly all patient satisfaction surveys used by health systems (Figure 3, item 6).

The opioid epidemic has high-lighted the association of opioid pre-scribing with overdose deaths. Opioid prescriptions plateaued in 2014–15, with declines in subsequent years. Is the number of opioid prescriptions an appropriate indicator for optimal pain management? Many clinicians and patients fear that our efforts to reduce opioid prescribing will have unintend-ed consequences, such as restricting access to patients who legitimately need access to opioid analgesics. The concern that the pendulum does not swing too far back is apt.


References1. Dowell D, Arias E, Kochanek K et

al. Contribution of opioid-involved poisoning to the change in life expec-tancy in the United States, 2000–2015. JAMA. 2017; 318:1065-7.

2. Katzman JG, Comerci G Jr, Boyle JF et al. Innovative telementoring for pain management: project ECHO pain. J Contin Educ Health Prof. 2014; 34(1):68-75.

3. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opi-oids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016; 65:1-49.

4. Brooklyn JR, Sigmon SC. Ver-mont hub-and-spoke model of care for opioid use disorder: development, implementation, and impact. J Addict Med. 2017; 11:286-92.

5. SAMHSA-HRSA Center for Integrated Health Solutions. SBIRT: screening, brief intervention, and referral to treatment. www.integration.samhsa.gov/clinical-practice/sbirt (accessed 2018 Sep 25).

6. Herzig SJ, Calcaterra SL, Mosher HJ et al. Safe opioid prescribing for

acute noncancer pain in hospital-ized adults: a systematic review of existing guidelines. J Hosp Med. 2018; 13:256-62.

7. Manchikanti L, Kaye AM, Knezevic NN et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physi-cians (ASIPP) guidelines. Pain Physi-cian. 2017; 20:S3-92.

8. Meghani SH, Vapiwala N. Bridging the critical divide in pain management guidelines from the CDC, NCCN, and ASCO for cancer survivors. JAMA Oncol. Epub ahead of print (DOI 10.1001/jamaoncol.2018.1574).

9. Terfera L, Lehrman WG, Conway P. Measurement of the patient experi-ence. Clarifying facts, myths and approaches. JAMA. 2016; 315:2167-8.

10. Thompson CA. HCAHPS survey to measure pain communication, not management. Am J Health-Syst Pharm. 2017; 74:1924-6.


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PHARMACY FORECAST 2019ETHICAL ISSUES



Ethical Issues: Conflicting Imperatives and Erosion of Behavioral Norms

William A. Zellmer, B.S.Pharm., M.P.H., FFIP, President, Pharmacy Foresight Consulting, Bethesda, MD.

Amanda Hine, Ph.D., Assistant Professor, Rueckert-Hartman College of Health Professions, Regis University, Denver, CO.

Address correspondence to Mr. Zellmer ([email protected]).


Pharmacy Forecast 2019 survey items on ethical topics touch on

several profound social issues that have the potential to enmesh health-system pharmacy. These issues in-clude tensions between respect for patient autonomy and honoring sci-entific evidence, conflicts between economic imperatives and profes-sional obligations, expansive and secret uses of big data, and the flout-ing of ethical standards by leaders in business and government.

RIGHT TO TRY

Nearly 70% of Forecast Panel-ists (FPs) said it is at least somewhat likely that a large majority of health systems over the next 5 years will have an explicit policy on how to respond to patient demand for diagnostic proce-dures or therapies that lack evidence of safety or effectiveness or both (Fig-ure 4, item 1). This issue has risen in prominence after federal approval of right-to-try legislation in May 2018.1

The new law might cause an upsurge in requests from patients with life-threatening conditions to use unprov-en therapies. However, it is uncertain if this law offers advantages over the Food and Drug Administration’s well-

established process for expanded ac-cess to investigational drugs.1

The right to try—which brings to mind the Laetrile craze of the 1970s and the advocacy of heroin for intrac-table pain in the 1980s2—has political and ethical implications related to freedom of choice, freedom of speech, the reach of government, patient au-tonomy, and scientific truth. Health-system policymakers are likely to be guided on this matter by their respect for objective evidence. Pharmacists might be challenged at times to justify evidence-based institutional policies to patients who are pursuing a last-ditch cure.

HARVESTING PATIENT DATA

Survey results are suggestive of both potential benefits and potential risks associated with the use of per-sonal nonhealth data in healthcare (Figure 4, items 2 and 3). Sources of such data include social media, Web searches, fitness trackers, commer-cial genetic testing, and consumer purchases. Six out of 10 FPs predicted that a small number of health systems will access such data for the purpose of improving care and outcomes. The Health Insurance Portability and Ac-countability Act protects only medical information. A majority of FPs pre-dicted that insurers will use nonhealth data in making individual coverage decisions (e.g., premiums, deduct-ibles, copays, scope of benefits), a practice that already occurs.3

There is a connection here with the news about foreign influence on U.S. elections through covert access to information on millions of citizens and their networks of contacts on so-cial media.4 This perversity was part of the “surveillance capitalism” business model of social media.5

The central ethical issue in all of this relates to a person’s right to pri-vacy and the need for individuals to grant their consent for others to ac-cess information about their personal activities. Health systems and insurers that consider using individuals’ non-health data should obtain their con-sent, using clear language on how the data will be used.

CONFLICTS OF INTEREST

Two types of financial conflicts of interest underpin 2 survey items (Figure 4, items 4 and 5)—one related to individuals and the other to institu-tions. The genesis of item 4 relates to the highly publicized ethical lapses of some business and governmental leaders: If they can engage, with im-punity, in behavior that is contrary to well-established norms for avoiding conflicts of interest, can we anticipate a similar downward spiral in other areas of society? At least with respect to the rules for pharmacy and thera-peutics committees, a large majority (83%) of FPs believed that this is not likely to happen.

In item 5, FPs predicted that a small number of health systems will adopt policies that prohibit “revenue enhancement” as the primary consid-eration in selecting among alternative treatments. That some health systems might feel compelled to express such a policy reflects tension between in-stitutional financial well-being and patients’ best interests.

Over recent decades, health pro-fessional societies, healthcare insti-tutions, and regulatory bodies have greatly enhanced protections against unethical behavior caused by conflicts of interest in patient care. Pharmacists should be vigilant in guarding these protections.

PHARMACY FORECAST 2019 ETHICAL ISSUES



Figure 4 (Ethics). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 At least 75% of health systems will have an explicit policy that addresses patient demand for diagnostic procedures or therapies that lack evidence of safety and/or effectiveness (including unapproved medications covered under “right-to-try” regulations).

0%

20%

40%

60%

80%

21%

48%

25%

6%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 In at least 10% of health systems, physicians, pharmacists, and other health professionals will be engaged in jointly addressing challenges to professional autonomy that stem from consolidation of healthcare providers, payer requirements, and other factors.

0%

20%

40%

60%

80%

34%

51%

13%2%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 At least 10% of health systems will analyze patient’s personal non-health data (e.g., activity on social media, fitness trackers, consumer purchases) for the purpose of improving care and outcomes.

0%

20%

40%

60%

80%

19%

41%

29%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 Insurers will reduce coverage or increase out-of-pocket expense for at least 25% of patients based on patient’s personal non-health data (e.g., activity on social media, fitness trackers, consumer purchases) that suggest behaviors that compromise health status.

0%

20%

40%

60%

80%

10%

45%

34%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 At least 10% of health systems will soften their conflict-of-interest rules for members of their pharmacy and therapeutics committee, making their requirements less restrictive.

0%

20%

40%

60%

80%

2%

15%

46%

37%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 10% of health systems will have a policy that prohibits practitioners from choosing among alternative treatments based primarily on the basis of maximizing revenue.

0%

20%

40%

60%

80%

13%

44%

34%

10%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2019


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Ethical Issues: Conflicting Imperatives and Erosion of Behavioral Norms

William A. Zellmer, B.S.Pharm., M.P.H., FFIP, President, Pharmacy Foresight Consulting, Bethesda, MD.

Amanda Hine, Ph.D., Assistant Professor, Rueckert-Hartman College of Health Professions, Regis University, Denver, CO.

Address correspondence to Mr. Zellmer ([email protected]).


Pharmacy Forecast 2019 survey items on ethical topics touch on

several profound social issues that have the potential to enmesh health-system pharmacy. These issues in-clude tensions between respect for patient autonomy and honoring sci-entific evidence, conflicts between economic imperatives and profes-sional obligations, expansive and secret uses of big data, and the flout-ing of ethical standards by leaders in business and government.

RIGHT TO TRY

Nearly 70% of Forecast Panel-ists (FPs) said it is at least somewhat likely that a large majority of health systems over the next 5 years will have an explicit policy on how to respond to patient demand for diagnostic proce-dures or therapies that lack evidence of safety or effectiveness or both (Fig-ure 4, item 1). This issue has risen in prominence after federal approval of right-to-try legislation in May 2018.1

The new law might cause an upsurge in requests from patients with life-threatening conditions to use unprov-en therapies. However, it is uncertain if this law offers advantages over the Food and Drug Administration’s well-

established process for expanded ac-cess to investigational drugs.1

The right to try—which brings to mind the Laetrile craze of the 1970s and the advocacy of heroin for intrac-table pain in the 1980s2—has political and ethical implications related to freedom of choice, freedom of speech, the reach of government, patient au-tonomy, and scientific truth. Health-system policymakers are likely to be guided on this matter by their respect for objective evidence. Pharmacists might be challenged at times to justify evidence-based institutional policies to patients who are pursuing a last-ditch cure.

HARVESTING PATIENT DATA

Survey results are suggestive of both potential benefits and potential risks associated with the use of per-sonal nonhealth data in healthcare (Figure 4, items 2 and 3). Sources of such data include social media, Web searches, fitness trackers, commer-cial genetic testing, and consumer purchases. Six out of 10 FPs predicted that a small number of health systems will access such data for the purpose of improving care and outcomes. The Health Insurance Portability and Ac-countability Act protects only medical information. A majority of FPs pre-dicted that insurers will use nonhealth data in making individual coverage decisions (e.g., premiums, deduct-ibles, copays, scope of benefits), a practice that already occurs.3

There is a connection here with the news about foreign influence on U.S. elections through covert access to information on millions of citizens and their networks of contacts on so-cial media.4 This perversity was part of the “surveillance capitalism” business model of social media.5

The central ethical issue in all of this relates to a person’s right to pri-vacy and the need for individuals to grant their consent for others to ac-cess information about their personal activities. Health systems and insurers that consider using individuals’ non-health data should obtain their con-sent, using clear language on how the data will be used.

CONFLICTS OF INTEREST

Two types of financial conflicts of interest underpin 2 survey items (Figure 4, items 4 and 5)—one related to individuals and the other to institu-tions. The genesis of item 4 relates to the highly publicized ethical lapses of some business and governmental leaders: If they can engage, with im-punity, in behavior that is contrary to well-established norms for avoiding conflicts of interest, can we anticipate a similar downward spiral in other areas of society? At least with respect to the rules for pharmacy and thera-peutics committees, a large majority (83%) of FPs believed that this is not likely to happen.

