The majority of the population get their insurance through their employer1. The employer chooses a healthcare plan which covers all the medical expenses associated with a patient’s medical care: visits to the hospital, physician office or urgent care center, etc. However, if the patient is prescribed any medication, the health insurance plan segments out the pharmacological care to a pharmacy benefits manager, or PBM. The PBM then identifies where the patient can receive their pharmacological therapy – specifically identifying which pharmacy is considered in network for the patient.
This leads to a significant fragmentation of care – especially for complex diseases. For the therapy to be successful in disease treatment or management, adherence and close monitoring of pharmacological therapy is paramount2. The pharmacist plays a vital role in managing, monitoring and coordinating with the physician to help drive optimal patient outcomes. For hospitals, their pharmacy is the ideal resource to implement this care model.
Hospital pharmacies are able to monitor medication dispenses, refills and adherence rates for their patients – fully managing the downstream care once when a patient is discharged. The hospital pharmacy dispense systems are directly linked to the hospital’s electronic medical record and have the quickest access to the providers and specialists prescribing the medications.
Christine Berard-Collins of the Lifespan, a Rhode Island based health system, stated in an interview with the Hospitals and Health Networks (HHN) Magazine, “Complex, sometimes toxic, specialty medications can be managed better by the clinical pharmacists who are working with the rest of the patient’s care team using a shared EHR”3
Due to their physical proximity and established relationship with physicians, hospital pharmacists are quicker to review and therapy to the patient once it is prescribed4. This helps cultivate a personal relationship that exists between the three groups: the medical team, the pharmacological team and the patient. Patients rely on physicians to determine the care plan and on the hospital pharmacist to help execute that treatment regimen. It is imperative that hospital pharmacies have equally unfettered access to service their patients for the long term, once they leave the hospital.
However, that is not the case for all hospitals today. PBMs have set up a number of roadblocks to prevent hospital pharmacists from taking on this role. They have established accreditation requirements, call center requirements and access to numerous drugs5. PBMs establish their own pharmacies, which are not integrated into the care team at the hospital or the electronic medical record. This operational workflow fragmentation prevents hospital pharmacists from taking care of their patients. Berard-Collins continues in HHN:
“The clinical pharmacists in my clinics are seeing the patients, teaching them about their medications, following up with them to see if they’re having any side effects, checking their lab values … They were doing all this work and then sending the prescription out to be filled by some out-of-state pharmacy…”6
Hospitals are taking note and fighting this unnecessary fragmentation of care. They are realizing the importance of the specialty pharmacy for patient care and are pushing for their network contracts to include coverage of long term retail and specialty pharmacological therapy. This is a grueling but necessary task as hospitals take on the responsibility of post-discharge care. Hospital pharmacists are pushing harder to be able to manage the long term care for these patients – and are instrumental in fighting the PBM’s.
The Hospital Pharmacist, who is responsible for monitoring the care for the sickest patients, should not be elbowed out of the care paradigm by the PBMs. Hospital pharmacists should be able to access all patients that are being treated at the hospital, even after they leave the four walls of the facility. As Berard-Collins concludes, “Their patients are our patients, so we have a personal and vested interest in them.”6
Prashant K. Dilwali, MHA
Director of Business Operations – Shields Health Solutions
Prashant holds a Master of Health Administration from Johns Hopkins Bloomberg School of Public Health and a Bachelor of Science from the Massachusetts Institute of Technology. He has published in the Journal of Healthcare Management about reducing fragmentation of care and is actively involved with the American College of Healthcare Executives.
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[1] https://www.census.gov/newsroom/press-releases/2015/cb15-157.html
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668/
[4] https://www.todayshospitalist.com/Hospitalists-and-pharmacists-breaking-new-ground-by-teaming-up/
[5] https://www.pcmanet.org/wp-content/uploads/2017/04/sPCMA_The_Management_of_Specialty_Drugs.pdf
https://www.census.gov/newsroom/press-releases/2015/cb15-157.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668/
https://www.hhnmag.com/articles/6930-how-hospitals-pharmacists-improve-care-without-breaking-the-bank
https://www.todayshospitalist.com/Hospitalists-and-pharmacists-breaking-new-ground-by-teaming-up/
https://www.pcmanet.org/wp-content/uploads/2017/04/sPCMA_The_Management_of_Specialty_Drugs.pdf
https://www.hhnmag.com/articles/6930-how-hospitals-pharmacists-improve-care-without-breaking-the-bank
