Charity Care and Ethics

We as hospital pharmacistshave traditionally minimizeddrug expense through formularymanagement, negotiation ofcontracts, elimination of waste anddiversion, and optional inventory-managementpractices. Continuing efforts topromote cost-effective prescribing,emphasizing a focus on optional drug-therapyoutcomes, and enabling pharmaciststo modify orders based on therapeutic-interchange policies also havecontributed to limiting drug-expenseinflation. When I look retrospectively atthe growth of my drug budget over thelast 8 years, I am proud of my staff'sefforts to assume a sense of fiscalresponsibility for the clinical enterprisewithout compromising the quality ofcare we provide.

Despite this success, I am anxiousabout our preparedness for the future.The cost of technology,skyrocketing pharmacistsalaries, novel drugswith 5-digit prices, andindividualized therapybased on genetics promiseto keep us under thefinancial microscopeduring the foreseeablefuture. Without question,hospital executives willlook to our professionand its members forguidance and leadershipto ensure that drug therapydoes not "break thebank."

Among the many factorsthat will increasecosts of providing comprehensivepharmacy services in thefuture, the provision of charity care isthe most daunting. Our first challenge isto understand the definition of charitycare from an accounting perspective,from state and federal government perspectives,and from the hospital perspective.Presuming that charity care isdifferentiated from bad debt, pharmacistsneed to appreciate those differencesas well. The concept ofcharity care is daunting, becauseI believe that we areapproaching a time when hospitalsand society must cometo grips with the financial implicationsof providing unabatedcharity care. In doing so, I suspectthat the use of drugs forpatients for whom limited ornonexistent payments areanticipated will come intoquestion. These patients arenot limited to "indigent" or"homeless" people but includethose of "limited means," suchas seniors on fixed incomesand illegal aliens.

Pharmacists with patient-focusedor administrative responsibilities mustbe prepared to actively participate in,or even lead, discussions about limitingdrug use in selected populations.As distasteful as this practice sounds,it appears inevitable unless healthcare financing reform takes place. Wewill need to understand the principlesof ethics that apply to making healthcare decisions, policies that guidepractitioners objectively and consistently,tools to assess comparativevalue of health care interventions, andmuch much more. Finally, we willneed to determine where all of thisunderstanding fits into similar strategicplanning for the entire clinicalenterprise.

It seems to me that the best placeto start is by partnering with schoolsof pharmacy and professional associationsto develop educational opportunitiesfor current practitioners, residentsand future leaders, and all ourstudents. We must become facile withethics, comparative value, and the principleson which both are based.

Mr. McAllister is director of pharmacyat University of North Carolina (UNC)Hospitals and Clinics and associatedean for clinical affairs at UNCSchool of Pharmacy, Chapel Hill.