In item 5, FPs predicted that a small number of health systems will adopt policies that prohibit “revenue enhancement” as the primary consid-eration in selecting among alternative treatments. That some health systems might feel compelled to express such a policy reflects tension between in-stitutional financial well-being and patients’ best interests.

Over recent decades, health pro-fessional societies, healthcare insti-tutions, and regulatory bodies have greatly enhanced protections against unethical behavior caused by conflicts of interest in patient care. Pharmacists should be vigilant in guarding these protections.

PHARMACY FORECAST 2019 ETHICAL ISSUES



Figure 4 (Ethics). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 At least 75% of health systems will have an explicit policy that addresses patient demand for diagnostic procedures or therapies that lack evidence of safety and/or effectiveness (including unapproved medications covered under “right-to-try” regulations).

0%

20%

40%

60%

80%

21%

48%

25%

6%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 In at least 10% of health systems, physicians, pharmacists, and other health professionals will be engaged in jointly addressing challenges to professional autonomy that stem from consolidation of healthcare providers, payer requirements, and other factors.

0%

20%

40%

60%

80%

34%

51%

13%2%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 At least 10% of health systems will analyze patient’s personal non-health data (e.g., activity on social media, fitness trackers, consumer purchases) for the purpose of improving care and outcomes.

0%

20%

40%

60%

80%

19%

41%

29%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 Insurers will reduce coverage or increase out-of-pocket expense for at least 25% of patients based on patient’s personal non-health data (e.g., activity on social media, fitness trackers, consumer purchases) that suggest behaviors that compromise health status.

0%

20%

40%

60%

80%

10%

45%

34%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 At least 10% of health systems will soften their conflict-of-interest rules for members of their pharmacy and therapeutics committee, making their requirements less restrictive.

0%

20%

40%

60%

80%

2%

15%

46%

37%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 10% of health systems will have a policy that prohibits practitioners from choosing among alternative treatments based primarily on the basis of maximizing revenue.

0%

20%

40%

60%

80%

13%

44%

34%

10%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely


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1. Ensure that your pharmacy enterprise is represented by a permanent member on the hospital’s or health system’s ethics committee.

2. Assist your institution in pre-paring for a potential increase in patient requests for treat-ments that lack evidence of safety or effectiveness or both. Train frontline practitioners how to respond when con-fronted with patient requests that conflict sharply with scientific evidence.

3. Always ensure that “good intentions” for use of patient data are met with a firm com-mitment to transparency and patient consent.

4. Resist any effort to dilute policies related to avoiding conflicts of interest in commit-tee activities and patient care.

5. Build support in your in-stitution for regular cross-disciplinary discussions of ethical challenges in patient care and the weakening of professional autonomy.

COMMUNITY OF INTEREST

As pharmacists continue to expand their patient care roles, they will face a wider array of ethical issues. Lead-ers in pharmacy practice should look for opportunities to engage with other health professionals who are seeking to enhance their ability to wrestle with moral conflicts and ethical dilemmas.

Notably, nursing has been quite active in offering guidance on pro-fessional ethics.6 Pharmacy would do well to link with such initiatives, which would be consistent with a prediction of FPs related to jointly addressing, at the local level, challenges to profes-sional autonomy (Figure 4, item 6). Shoring up clinicians’ sense of au-tonomy is a facet of a major program of the National Academy of Medicine focused on enhancing resilience and preventing burnout7; ASHP is a spon-sor of this effort.

Timothy Snyder,8 the author of a popular book attuned to current so-cial trends in the United States, points out that fidelity to ethical standards has an importance that transcends the immediate work of professional persons:

Professions can create forms of ethi-cal conversation that are impossible between a lonely individual and a dis-tant government. If members of pro-fessions think of themselves as groups with common interests, with norms and rules that oblige them at all times, then they can gain confidence and in-deed a certain kind of power. Profes-sional ethics must guide us precisely when we are told that the situation is exceptional.

DisclosuresMr. Zellmer is a contributing editor for AJHP. The authors have declared no other potential conflicts of interest.

References1. Traynor K. Federal right-to-try law

aims to broaden access to investiga-tional drugs. Am J Health-Syst Pharm. 2018; 75:1085-6.

2. Richert L. “Right to try” (again): a history of the experimental therapy movement (April 16, 2018). www.baas.ac.uk/usso/right-to-try-again-a-history-of-the-experimental-therapy-movement/ (accessed 2018 Jul 18).

3. Allen M. Health insurers are vacu-uming up details about you—and it could raise your rates (July 17, 2018). www.npr.org/sections/health-shots/2018/07/17/629441555/health-insurers-are-vacuuming-up-details-about-you-and-it-could-raise-your-rates (accessed 2018 Jul 24).

4. Koopman C. The stone: how democracy can survive big data (March 22, 2018). https://nyti.ms/2Gaq2On (accessed 2018 Mar 22).

5. Radio Open Source. Facebook and the reign of surveillance capitalism (April 12, 2018). http://radioopen-source.org/facebook-the-reign-of-

surveillance-capitalism/ (accessed 2018 Apr 13).

6. Johns Hopkins Berman Institute of Bioethics. A blueprint for 21st century nursing ethics—report of the National Nursing Summit. www.bioethicsinstitute.org/nursing-ethics-summit-report?doing_wp_cron=1531962783.1886880397796630859375 (accessed 2018 Jul 18).

7. National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience. Organizational leadership, culture, and policies can play a significant role in burnout and well-being. https://nam.edu/clinicianwellbeing/causes/organizational-factors/ (accessed 2018 Jul 24).

8. Snyder T. On tyranny—twenty lessons from the twentieth century. New York: Penguin Random House; 2017.

PHARMACY FORECAST 2019 TECHNOLOGY INNOVATIONS



Technology Innovations and Involvement by Pharmacy Leaders

Sylvia Belford, Pharm.D., M.S., CPHIMS, FASHP, Operations Administrator, Department of Administration, Mayo Clinic, Rochester, MN.

Steve G. Peters, M.D., Vice Chief Medical Information Officer, Professor of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN.

Address correspondence to Dr. Belford ([email protected]).


Interactions among patients, phar-macists, and other healthcare pro-

viders increasingly have become mediated by technology, resulting in a growing multidimensional and sociotechnical system.1 The entire health system benefits from strong informatics teams, especially phar-macy informaticists and the tech-nology they support.2 During this information age, secure application programming interfaces and other technologies allow abundant shar-ing of clinical and medication data. Patient-centered applications and the “internet of things” offer un-precedented opportunities for re-mote monitoring, clinical advisories, and intervention. In this landscape the pharmacy informatics team, in partnership with other areas of the healthcare organization, must play a leadership role. Opportunities are increasing for pharmacy leaders to be engaged in these initiatives and to provide pharmacy informatics re-sources to assist with strategic vision and execution within health systems.

ENGAGE PHARMACY INFORMATICISTS IN STRATEGIC DECISIONS

Pharmacists with knowledge and

skills in informatics are key contribu-tors to the creation or purchase of reli-able technologies to assist with clini-cal decision-making.2 Automation of manual tasks is certain to be a factor: 63% of the Forecast Panelists (FPs) in-dicated opportunities in this activity, agreeing it is likely that artificial tech-nologies will reduce pharmacist time on routine clinical tasks (Figure 5, item 1). The extent that technologies could further replace pharmacists’ opera-tional or clinical activities remains to be seen; sophisticated algorithms are being developed through the use of machine learning.3 These algorithms are parts of clinical decision-support systems that rely on pharmacists’ knowledge, and 76% of FPs agreed that the pharmacy department likely will have primary responsibility for evaluating and supporting clinical decision-support systems (Figure 5, item 2). Pharmacy leaders must achieve ASHP’s Pharmacy Advance-ment Initiative recommendation that “sufficient pharmacy resources must be available to safely develop, imple-ment, and maintain technology-related medication-use safety stan-dards.”4 This includes not only the development and assessment of new technologies, but also participation in the creation of machine-learning algorithms.

Health-system pharmacy lead-ers typically focus on the 2 areas of clinical pharmacy and pharmacy operations. A third pillar must be pharmacy informatics, separate from operations and used to strategically support initiatives across the organ-ization. Each organization benefits from a strategic and knowledgeable leader and pharmacy informaticists who work across the spectrum of care to lead the redesign of technology and systems supporting all areas of medication management.2

Informatics contributes to strate-gic planning to ensure the initiatives, resources, and timelines align for de-livering solutions to support the or-ganization. In the absence of proac-tive involvement, external regulations may dominate design. For example, end user satisfaction is a common measure of an electronic health rec-ord (EHR). FPs had a split response for the question regarding regulatory in-volvement, with 58% indicating that it is likely to occur based on low end user satisfaction (Figure 5, item 3). Regula-tory involvement will more likely be based on targeted patient outcome measures and the degree of data inte-gration and sharing.

PROMOTE INTEGRATION OF HEALTH INFORMATION

There are few technical limitations to information sharing in a manner compliant with the Health Insurance Portability and Accountability Act or other regulations. As a result, it is perhaps surprising or discouraging that only 62% of FPs responded that access to patient laboratory data or other information will no longer be limited to an organization’s providers and will be available to community pharmacists (Figure 5, item 4). Further uncertainty is reflected in responses regarding prescription drug monitor-ing programs: 79% of FPs anticipated growth in information sharing beyond current prescription drug monitoring programs to additional therapeutic areas, recognizing that only 53% of FPs indicated that these are timely, accurate, or accessible (Figure 5, item 5). The limitations to sharing these data are not technical; with vision and management the barriers can be overcome. One key to success is data standardization and stewardship. For example, for genetic data to be acces-sible for pharmacogenomics analysis,


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1. Ensure that your pharmacy enterprise is represented by a permanent member on the hospital’s or health system’s ethics committee.

2. Assist your institution in pre-paring for a potential increase in patient requests for treat-ments that lack evidence of safety or effectiveness or both. Train frontline practitioners how to respond when con-fronted with patient requests that conflict sharply with scientific evidence.

3. Always ensure that “good intentions” for use of patient data are met with a firm com-mitment to transparency and patient consent.

4. Resist any effort to dilute policies related to avoiding conflicts of interest in commit-tee activities and patient care.

5. Build support in your in-stitution for regular cross-disciplinary discussions of ethical challenges in patient care and the weakening of professional autonomy.

COMMUNITY OF INTEREST

As pharmacists continue to expand their patient care roles, they will face a wider array of ethical issues. Lead-ers in pharmacy practice should look for opportunities to engage with other health professionals who are seeking to enhance their ability to wrestle with moral conflicts and ethical dilemmas.

Notably, nursing has been quite active in offering guidance on pro-fessional ethics.6 Pharmacy would do well to link with such initiatives, which would be consistent with a prediction of FPs related to jointly addressing, at the local level, challenges to profes-sional autonomy (Figure 4, item 6). Shoring up clinicians’ sense of au-tonomy is a facet of a major program of the National Academy of Medicine focused on enhancing resilience and preventing burnout7; ASHP is a spon-sor of this effort.

Timothy Snyder,8 the author of a popular book attuned to current so-cial trends in the United States, points out that fidelity to ethical standards has an importance that transcends the immediate work of professional persons:

Professions can create forms of ethi-cal conversation that are impossible between a lonely individual and a dis-tant government. If members of pro-fessions think of themselves as groups with common interests, with norms and rules that oblige them at all times, then they can gain confidence and in-deed a certain kind of power. Profes-sional ethics must guide us precisely when we are told that the situation is exceptional.

DisclosuresMr. Zellmer is a contributing editor for AJHP. The authors have declared no other potential conflicts of interest.

References1. Traynor K. Federal right-to-try law

aims to broaden access to investiga-tional drugs. Am J Health-Syst Pharm. 2018; 75:1085-6.

2. Richert L. “Right to try” (again): a history of the experimental therapy movement (April 16, 2018). www.baas.ac.uk/usso/right-to-try-again-a-history-of-the-experimental-therapy-movement/ (accessed 2018 Jul 18).

3. Allen M. Health insurers are vacu-uming up details about you—and it could raise your rates (July 17, 2018). www.npr.org/sections/health-shots/2018/07/17/629441555/health-insurers-are-vacuuming-up-details-about-you-and-it-could-raise-your-rates (accessed 2018 Jul 24).

4. Koopman C. The stone: how democracy can survive big data (March 22, 2018). https://nyti.ms/2Gaq2On (accessed 2018 Mar 22).

5. Radio Open Source. Facebook and the reign of surveillance capitalism (April 12, 2018). http://radioopen-source.org/facebook-the-reign-of-

surveillance-capitalism/ (accessed 2018 Apr 13).

6. Johns Hopkins Berman Institute of Bioethics. A blueprint for 21st century nursing ethics—report of the National Nursing Summit. www.bioethicsinstitute.org/nursing-ethics-summit-report?doing_wp_cron=1531962783.1886880397796630859375 (accessed 2018 Jul 18).

7. National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience. Organizational leadership, culture, and policies can play a significant role in burnout and well-being. https://nam.edu/clinicianwellbeing/causes/organizational-factors/ (accessed 2018 Jul 24).

8. Snyder T. On tyranny—twenty lessons from the twentieth century. New York: Penguin Random House; 2017.




Technology Innovations and Involvement by Pharmacy Leaders

Sylvia Belford, Pharm.D., M.S., CPHIMS, FASHP, Operations Administrator, Department of Administration, Mayo Clinic, Rochester, MN.

Steve G. Peters, M.D., Vice Chief Medical Information Officer, Professor of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN.

Address correspondence to Dr. Belford ([email protected]).


Interactions among patients, phar-macists, and other healthcare pro-

viders increasingly have become mediated by technology, resulting in a growing multidimensional and sociotechnical system.1 The entire health system benefits from strong informatics teams, especially phar-macy informaticists and the tech-nology they support.2 During this information age, secure application programming interfaces and other technologies allow abundant shar-ing of clinical and medication data. Patient-centered applications and the “internet of things” offer un-precedented opportunities for re-mote monitoring, clinical advisories, and intervention. In this landscape the pharmacy informatics team, in partnership with other areas of the healthcare organization, must play a leadership role. Opportunities are increasing for pharmacy leaders to be engaged in these initiatives and to provide pharmacy informatics re-sources to assist with strategic vision and execution within health systems.

ENGAGE PHARMACY INFORMATICISTS IN STRATEGIC DECISIONS

Pharmacists with knowledge and

skills in informatics are key contribu-tors to the creation or purchase of reli-able technologies to assist with clini-cal decision-making.2 Automation of manual tasks is certain to be a factor: 63% of the Forecast Panelists (FPs) in-dicated opportunities in this activity, agreeing it is likely that artificial tech-nologies will reduce pharmacist time on routine clinical tasks (Figure 5, item 1). The extent that technologies could further replace pharmacists’ opera-tional or clinical activities remains to be seen; sophisticated algorithms are being developed through the use of machine learning.3 These algorithms are parts of clinical decision-support systems that rely on pharmacists’ knowledge, and 76% of FPs agreed that the pharmacy department likely will have primary responsibility for evaluating and supporting clinical decision-support systems (Figure 5, item 2). Pharmacy leaders must achieve ASHP’s Pharmacy Advance-ment Initiative recommendation that “sufficient pharmacy resources must be available to safely develop, imple-ment, and maintain technology-related medication-use safety stan-dards.”4 This includes not only the development and assessment of new technologies, but also participation in the creation of machine-learning algorithms.

Health-system pharmacy lead-ers typically focus on the 2 areas of clinical pharmacy and pharmacy operations. A third pillar must be pharmacy informatics, separate from operations and used to strategically support initiatives across the organ-ization. Each organization benefits from a strategic and knowledgeable leader and pharmacy informaticists who work across the spectrum of care to lead the redesign of technology and systems supporting all areas of medication management.2

Informatics contributes to strate-gic planning to ensure the initiatives, resources, and timelines align for de-livering solutions to support the or-ganization. In the absence of proac-tive involvement, external regulations may dominate design. For example, end user satisfaction is a common measure of an electronic health rec-ord (EHR). FPs had a split response for the question regarding regulatory in-volvement, with 58% indicating that it is likely to occur based on low end user satisfaction (Figure 5, item 3). Regula-tory involvement will more likely be based on targeted patient outcome measures and the degree of data inte-gration and sharing.

PROMOTE INTEGRATION OF HEALTH INFORMATION

There are few technical limitations to information sharing in a manner compliant with the Health Insurance Portability and Accountability Act or other regulations. As a result, it is perhaps surprising or discouraging that only 62% of FPs responded that access to patient laboratory data or other information will no longer be limited to an organization’s providers and will be available to community pharmacists (Figure 5, item 4). Further uncertainty is reflected in responses regarding prescription drug monitor-ing programs: 79% of FPs anticipated growth in information sharing beyond current prescription drug monitoring programs to additional therapeutic areas, recognizing that only 53% of FPs indicated that these are timely, accurate, or accessible (Figure 5, item 5). The limitations to sharing these data are not technical; with vision and management the barriers can be overcome. One key to success is data standardization and stewardship. For example, for genetic data to be acces-sible for pharmacogenomics analysis,

2019


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PHARMACY FORECAST 2019TECHNOLOGY INNOVATIONS



Figure 5 (Technology). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

4 At least 25% of health systems will give community pharmacists outside their organization access to their patient information (including results of laboratory tests and clinical notes) from their EHRs to enable those pharmacists to perform patient care services.

0%

20%

40%

60%

80%

25%

37%

25%

13%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

1 Artificial intelligence (i.e., the use of computers to make decisions that would otherwise require human perception and judgment) will reduce the time pharmacists spend on routine clinical tasks such as drug selection and dosing by 25%.

0%

20%

40%

60%

80%

20%

43%

31%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 The pharmacy department in at least 25% of health systems will have primary responsibility for the evaluation and deployment of computerized clinical decision-support systems such as predictive models and prescribing algorithms. {Note: For an example of a “predictive model” see Jeon et al., Am J Health-Syst Pharm. 2017; 74:1865-77.}

0%

20%

40%

60%

80%

27%

49%

20%

4%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 End-user dissatisfaction related to the current capabilities of EHRs will lead to significant regulatory intervention (e.g., a new “Meaningful Use” program) that requires EHR vendors to make specific improvements in their systems.

0%

20%

40%

60%

80%

10%

48%

34%

8%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 In at least 50% of health systems, pharmacists will be responsible for evaluating and recommending digiceutical apps (FDA-approved apps that collect patient data and provide treatment guidance) as acceptable therapy (i.e., as an “app formulary”).

0%

20%

40%

60%

80%

9%

39% 39%

14%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 25% of health systems will participate in medication prescription data-sharing projects intended to expand the scope of Prescription Drug Monitoring Programs beyond controlled substance prescribing.

0%

20%

40%

60%

80%

28%

51%

17%

4%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely





1. Resource and develop a robust pharmacy informatics team with leadership at the highest level of the pharmacy or other accountable organizational department. Ensure that phar-macists, analysts, and data sci-entists work together to deliver electronic support for clinical algorithms, decision support, and surveillance systems.

2. Create, utilize, and maintain a single, reliable source of medication data and therapy information in your organi-zation. Streamline the flow of information from the sup-ply chain to the medications prescribed or dispensed and exchange information across all care settings.

3. Engage in the design and im-plementation of the health

information record to align laboratory results, including precision medicine testing, with drug therapy recommen-dations. Remove barriers to the legitimate sharing of data with the patient care team, across all transitions and organiza-tions, as allowed and expected by regulations.

4. Create new service offerings for pharmacists to engage with patients in their medication therapy management ac-tivities by leveraging available technology, particularly in areas such as specialty phar-macy (including digiceutical evaluations), population health management, care planning, and communication through the patient portals.

the data need to be stored in a stan-dard manner and paired with medica-tions to allow clinical decision support across technologies.5 Many EHR ven-dors and third parties are working to provide this service. Pharmacy lead-ers can have a major influence on the decisions that health systems make regarding these technologies.

INCREASE ENGAGEMENT WITH PATIENTS

Smartphones have changed the world by leveraging the flexibility and appeal of personal technologies. For healthcare providers, patient engage-ment is primarily encouraged via pa-tient portals. But personal apps, phys-iological monitoring, and feedback loops will revolutionize patient em-powerment and engagement.6 Phar-macy leadership should capitalize on these opportunities. This growing area of digital therapeutics is called “digi-ceutical” care, and oversight is needed to ensure quality information is avail-able for patients and providers to manage their care. The FPs were less supportive of the pharmacist’s role in the evaluation and recommendation of these applications, since only 48% agreed to the likelihood that pharma-cists will be involved (Figure 5, item 6). It is possible that the FPs were not familiar with this term and topic, but this is an area to monitor, since it is expected to grow with the usability of the applications and the integration with other databases and decision-support systems. The recent introduc-tion of Abilify MyCite is an example of that opportunity for pharmacists.7


References1. Sittig DF, Singh HA. New sociotech-

nical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care. 2010; 19:i68-74.

2. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in clinical informat-ics. Am J Health-Syst Pharm. 2016; 73:410-3.

3. Beam AL, Kohane IS. Big data and machine learning in health care. JAMA. 2018; 319:1317-8.

4. American Society of Health-System Pharmacists. The consensus of the Pharmacy Practice Model Sum-mit. Am J Health-Syst Pharm. 2011; 68:1148-52.

5. Sittig DF, Belmont E, Singh H. Im-proving the safety of health infor-mation technology requires shared responsibility: it is time we all step up. Healthcare. 2018; 6(1):7-12.

6. The Economist. A new sort of health app can do the job of drugs. www.economist.com/business/2018/02/01/a-new-sort-of-health-app-can-do-the-job-of-drugs (accessed 2018 Jul 27).

7. Rosenthal M. First ‘digiceutical’ OK’d; opens door for pharmacists. www.pharmacypracticenews.com/Clinical/Article/12-17/1st-‘Digiceutical’-OK’d-Opens-Door-For-Pharmacists/46403 (accessed 2018 Jul 27).


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PHARMACY FORECAST 2019TECHNOLOGY INNOVATIONS



Figure 5 (Technology). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

4 At least 25% of health systems will give community pharmacists outside their organization access to their patient information (including results of laboratory tests and clinical notes) from their EHRs to enable those pharmacists to perform patient care services.

0%

20%

40%

60%

80%

25%

37%

25%

13%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

1 Artificial intelligence (i.e., the use of computers to make decisions that would otherwise require human perception and judgment) will reduce the time pharmacists spend on routine clinical tasks such as drug selection and dosing by 25%.

0%

20%

40%

60%

80%

20%

43%

31%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 The pharmacy department in at least 25% of health systems will have primary responsibility for the evaluation and deployment of computerized clinical decision-support systems such as predictive models and prescribing algorithms. {Note: For an example of a “predictive model” see Jeon et al., Am J Health-Syst Pharm. 2017; 74:1865-77.}

0%

20%

40%

60%

80%

27%

49%

20%

4%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 End-user dissatisfaction related to the current capabilities of EHRs will lead to significant regulatory intervention (e.g., a new “Meaningful Use” program) that requires EHR vendors to make specific improvements in their systems.

0%

20%

40%

60%

80%

10%

48%

34%

8%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 In at least 50% of health systems, pharmacists will be responsible for evaluating and recommending digiceutical apps (FDA-approved apps that collect patient data and provide treatment guidance) as acceptable therapy (i.e., as an “app formulary”).

0%

20%

40%

60%

80%

9%

39% 39%

14%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 25% of health systems will participate in medication prescription data-sharing projects intended to expand the scope of Prescription Drug Monitoring Programs beyond controlled substance prescribing.

0%

20%

40%

60%

80%

28%

51%

17%

4%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely





1. Resource and develop a robust pharmacy informatics team with leadership at the highest level of the pharmacy or other accountable organizational department. Ensure that phar-macists, analysts, and data sci-entists work together to deliver electronic support for clinical algorithms, decision support, and surveillance systems.

2. Create, utilize, and maintain a single, reliable source of medication data and therapy information in your organi-zation. Streamline the flow of information from the sup-ply chain to the medications prescribed or dispensed and exchange information across all care settings.

3. Engage in the design and im-plementation of the health

information record to align laboratory results, including precision medicine testing, with drug therapy recommen-dations. Remove barriers to the legitimate sharing of data with the patient care team, across all transitions and organiza-tions, as allowed and expected by regulations.

4. Create new service offerings for pharmacists to engage with patients in their medication therapy management ac-tivities by leveraging available technology, particularly in areas such as specialty phar-macy (including digiceutical evaluations), population health management, care planning, and communication through the patient portals.

the data need to be stored in a stan-dard manner and paired with medica-tions to allow clinical decision support across technologies.5 Many EHR ven-dors and third parties are working to provide this service. Pharmacy lead-ers can have a major influence on the decisions that health systems make regarding these technologies.

INCREASE ENGAGEMENT WITH PATIENTS

Smartphones have changed the world by leveraging the flexibility and appeal of personal technologies. For healthcare providers, patient engage-ment is primarily encouraged via pa-tient portals. But personal apps, phys-iological monitoring, and feedback loops will revolutionize patient em-powerment and engagement.6 Phar-macy leadership should capitalize on these opportunities. This growing area of digital therapeutics is called “digi-ceutical” care, and oversight is needed to ensure quality information is avail-able for patients and providers to manage their care. The FPs were less supportive of the pharmacist’s role in the evaluation and recommendation of these applications, since only 48% agreed to the likelihood that pharma-cists will be involved (Figure 5, item 6). It is possible that the FPs were not familiar with this term and topic, but this is an area to monitor, since it is expected to grow with the usability of the applications and the integration with other databases and decision-support systems. The recent introduc-tion of Abilify MyCite is an example of that opportunity for pharmacists.7


References1. Sittig DF, Singh HA. New sociotech-

nical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care. 2010; 19:i68-74.

2. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in clinical informat-ics. Am J Health-Syst Pharm. 2016; 73:410-3.

3. Beam AL, Kohane IS. Big data and machine learning in health care. JAMA. 2018; 319:1317-8.

4. American Society of Health-System Pharmacists. The consensus of the Pharmacy Practice Model Sum-mit. Am J Health-Syst Pharm. 2011; 68:1148-52.

5. Sittig DF, Belmont E, Singh H. Im-proving the safety of health infor-mation technology requires shared responsibility: it is time we all step up. Healthcare. 2018; 6(1):7-12.

6. The Economist. A new sort of health app can do the job of drugs. www.economist.com/business/2018/02/01/a-new-sort-of-health-app-can-do-the-job-of-drugs (accessed 2018 Jul 27).

7. Rosenthal M. First ‘digiceutical’ OK’d; opens door for pharmacists. www.pharmacypracticenews.com/Clinical/Article/12-17/1st-‘Digiceutical’-OK’d-Opens-Door-For-Pharmacists/46403 (accessed 2018 Jul 27).


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PHARMACY FORECAST 2019EMPOWERING PATIENTS



Empowering Patients to Optimize Medication Use

James M. Hoffman, Pharm.D., M.S., BCPS, FASHP, Chief Patient Safety Officer, Office of Quality and Patient Care, and Associate Member, Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN.

William E. Schwab, M.D., Professor and Vice Chair of Education, Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI.

Address correspondence to Dr. Hoffman ([email protected]).


The importance of customizing pa-tient care to patient needs and val-

ues has been well recognized as an es-sential component of quality patient care.1 Health systems are investing in various tools and structures to engage and empower patients and families in their care. These efforts can take a range of forms. Models are emerging where patients and families (broadly defined) are true partners in code-signing care processes and their spe-cific plans of care. However, there is substantial variation in the use of best practices for patient and family en-gagement.2 In some scenarios, patient engagement may amount to empty platitudes. Patients and families are essential allies to improve quality and patient safety, and pharmacists are uniquely positioned to facilitate genu-ine patient engagement to optimize medication use.

STRUCTURES FOR PATIENT ENGAGEMENT

Patient and family advisory coun-cils (PFACs) are a fundamental struc-ture that facilitates the inclusion of patient perspectives on a range of is-sues for a health system, such as staff-

ing, policies, communications, facili-ties, and governance. PFACs can serve as an avenue for patients and families to become more deeply involved in specific committees and projects. The presence of a PFAC has been as-sociated with better performance on quality measures and Hospital Consumer Assessment of Healthcare Providers and Systems scores when compared with hospitals without a PFAC.3 In 1 national survey, 38% of hospitals reported having a PFAC.2 In a more recent survey of New York state hospitals by the Institute for Pa-tient and Family Centered Care, 59% of hospitals in New York had a PFAC, but only 29% of hospitals had a high-functioning PFAC.3

A robust PFAC will often lead to pa-tient and family involvement on ini-tiatives and committees throughout the organization. With 44% of Forecast Panelists (FPs) responding that it was very or somewhat likely that at least 50% of health-system pharmacy and therapeutics committees would in-clude a patient or caregiver as a mem-ber (Figure 6, item 1), FPs were roughly split on the prospect of greater patient and family involvement in develop-ing an organization’s medication-use policies. Organizations that do not formally engage patients and families in organizational decision-making, such as that done in the pharmacy and therapeutics committee, miss op-portunities to harvest unique perspec-tives to improve patient care. Patients are well positioned and often more capable of directly identifying and re-porting adverse drug events than are clinicians.4 Given the substantial vari-ation in the quality of evidence used by the Food and Drug Administration for drug approval and a shifting para-digm for the evidence needed to bring a new drug to the market, a wide range of thoughtful perspectives will be in-creasingly essential for sound formu-lary decisions.5,6

PATIENT ENGAGEMENT AND THE HEALTH SYSTEM’S BRAND

Marketing the health system’s ser-vices and protecting the brand can become interlaced with patient en-gagement. A majority of FPs expected at least 50% of health systems to have a process in place to respond to nega-tive comments on social media about the organization and its services (Figure 6, item 2). FPs also thought it was likely that at least 25% of health systems would highlight pharma-cists’ patient care in clinics in their marketing efforts (Figure 6, item 3). While marketing efforts may present a unique opportunity to communicate the pharmacist’s contributions to pa-tient care to the public, it is essential that health systems do not equate a marketing strategy with meaningful engagement with patients and their families.

PARTNERSHIP AT THE POINT OF CARE

As pharmacists continue to make deeper contributions to patient care, especially through team-based models of care, opportunities exist to develop enhanced collaboration with patients and families to share decision-making to achieve the best outcomes. The team must use a com-mon framework that facilitates con-sistent partnership, instead of simply lecturing patients on best practices. While only 35% of FPs thought it was likely that at least 25% of prescribing decisions would give greater weight to patient preferences over objec-tive evidence from clinical trials and evidence-based guidelines (Figure 6, item 4), the significance of patient preferences should not be mini-mized. Ultimately, patients are likely to be better served by the medication they will consistently take, even if that medication may not be the best practice based on the latest guideline.

PHARMACY FORECAST 2019 EMPOWERING PATIENTS



Figure 6 (Patient Empowerment). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

3 At least 25% of health systems will highlight in their marketing that pharmacists provide patient care in their clinics.

0%

20%

40%

60%

80%

40%35%

20%

5%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

1 At least 50% of health system pharmacy and therapeutics committees will include a patient or patient’s caregiver as a member (either voting or non-voting).

0%

20%

40%

60%

80%

16%

28%38%

18%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 At least 50% of health systems will have a process in place for responding promptly and assertively to negative comments on social media about their organization and its services.

0%

20%

40%

60%

80%

55%

35%

9%1%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 50% of hospitals will provide free transportation to appointments through ride-share apps (e.g., Uber, Lyft).

0%

20%

40%

60%

80%

20%

47%

26%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 At least 50% of health systems will publicly post results of patient satisfaction surveys, fully identified at the provider-level.

0%

20%

40%

60%

80%

21%

39%

27%

14%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 In at least 25% of clinical interactions that involve medication prescribing, patient preferences will be given greater weight than objective evidence from clinical trials and evidence-based guidelines.

0%

20%

40%

60%

80%

5%

30%

47%

18%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2019


Dow



P Mem





Empowering Patients to Optimize Medication Use

James M. Hoffman, Pharm.D., M.S., BCPS, FASHP, Chief Patient Safety Officer, Office of Quality and Patient Care, and Associate Member, Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN.

William E. Schwab, M.D., Professor and Vice Chair of Education, Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI.

Address correspondence to Dr. Hoffman ([email protected]).


The importance of customizing pa-tient care to patient needs and val-

ues has been well recognized as an es-sential component of quality patient care.1 Health systems are investing in various tools and structures to engage and empower patients and families in their care. These efforts can take a range of forms. Models are emerging where patients and families (broadly defined) are true partners in code-signing care processes and their spe-cific plans of care. However, there is substantial variation in the use of best practices for patient and family en-gagement.2 In some scenarios, patient engagement may amount to empty platitudes. Patients and families are essential allies to improve quality and patient safety, and pharmacists are uniquely positioned to facilitate genu-ine patient engagement to optimize medication use.

STRUCTURES FOR PATIENT ENGAGEMENT

Patient and family advisory coun-cils (PFACs) are a fundamental struc-ture that facilitates the inclusion of patient perspectives on a range of is-sues for a health system, such as staff-

ing, policies, communications, facili-ties, and governance. PFACs can serve as an avenue for patients and families to become more deeply involved in specific committees and projects. The presence of a PFAC has been as-sociated with better performance on quality measures and Hospital Consumer Assessment of Healthcare Providers and Systems scores when compared with hospitals without a PFAC.3 In 1 national survey, 38% of hospitals reported having a PFAC.2 In a more recent survey of New York state hospitals by the Institute for Pa-tient and Family Centered Care, 59% of hospitals in New York had a PFAC, but only 29% of hospitals had a high-functioning PFAC.3

A robust PFAC will often lead to pa-tient and family involvement on ini-tiatives and committees throughout the organization. With 44% of Forecast Panelists (FPs) responding that it was very or somewhat likely that at least 50% of health-system pharmacy and therapeutics committees would in-clude a patient or caregiver as a mem-ber (Figure 6, item 1), FPs were roughly split on the prospect of greater patient and family involvement in develop-ing an organization’s medication-use policies. Organizations that do not formally engage patients and families in organizational decision-making, such as that done in the pharmacy and therapeutics committee, miss op-portunities to harvest unique perspec-tives to improve patient care. Patients are well positioned and often more capable of directly identifying and re-porting adverse drug events than are clinicians.4 Given the substantial vari-ation in the quality of evidence used by the Food and Drug Administration for drug approval and a shifting para-digm for the evidence needed to bring a new drug to the market, a wide range of thoughtful perspectives will be in-creasingly essential for sound formu-lary decisions.5,6

PATIENT ENGAGEMENT AND THE HEALTH SYSTEM’S BRAND

Marketing the health system’s ser-vices and protecting the brand can become interlaced with patient en-gagement. A majority of FPs expected at least 50% of health systems to have a process in place to respond to nega-tive comments on social media about the organization and its services (Figure 6, item 2). FPs also thought it was likely that at least 25% of health systems would highlight pharma-cists’ patient care in clinics in their marketing efforts (Figure 6, item 3). While marketing efforts may present a unique opportunity to communicate the pharmacist’s contributions to pa-tient care to the public, it is essential that health systems do not equate a marketing strategy with meaningful engagement with patients and their families.

PARTNERSHIP AT THE POINT OF CARE

As pharmacists continue to make deeper contributions to patient care, especially through team-based models of care, opportunities exist to develop enhanced collaboration with patients and families to share decision-making to achieve the best outcomes. The team must use a com-mon framework that facilitates con-sistent partnership, instead of simply lecturing patients on best practices. While only 35% of FPs thought it was likely that at least 25% of prescribing decisions would give greater weight to patient preferences over objec-tive evidence from clinical trials and evidence-based guidelines (Figure 6, item 4), the significance of patient preferences should not be mini-mized. Ultimately, patients are likely to be better served by the medication they will consistently take, even if that medication may not be the best practice based on the latest guideline.

PHARMACY FORECAST 2019 EMPOWERING PATIENTS



Figure 6 (Patient Empowerment). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

3 At least 25% of health systems will highlight in their marketing that pharmacists provide patient care in their clinics.

0%

20%

40%

60%

80%

40%35%

20%

5%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

1 At least 50% of health system pharmacy and therapeutics committees will include a patient or patient’s caregiver as a member (either voting or non-voting).

0%

20%

40%

60%

80%

16%

28%38%

18%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 At least 50% of health systems will have a process in place for responding promptly and assertively to negative comments on social media about their organization and its services.

0%

20%

40%

60%

80%

55%

35%

9%1%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 50% of hospitals will provide free transportation to appointments through ride-share apps (e.g., Uber, Lyft).

0%

20%

40%

60%

80%

20%

47%

26%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 At least 50% of health systems will publicly post results of patient satisfaction surveys, fully identified at the provider-level.

0%

20%

40%

60%

80%

21%

39%

27%

14%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 In at least 25% of clinical interactions that involve medication prescribing, patient preferences will be given greater weight than objective evidence from clinical trials and evidence-based guidelines.

0%

20%

40%

60%

80%

5%

30%

47%

18%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely


Dow



P Mem






1. Participate in your health system’s processes to en-gage patients and families in decision-making, including involvement with PFACs where present or advocating for PFAC development if not present.

2. Identify opportunities to actively engage patients and families in medication-use decisions at the system level through membership on pharmacy and therapeutics committees and in the care of individual patients. Codesign of medication-use processes can improve quality, safety, efficiency, and the experi-ence of care for patients and professionals.

3. Evaluate team-based care models that include pharma-cists to verify that the pharma-cist’s identified role is valued and helpful to patients and their families.

4. Develop clinical skills to be able to effectively implement care models that promote shared decision-making and lead to partnership to obtain the best outcomes. Eliminate paternalistic models that are primarily intended to convince patients to follow advice or rules rather than to come up with the best plans for their situation, taking into account their values, preferences, and circumstances.

Further, socioeconomic status is an important health determinant that must be considered throughout the partnership with patients. As an example, in some cases, a patient’s economic situation can make it chal-lenging to travel to clinic appoint-ments or to meet with pharmacists, including picking up medications. FPs were asked about the likelihood that at least 50% of hospitals would provide free transportation to appointments through ride-share apps (e.g., Uber, Lyft), and 67% of respondents thought this was likely (Figure 6, item 5). This result is an encouraging sign, as phar-macists and other clinicians are in-creasingly recognizing the importance of the social determinants of health to delivering quality care.

Pharmacists are the logical inter-face between patients and families and the health system’s medication-use process, Purposeful and authentic engagement of patients and families should become the standard across all health systems, which will yield fur-ther optimization of the medication-use process.

DisclosuresDr. Hoffman is a member of the AJHP Edi-torial Board. The authors have declared no other potential conflicts of interest.

References 1. Committee on Quality of Health

Care in America. Crossing the quality chasm: a new health system for the 21st century (March 2001). www.nationalacademies.org/hmd/~/

media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf (accessed 2018 Jul 31).

2. Herrin J, Harris KG, Kenward K et al. Patient and family engagement: a survey of US hospital practices. BMJ Qual Saf. 2016; 25:182-9.

3. New York State Health Foundation. Strategically advancing patient family advisory councils in New York state hospitals. A report from the Institute for Patient and Family-Centered Care. https://nyshealthfoundation.org/resource/strategically-advancing-

patient-and-family-advisory-coun-cils-in-new-york-state-hospitals/ (accessed 2018 Jul 31).

4. Bash E. The missing voice of patients in drug-safety reporting. N Engl J Med. 2010; 362:865-9.

5. Downing NS, Aminawung JA, Shah ND et al. Clinical trial evidence supporting FDA approval of novel therapeutic agents, 2005-2012. JAMA. 2014; 311:368-77.

6. Kesselheim AS, Avorn J. New “21st Century Cures” legislation: speed and ease vs. science. JAMA. 2017; 317:581-2.

PHARMACY FORECAST 2019 PATIENT CARE



Pharmacists in Patient Care

Scott Knoer, M.S., Pharm.D., FASHP, Chief Pharmacy Officer, Department of Pharmacy, Cleveland Clinic, Cleveland, OH.

Delos (Toby) Cosgrove, M.D., Executive Advisor and former Chief Executive Officer and President, Cleveland Clinic, Cleveland, OH.

Address correspondence to Dr. Knoer ([email protected]).


DRIVING PHARMACY CARE FORWARD IN UNCERTAIN TIMES

The future of healthcare reform as dictated by the Affordable Care

Act remains unclear. Although not re-pealed, the act is being dismantled—the individual mandate was rescind-ed,1 the U.S. Justice Department may not defend mandated coverage of preexisting conditions,2 and Med-icaid expansion is at risk in many states.3 Regardless of the fate of the Affordable Care Act, the cost of our healthcare system is unsustainable and must be reigned in. To achieve this goal, healthcare organizations must maximize efficiency and ensure that all members of the patient care team are acting at the top of their li-censes.4 This environment of uncer-tainty and change provides pharma-cists with an opportunity to cement and expand their role in direct pa-tient care.

PRESCRIBING AUTHORITY

Sixty-nine percent of Forecast Panelists (FPs) found it somewhat or very likely that at least 75% of states will grant pharmacists independent prescribing authority for some medi-cines (Figure 7, item 1). While most states grant some form of prescrib-

ing authority in collaboration with physicians, independent prescribing is needed for pharmacists to achieve their full potential.

Pharmacists have long sought provider status from the Centers for Medicare and Medicaid Services, al-lowing billing for the provision of clinical services, but that regulatory change has not been achieved. How-ever, the ability to bill for services is of little importance in a value-based financial system where quality, safe-ty, and overall cost are rewarded over the volume of care provided. As the country continues to move toward value-based payment, pharmacists must focus on demonstrating their ability to contribute meaningfully to interdisciplinary care teams. They must expand their role to include in-dependent prescribing authority to ensure the quality of medication use and the lowest possible total cost of care. State pharmacy practice acts will need to be modified to enable these changes, and successful models have been implemented in some states.5

PRIVILEGING AND CREDENTIALING

Seventy-six percent of FPs pre-dicted that pharmacists in at least 50% of health systems will be subject to the same credentialing and privileg-ing that their state requires for other advanced-practice providers (Figure 7, item 2). For pharmacists to expand their practice, they must not fear prov-ing competence, just as other provid-ers are required to do. Pharmacists must embrace peer review, residency training, and board certification as prerequisites before legislators, regu-lators, health-system executives, and other providers will accept them as in-dependent practitioners with autono-my related to medication prescribing.

SKIN IN THE GAME

Only 35% of FPs predicted it likely

that at least 25% of health systems will tie pharmacist salaries to popu-lation health outcome metrics (Fig-ure 7, item 3). While this may be due to rising risk aversion created by the chaotic environment of healthcare, pharmacists should not fear being held accountable for the care they provide.

In value-based financial models, health systems are rewarded for bet-ter outcomes. By demonstrating that patients cared for by pharmacists achieve and maintain therapeutic goals faster and more consistently, pharmacists will continue to gain credibility. Reducing readmissions, demonstrating higher patient adher-ence to care recommendations, and providing evidence of other outcomes will show the impact of pharmacists under risk-based models.

However, to truly be accountable for patient care, pharmacists must become more integrated into the pa-tient’s medical record. A majority of FPs predicted that pharmacists’ as-sessments in electronic health re-cords will routinely include structured medication-use plans with measur-able goals in nearly all health systems (Figure 7, item 4).

AMBULATORY CARE AND SPECIALTY CLINICS

Surprisingly, only 22% of FPs pre-dicted that at least 75% of health systems will include pharmacists as patient care providers in nearly all specialty care clinics (Figure 7, item 5). The evidence of pharmacist value in specialty clinics is well document-ed.6,7 It was the success of pharmacists caring for specialty patients that led to expanded models in primary care. Although the aggressive move to em-bed pharmacists in primary care is ex-tremely valuable to improve popula-tion health, it is important to not lose sight of the proven value that focused pharmacy practice has to specialty


Dow



P Mem






1. Participate in your health system’s processes to en-gage patients and families in decision-making, including involvement with PFACs where present or advocating for PFAC development if not present.

2. Identify opportunities to actively engage patients and families in medication-use decisions at the system level through membership on pharmacy and therapeutics committees and in the care of individual patients. Codesign of medication-use processes can improve quality, safety, efficiency, and the experi-ence of care for patients and professionals.

3. Evaluate team-based care models that include pharma-cists to verify that the pharma-cist’s identified role is valued and helpful to patients and their families.

4. Develop clinical skills to be able to effectively implement care models that promote shared decision-making and lead to partnership to obtain the best outcomes. Eliminate paternalistic models that are primarily intended to convince patients to follow advice or rules rather than to come up with the best plans for their situation, taking into account their values, preferences, and circumstances.

Further, socioeconomic status is an important health determinant that must be considered throughout the partnership with patients. As an example, in some cases, a patient’s economic situation can make it chal-lenging to travel to clinic appoint-ments or to meet with pharmacists, including picking up medications. FPs were asked about the likelihood that at least 50% of hospitals would provide free transportation to appointments through ride-share apps (e.g., Uber, Lyft), and 67% of respondents thought this was likely (Figure 6, item 5). This result is an encouraging sign, as phar-macists and other clinicians are in-creasingly recognizing the importance of the social determinants of health to delivering quality care.

Pharmacists are the logical inter-face between patients and families and the health system’s medication-use process, Purposeful and authentic engagement of patients and families should become the standard across all health systems, which will yield fur-ther optimization of the medication-use process.

DisclosuresDr. Hoffman is a member of the AJHP Edi-torial Board. The authors have declared no other potential conflicts of interest.

References 1. Committee on Quality of Health

Care in America. Crossing the quality chasm: a new health system for the 21st century (March 2001). www.nationalacademies.org/hmd/~/

media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf (accessed 2018 Jul 31).

2. Herrin J, Harris KG, Kenward K et al. Patient and family engagement: a survey of US hospital practices. BMJ Qual Saf. 2016; 25:182-9.

3. New York State Health Foundation. Strategically advancing patient family advisory councils in New York state hospitals. A report from the Institute for Patient and Family-Centered Care. https://nyshealthfoundation.org/resource/strategically-advancing-

patient-and-family-advisory-coun-cils-in-new-york-state-hospitals/ (accessed 2018 Jul 31).

4. Bash E. The missing voice of patients in drug-safety reporting. N Engl J Med. 2010; 362:865-9.

5. Downing NS, Aminawung JA, Shah ND et al. Clinical trial evidence supporting FDA approval of novel therapeutic agents, 2005-2012. JAMA. 2014; 311:368-77.

6. Kesselheim AS, Avorn J. New “21st Century Cures” legislation: speed and ease vs. science. JAMA. 2017; 317:581-2.




Pharmacists in Patient Care

Scott Knoer, M.S., Pharm.D., FASHP, Chief Pharmacy Officer, Department of Pharmacy, Cleveland Clinic, Cleveland, OH.

Delos (Toby) Cosgrove, M.D., Executive Advisor and former Chief Executive Officer and President, Cleveland Clinic, Cleveland, OH.

Address correspondence to Dr. Knoer ([email protected]).


DRIVING PHARMACY CARE FORWARD IN UNCERTAIN TIMES

The future of healthcare reform as dictated by the Affordable Care

Act remains unclear. Although not re-pealed, the act is being dismantled—the individual mandate was rescind-ed,1 the U.S. Justice Department may not defend mandated coverage of preexisting conditions,2 and Med-icaid expansion is at risk in many states.3 Regardless of the fate of the Affordable Care Act, the cost of our healthcare system is unsustainable and must be reigned in. To achieve this goal, healthcare organizations must maximize efficiency and ensure that all members of the patient care team are acting at the top of their li-censes.4 This environment of uncer-tainty and change provides pharma-cists with an opportunity to cement and expand their role in direct pa-tient care.

PRESCRIBING AUTHORITY

Sixty-nine percent of Forecast Panelists (FPs) found it somewhat or very likely that at least 75% of states will grant pharmacists independent prescribing authority for some medi-cines (Figure 7, item 1). While most states grant some form of prescrib-

ing authority in collaboration with physicians, independent prescribing is needed for pharmacists to achieve their full potential.

Pharmacists have long sought provider status from the Centers for Medicare and Medicaid Services, al-lowing billing for the provision of clinical services, but that regulatory change has not been achieved. How-ever, the ability to bill for services is of little importance in a value-based financial system where quality, safe-ty, and overall cost are rewarded over the volume of care provided. As the country continues to move toward value-based payment, pharmacists must focus on demonstrating their ability to contribute meaningfully to interdisciplinary care teams. They must expand their role to include in-dependent prescribing authority to ensure the quality of medication use and the lowest possible total cost of care. State pharmacy practice acts will need to be modified to enable these changes, and successful models have been implemented in some states.5

PRIVILEGING AND CREDENTIALING

Seventy-six percent of FPs pre-dicted that pharmacists in at least 50% of health systems will be subject to the same credentialing and privileg-ing that their state requires for other advanced-practice providers (Figure 7, item 2). For pharmacists to expand their practice, they must not fear prov-ing competence, just as other provid-ers are required to do. Pharmacists must embrace peer review, residency training, and board certification as prerequisites before legislators, regu-lators, health-system executives, and other providers will accept them as in-dependent practitioners with autono-my related to medication prescribing.

SKIN IN THE GAME

Only 35% of FPs predicted it likely

that at least 25% of health systems will tie pharmacist salaries to popu-lation health outcome metrics (Fig-ure 7, item 3). While this may be due to rising risk aversion created by the chaotic environment of healthcare, pharmacists should not fear being held accountable for the care they provide.

In value-based financial models, health systems are rewarded for bet-ter outcomes. By demonstrating that patients cared for by pharmacists achieve and maintain therapeutic goals faster and more consistently, pharmacists will continue to gain credibility. Reducing readmissions, demonstrating higher patient adher-ence to care recommendations, and providing evidence of other outcomes will show the impact of pharmacists under risk-based models.

However, to truly be accountable for patient care, pharmacists must become more integrated into the pa-tient’s medical record. A majority of FPs predicted that pharmacists’ as-sessments in electronic health re-cords will routinely include structured medication-use plans with measur-able goals in nearly all health systems (Figure 7, item 4).

AMBULATORY CARE AND SPECIALTY CLINICS

Surprisingly, only 22% of FPs pre-dicted that at least 75% of health systems will include pharmacists as patient care providers in nearly all specialty care clinics (Figure 7, item 5). The evidence of pharmacist value in specialty clinics is well document-ed.6,7 It was the success of pharmacists caring for specialty patients that led to expanded models in primary care. Although the aggressive move to em-bed pharmacists in primary care is ex-tremely valuable to improve popula-tion health, it is important to not lose sight of the proven value that focused pharmacy practice has to specialty

2019


Dow



P Mem


PHARMACY FORECAST 2018PATIENT CARE



Figure 7 (Pharmacists in Patient Care). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 At least 75% of states will grant pharmacists independent prescribing authority for some medicines.

0%

20%

40%

60%

80%

29%

40%

21%

10%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 Pharmacists in at least 50% of health systems will be subject to the same credentialing and privileging their state requires for other advanced-practice providers.

0%

20%

40%

60%

80%

25%

51%

20%

5%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 75% of health systems will include pharmacists as patient care providers in nearly all specialty care clinics.

0%

20%

40%

60%

80%

22%

39%28%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 At least 25% of health systems will tie pharmacist’s salaries to population health outcome metrics that are sensitive to the care pharmacists provide.

0%

20%

40%

60%

80%

6%

29%

46%

19%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 When assessing whether to initiate or expand patient-care engagement of pharmacists in clinics, at least 25% of health systems will give greater weight to the prospect of improved quality of care than to financial performance.

0%

20%

40%

60%

80%

16%

44%

33%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 In nearly all health systems, pharmacist assessments in EHRs will routinely include structured medication use plans with measurable goals.

0%

20%

40%

60%

80%

28%

47%

20%

5%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely





1. Do not allow the lack of provid-er status to hinder the impact of pharmacists on patient care, and instead focus on state-based legislation granting inde-pendent prescribing authority to pharmacists who meet strict credentialing criteria.

2. Define credentialing standards for your organization and for your state’s prescribing authority laws. Tie this work into existing credentialing infrastructure, but also be prepared to justify additional resources needed to ensure peer review and competency documentation.

3. To succeed in the impending risk-based world, pharmacists must aggressively expand into ambulatory care prac-tices in both primary care and specialty clinics and lead medication-based population health initiatives.

4. Health-system pharmacists must leverage the flexibility afforded them under organized medical staff governance struc-tures to practice at the very top of their current licenses, taking responsibility for indepen-dently managing patients, thus freeing physicians up to care for more patients. Respond to the high degree of physician burnout by partnering with physicians and taking account-ability for challenging patient care that strains them.

5. Get to the table with your con-tracting team at your health system to ensure that risk-based contracts include both the pharmacy and medical benefits and that pharmacists are able to manage the formu-lary and prior authorizations for your health system.

clinics (e.g., pain management, endo-crine, neurology, cardiology).

PRACTICE RELATED TO MANAGING RISK

Societal drug spending, driven largely by the rise of specialty phar-macy, is unsustainable, and only pharmacy has the skills to control it. As an example, the Cleveland Clinic accepts full risk for the cost of their 100,000 employee health plan mem-bers. Pharmacists and physicians have worked together to limit increases in drug spending compared with the national average. Through careful at-tention to appropriate utilization, Cleveland Clinic pharmacy costs are approximately $29 per member per month less than the national average for similar employee health plans. In order for health systems to succeed in the risk-based world, pharmacists must dramatically expand their prac-tice in managed care through disease management, contracting and ensur-ing appropriate utilization.

A majority of FPs said it was likely that at least 25% of health systems will give greater weight to the prospect of improved quality of care over financial performance (Figure 7, item 6). The Cleveland Clinic experience demon-strates that pharmacists involved in managing risk actually improve both the quality of care provided and the financial performance of an organiza-tion. Pharmacy practice will advance faster when pharmacists prove their value by decreasing costs and improv-ing quality for at-risk populations.

DisclosuresDr. Knoer is a contributing editor for AJHP. The authors have declared no other potential conflicts of interest.

References1. Jost T. The tax bill and the individual

mandate: what happened, and what

does it mean? www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/ (accessed 2018 Jul 23).

2. Teichert E. Justice Department won’t defend Obamacare in GOP states’ lawsuit. www.modern-healthcare.com/article/20180607/NEWS/180609927 (accessed 2018 Jul 23).

3. Meyer H. Maine governor balks at submitting Medicaid expansion plan to CMS. www.modernhealthcare.com/article/20180330/NEWS/180339984 (accessed 2018 Jul 23).

4. Kacik A. Healthcare costs increasing at unsustainable pace. www.modernhealthcare.com/article/20180613/NEWS/180619961 (accessed 2018 Jul 23).

5. Bonner L. Kentucky pharmacists have new authorities to improve patient, public health. www.pharmacist.com/article/kentucky-pharmacists-have-new-authorities-improve-patient-public-health (accessed 2018 Jul 23).

6. Shay B, Louden L, Kirschenbaum B et al. Specialty pharmacy services: preparing for a new era in health-system pharmacy. Hosp Pharm. 2015; 50:834-9.

7. Bagwell A, Kelley T, Carver A et al. Advancing patient care through specialty pharmacy services in an academic health system. J Manag Care Spec Pharm. 2017; 23:815-20.

9


Dow



P Mem


PHARMACY FORECAST 2018PATIENT CARE



Figure 7 (Pharmacists in Patient Care). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 At least 75% of states will grant pharmacists independent prescribing authority for some medicines.

0%

20%

40%

60%

80%

29%

40%

21%

10%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 Pharmacists in at least 50% of health systems will be subject to the same credentialing and privileging their state requires for other advanced-practice providers.

0%

20%

40%

60%

80%

25%

51%

20%

5%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 At least 75% of health systems will include pharmacists as patient care providers in nearly all specialty care clinics.

0%

20%

40%

60%

80%

22%

39%28%

11%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 At least 25% of health systems will tie pharmacist’s salaries to population health outcome metrics that are sensitive to the care pharmacists provide.

0%

20%

40%

60%

80%

6%

29%

46%

19%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 When assessing whether to initiate or expand patient-care engagement of pharmacists in clinics, at least 25% of health systems will give greater weight to the prospect of improved quality of care than to financial performance.

0%

20%

40%

60%

80%

16%

44%

33%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 In nearly all health systems, pharmacist assessments in EHRs will routinely include structured medication use plans with measurable goals.

0%

20%

40%

60%

80%

28%

47%

20%

5%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely





1. Do not allow the lack of provid-er status to hinder the impact of pharmacists on patient care, and instead focus on state-based legislation granting inde-pendent prescribing authority to pharmacists who meet strict credentialing criteria.

2. Define credentialing standards for your organization and for your state’s prescribing authority laws. Tie this work into existing credentialing infrastructure, but also be prepared to justify additional resources needed to ensure peer review and competency documentation.

3. To succeed in the impending risk-based world, pharmacists must aggressively expand into ambulatory care prac-tices in both primary care and specialty clinics and lead medication-based population health initiatives.

4. Health-system pharmacists must leverage the flexibility afforded them under organized medical staff governance struc-tures to practice at the very top of their current licenses, taking responsibility for indepen-dently managing patients, thus freeing physicians up to care for more patients. Respond to the high degree of physician burnout by partnering with physicians and taking account-ability for challenging patient care that strains them.

5. Get to the table with your con-tracting team at your health system to ensure that risk-based contracts include both the pharmacy and medical benefits and that pharmacists are able to manage the formu-lary and prior authorizations for your health system.

clinics (e.g., pain management, endo-crine, neurology, cardiology).

PRACTICE RELATED TO MANAGING RISK

Societal drug spending, driven largely by the rise of specialty phar-macy, is unsustainable, and only pharmacy has the skills to control it. As an example, the Cleveland Clinic accepts full risk for the cost of their 100,000 employee health plan mem-bers. Pharmacists and physicians have worked together to limit increases in drug spending compared with the national average. Through careful at-tention to appropriate utilization, Cleveland Clinic pharmacy costs are approximately $29 per member per month less than the national average for similar employee health plans. In order for health systems to succeed in the risk-based world, pharmacists must dramatically expand their prac-tice in managed care through disease management, contracting and ensur-ing appropriate utilization.

A majority of FPs said it was likely that at least 25% of health systems will give greater weight to the prospect of improved quality of care over financial performance (Figure 7, item 6). The Cleveland Clinic experience demon-strates that pharmacists involved in managing risk actually improve both the quality of care provided and the financial performance of an organiza-tion. Pharmacy practice will advance faster when pharmacists prove their value by decreasing costs and improv-ing quality for at-risk populations.

DisclosuresDr. Knoer is a contributing editor for AJHP. The authors have declared no other potential conflicts of interest.

References1. Jost T. The tax bill and the individual

mandate: what happened, and what

does it mean? www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/ (accessed 2018 Jul 23).

2. Teichert E. Justice Department won’t defend Obamacare in GOP states’ lawsuit. www.modern-healthcare.com/article/20180607/NEWS/180609927 (accessed 2018 Jul 23).

3. Meyer H. Maine governor balks at submitting Medicaid expansion plan to CMS. www.modernhealthcare.com/article/20180330/NEWS/180339984 (accessed 2018 Jul 23).

4. Kacik A. Healthcare costs increasing at unsustainable pace. www.modernhealthcare.com/article/20180613/NEWS/180619961 (accessed 2018 Jul 23).

5. Bonner L. Kentucky pharmacists have new authorities to improve patient, public health. www.pharmacist.com/article/kentucky-pharmacists-have-new-authorities-improve-patient-public-health (accessed 2018 Jul 23).

6. Shay B, Louden L, Kirschenbaum B et al. Specialty pharmacy services: preparing for a new era in health-system pharmacy. Hosp Pharm. 2015; 50:834-9.

7. Bagwell A, Kelley T, Carver A et al. Advancing patient care through specialty pharmacy services in an academic health system. J Manag Care Spec Pharm. 2017; 23:815-20.


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PHARMACY FORECAST 2019DISRUPTIVE FORCES



Disruptive Forces in Healthcare

Stanley S. Kent, M.S., FASHP, Chief Pharmacy Officer, Michigan Medicine, Ann Arbor, MI, and Clinical Assistant Professor and Associate Dean for Clinical Affairs, University of Michigan College of Pharmacy, Ann Arbor, MI.

John S. Clark, Pharm.D., M.S., BCPS, FASHP, Associate Chief Pharmacy Officer, Michigan Medicine, Ann Arbor, MI, and Clinical Associate Professor, University of Michigan College of Pharmacy, Ann Arbor, MI.

Address correspondence to Mr. Kent ([email protected]).


Disrupters in healthcare are of utmost importance for aware-

ness and action by pharmacy lead-ers. Pharmacy futurists for decades have attempted to predict trends in healthcare and their impact on prac-tice, and the consideration of disrup-tive forces in healthcare is essential.

DISMANTLING THE AFFORDABLE CARE ACT

Forecast panelists (FPs) were un-sure about whether the Affordable Care Act (ACA) will be dismantled (Figure 8, item 1). At the extreme, full repeal of the ACA would have over-whelming consequences on the care of 20 million Americans. The effect of repeal would be felt by almost ev-ery provider of care, including phar-macists. At the time of writing, it was expected that moderate reductions in spending will occur, tightening bud-gets but not resulting in a crippling change.1

During this time of uncertainty, health-system pharmacists should determine how to add value in the continuum of care with other provid-ers of direct patient care. When health systems see a decrease in reimburse-ment from ACA changes, leadership

from pharmacists, supported by data, will be needed to effectively continue providing clinical services. Pharmacy leaders and practitioners need to re-evaluate the services they provide and stop spending time on activities that provide little proven value.

PRICING OF PHARMACEUTICALS AND TRANSPARENCY OF PRICING

Pricing of pharmaceuticals has been at the forefront of American news and politics. FPs were split on whether a federal law will be passed imposing limits on the pricing of pharmaceuti-cals (Figure 8, item 2). The media has been very critical of current drug pric-ing strategies by industry. Pharmacy leaders in health systems have also been vocal about the impact of high drug costs on patients and society.2

Given the poor track record of success in this area and the significant influ-ence of lobbying efforts by the phar-maceutical industry, it is unlikely that limits will be placed on pricing in the near future.

FPs were also split as to whether a federal law will be passed requiring complete transparency in drug pric-ing, allowing the public to understand who pays what for specific products (Figure 8, item 3). Even if transpar-ency in drug pricing does not occur through federal law, substantial ef-forts are being undertaken for patients and caregivers to better understand drug pricing to improve drug price visibility.3 Given the implications for the pharmaceutical industry and the strong influence that industry has on Congress, it is unlikely this transpar-ency will occur anytime soon.

DRUG MANUFACTURING BY HEALTH SYSTEMS

A large majority of FPs (70%) be-lieved that it is not likely that health systems will begin manufacturing products to reduce drug shortages

(Figure 8, item 4). However, a consor-tium of health systems is currently attempting to do just that. The doubt expressed by FPs is likely due to the overwhelming number of shortages currently being experienced by health systems. It is unclear what the impact will be on the market as a whole, but the health systems participating in this coalition are attempting to affect change, at least for their organiza-tions.4 Should many health systems elect to embark on a similar path, it would likely be by partnering with existing manufacturers, which ulti-mately would only change current contractual arrangements. Alterna-tively, if health systems were to build their own manufacturing facilities, they would face the same problems current manufacturers struggle with. Therefore, any real impact on the drug supply as a whole would likely not be seen for at least 10 years.

NONTRADITIONAL PARTICIPANTS IN HEALTHCARE DELIVERY

Fifty-eight percent of FPs thought that the entry of Amazon, Apple, Google, JP Morgan, and Berkshire Hathaway into the healthcare arena is likely to substantially reduce the role of fiscal and supply chain inter-mediaries (Figure 8, item 5). In order to reduce costs, it is postulated that intermediaries could be marginalized and that value to the system could be gained by spending those healthcare dollars on the provision of care.5 The entry of other nontraditional partici-pants into healthcare delivery is oc-curring. Amazon’s purchase of PillPack strengthens its entry into the online pharmacy market.6 Much like Amazon is interested in an online pharmacy, health systems are expected to partner with nontraditional healthcare partic-ipants. A large majority of FPs believed it is likely that this will occur in 25% of health systems (Figure 8, item 6). Once

PHARMACY FORECAST 2019 DISRUPTIVE FORCES



Figure 8 (Disruptive Forces in Healthcare). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 The dismantling of the Affordable Care Act will cause nearly all health systems to substantially reduce their commitment to population health.

0%

20%

40%

60%

80%

8%

28%

42%

22%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 A federal law will be passed imposing limits on the pricing of pharmaceuticals.

0%

20%

40%

60%

80%

7%

37% 36%

19%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 Drug manufacturing by a consortium of health systems will reduce the number of drug shortages by 50%.

0%

20%

40%

60%

80%

3%

28%

48%

22%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 The activity of nontraditional participants in healthcare delivery (e.g., Amazon, Apple, Google, JP Morgan, Berkshire Hathaway) will substantially reduce the role of fiscal and supply chain intermediaries (e.g., PBMs, GPOs, wholesaler/distributors).

0%

20%

40%

60%

80%

10%

48%

35%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 A federal law will be passed requiring complete transparency in drug pricing, which will allow the public to see who pays what for specific products.

0%

20%

40%

60%

80%

11%

38% 35%

16%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 At least 25% of health systems will partner with nontraditional participants in healthcare delivery (e.g., Amazon, Apple, Google, JP Morgan, Berkshire Hathaway) to reduce healthcare costs and increase quality.

0%

20%

40%

60%

80%

19%

52%

22%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2019


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Disruptive Forces in Healthcare

Stanley S. Kent, M.S., FASHP, Chief Pharmacy Officer, Michigan Medicine, Ann Arbor, MI, and Clinical Assistant Professor and Associate Dean for Clinical Affairs, University of Michigan College of Pharmacy, Ann Arbor, MI.

John S. Clark, Pharm.D., M.S., BCPS, FASHP, Associate Chief Pharmacy Officer, Michigan Medicine, Ann Arbor, MI, and Clinical Associate Professor, University of Michigan College of Pharmacy, Ann Arbor, MI.

Address correspondence to Mr. Kent ([email protected]).


Disrupters in healthcare are of utmost importance for aware-

ness and action by pharmacy lead-ers. Pharmacy futurists for decades have attempted to predict trends in healthcare and their impact on prac-tice, and the consideration of disrup-tive forces in healthcare is essential.

DISMANTLING THE AFFORDABLE CARE ACT

Forecast panelists (FPs) were un-sure about whether the Affordable Care Act (ACA) will be dismantled (Figure 8, item 1). At the extreme, full repeal of the ACA would have over-whelming consequences on the care of 20 million Americans. The effect of repeal would be felt by almost ev-ery provider of care, including phar-macists. At the time of writing, it was expected that moderate reductions in spending will occur, tightening bud-gets but not resulting in a crippling change.1

During this time of uncertainty, health-system pharmacists should determine how to add value in the continuum of care with other provid-ers of direct patient care. When health systems see a decrease in reimburse-ment from ACA changes, leadership

from pharmacists, supported by data, will be needed to effectively continue providing clinical services. Pharmacy leaders and practitioners need to re-evaluate the services they provide and stop spending time on activities that provide little proven value.

PRICING OF PHARMACEUTICALS AND TRANSPARENCY OF PRICING

Pricing of pharmaceuticals has been at the forefront of American news and politics. FPs were split on whether a federal law will be passed imposing limits on the pricing of pharmaceuti-cals (Figure 8, item 2). The media has been very critical of current drug pric-ing strategies by industry. Pharmacy leaders in health systems have also been vocal about the impact of high drug costs on patients and society.2

Given the poor track record of success in this area and the significant influ-ence of lobbying efforts by the phar-maceutical industry, it is unlikely that limits will be placed on pricing in the near future.

FPs were also split as to whether a federal law will be passed requiring complete transparency in drug pric-ing, allowing the public to understand who pays what for specific products (Figure 8, item 3). Even if transpar-ency in drug pricing does not occur through federal law, substantial ef-forts are being undertaken for patients and caregivers to better understand drug pricing to improve drug price visibility.3 Given the implications for the pharmaceutical industry and the strong influence that industry has on Congress, it is unlikely this transpar-ency will occur anytime soon.

DRUG MANUFACTURING BY HEALTH SYSTEMS

A large majority of FPs (70%) be-lieved that it is not likely that health systems will begin manufacturing products to reduce drug shortages

(Figure 8, item 4). However, a consor-tium of health systems is currently attempting to do just that. The doubt expressed by FPs is likely due to the overwhelming number of shortages currently being experienced by health systems. It is unclear what the impact will be on the market as a whole, but the health systems participating in this coalition are attempting to affect change, at least for their organiza-tions.4 Should many health systems elect to embark on a similar path, it would likely be by partnering with existing manufacturers, which ulti-mately would only change current contractual arrangements. Alterna-tively, if health systems were to build their own manufacturing facilities, they would face the same problems current manufacturers struggle with. Therefore, any real impact on the drug supply as a whole would likely not be seen for at least 10 years.

NONTRADITIONAL PARTICIPANTS IN HEALTHCARE DELIVERY

Fifty-eight percent of FPs thought that the entry of Amazon, Apple, Google, JP Morgan, and Berkshire Hathaway into the healthcare arena is likely to substantially reduce the role of fiscal and supply chain inter-mediaries (Figure 8, item 5). In order to reduce costs, it is postulated that intermediaries could be marginalized and that value to the system could be gained by spending those healthcare dollars on the provision of care.5 The entry of other nontraditional partici-pants into healthcare delivery is oc-curring. Amazon’s purchase of PillPack strengthens its entry into the online pharmacy market.6 Much like Amazon is interested in an online pharmacy, health systems are expected to partner with nontraditional healthcare partic-ipants. A large majority of FPs believed it is likely that this will occur in 25% of health systems (Figure 8, item 6). Once

PHARMACY FORECAST 2019 DISRUPTIVE FORCES



Figure 8 (Disruptive Forces in Healthcare). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2023 in the geographic region where you work?”

1 The dismantling of the Affordable Care Act will cause nearly all health systems to substantially reduce their commitment to population health.

0%

20%

40%

60%

80%

8%

28%

42%

22%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2 A federal law will be passed imposing limits on the pricing of pharmaceuticals.

0%

20%

40%

60%

80%

7%

37% 36%

19%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

4 Drug manufacturing by a consortium of health systems will reduce the number of drug shortages by 50%.

0%

20%

40%

60%

80%

3%

28%

48%

22%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

5 The activity of nontraditional participants in healthcare delivery (e.g., Amazon, Apple, Google, JP Morgan, Berkshire Hathaway) will substantially reduce the role of fiscal and supply chain intermediaries (e.g., PBMs, GPOs, wholesaler/distributors).

0%

20%

40%

60%

80%

10%

48%

35%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

3 A federal law will be passed requiring complete transparency in drug pricing, which will allow the public to see who pays what for specific products.

0%

20%

40%

60%

80%

11%

38% 35%

16%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

6 At least 25% of health systems will partner with nontraditional participants in healthcare delivery (e.g., Amazon, Apple, Google, JP Morgan, Berkshire Hathaway) to reduce healthcare costs and increase quality.

0%

20%

40%

60%

80%

19%

52%

22%

7%

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely


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1. As the ACA is being disman-tled, pharmacists should pro-vide data that describe efforts to improve patient care, in-cluding the impact on patient care outcomes, length of stay, and morbidity and mortality rates.

2. Pharmacy leaders should continue to advocate publicly for patients suffering from egregiously high drug prices.

3. Pharmacy leaders should partner with nontraditional healthcare participants to develop new strategies for care, specifically related to patient adherence and the accuracy of medication lists used for decision-making.

4. Transparency in drug pricing due to contracts and arrange-ments by manufacturers, pharmacy benefits managers, and wholesalers should be demanded by the profession as an important tool for patients and caregivers to better un-derstand costs associated with care provision.

5. Pharmacy leaders should improve their knowledge and skills related to change man-agement in order to make bold changes with flawless execu-tion to be seen as advanced healthcare leaders.

these “new” organizations begin to face the challenges of actually provid-ing or paying for healthcare, they will not succeed. Nonetheless, pharmacy leaders need to watch and understand the changes in supply chain and care delivery that could occur as a result of entry of nontraditional participants in healthcare delivery.

ADDITIONAL FORCES TO CONSIDER

Technological advances and soci-etal and political issues are disruptive forces that should also be considered. Technology will allow practitioners and patients to access data, improve the safety of care delivery, and lead to innovation. Societal and political forc-es can also be disrupters to healthcare. Consideration of the importance of civility and empathy, the provision of equity, and the recognition and relief from healthcare disparities are essen-tial for pharmacy leadership to make positive change.

PREPARATION FOR THE UNKNOWN

Disruption is a sudden and usu-ally unpredictable change in the status quo. Regardless of the specific disrupt-er, pharmacy leaders must be prepared to respond. Change may not result only in challenges, but also in tremendous opportunity. It is not enough for phar-macy leaders to merely think about what could change; they must know how to act differently to effectively re-spond. Action can be instructed by ef-fective change management.7


References1. Goodnough A. Trump’s new plan

for dismantling Obamacare comes with political risks. www.nytimes.com/2018/06/08/health/obamacare-pre-existing-conditions-mandate.html (accessed 2018 Jun 29).

2. Kacik A. Drug prices rise as pharma profit soars. www.modernhealth-care.com/article/20171228/NEWS/171229930 (accessed 2018 Jun 29).

3. Weintraub A. The call for drug-price transparency is growing louder but will it matter. www.forbes.com/sites/arleneweintraub/2018/03/30/the-call-for-drug-price-transparency-is-growing-louder-but-will-it-matter/ (accessed 2018 Jun 29).

4. Abelson R, Thomas K. Fed up with drug companies, hospitals decide

to start their own. www.nytimes.com/2018/01/18/health/drug-prices-hospitals.html (accessed 2018 Jun 29).

5. Myshko D. New entrants: the healthcare disrupters. www.pharmavoice.com/article/2015-11-nontraditional-players/ (accessed 2018 Jun 29).

6. Ballantine C, Thomas K. Amazon to buy on-line pharmacy PillPack, jumping into the drug business. www.nytimes.com/2018/06/28/business/dealbook/amazon-buying-pillpack-as-it-moves-into-pharmacies.html (accessed 2018 Jun 29).

7. Kotter JP. Leading change: why transformation efforts fail. https://hbr.org/2007/01/leading-change-why-transformation-efforts-fail (accessed 2018 Sep 25).


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For Personal Use Only. Any commercial use is …mhpharmacy-hospital-rotation.weebly.com/uploads/4/9/2/4/...of Crowds. According to Surow-iecki, the collective opinions of “wise crowds”—groups