Challenges, Opportunities Mark Health Care Landscape in 2022

This year, professionals in health-system pharmacy have had their fair share of challenges—and opportunities, too. Although it’s impossible to address them all, the ones discussed below seem to be on everyone’s list.

Challenges

Pharmacy technician shortages. It’s virtually impossible to attend an industry conference or even have a conversation with a colleague without discussing this problem, which continues to beset health-system pharmacies. Worse still, there is no indication that it will abate anytime soon. Results of a survey conducted in late 2021 by the American Society of Health-System Pharmacy (ASHP) showed the magnitude of the issue, with key findings that include the following:

•Most pharmacy executives reported technician turnover rates of 21% to 30%, and 10% of executives reported losing 41% or more of their technician workforce.

•A vacancy rate of 22.2% and 20.8% was reported for inpatient and ambulatory technician positions, respectively.

•Eighty-nine percent of pharmacy executives said that pharmacists were forced to perform technician duties, 53% that service reductions were required, and 48% that expansion of new services had been delayed.¹

Pharmacy executives continue to use a variety of strategies, not all with equal success, to recruit and retain technicians, including developing career ladders that provide advancement opportunities, implementing training programs, offering incentive pay for open shifts, raising salaries, paying the cost of meeting registrations and memberships, serving as rotation sites for external training programs to increase the pool of recruits, and offering sign-on bonuses. Another option available to them is the use of agency technicians to mitigate short-term staffing needs.¹

The ASHP also surveyed technicians, and results showed that a determining factor in their job satisfaction was having a positive relationship with supervising pharmacists. Although it’s imperative that pharmacy executives promote such relationships, salary is the main factor to be addressed. Seventy-five percent of technician respondents indicated that higher pay would help them stay in their current position. Heavy workloads and inadequate staffing were also given as reasons why technicians left their jobs.¹

Drug shortages. In the second quarter of 2022, there were 265 drug shortages. The amount of time and effort staff spent addressing them was staggering. In an ASHP survey from early this spring, more than 99% of respondents said that they had been affected by the scarcity of critical drugs.² More recently, the shortage of iohexol (Omnipaque), a contrasting agent for x-rays, made the national news, and human albumin is once again difficult to obtain in the quantities required. Pharmacy staff continue to mitigate shortages by switching to therapeutic alternatives, increasing conversion from intravenous to oral formulations, and changing order sets and protocols. On the operational side, they swap products in anesthesia trays and crash carts, purchase alternative or nonformulary vial sizes, and centralize inventory. Of note, slightly more than 20% of respondents said they had purchased drugs in short supply from a gray market wholesaler, and 7.1% reported that a medication safety event occurred as the result of a shortage.² To identify and implement long-term solutions, national pharmacy organizations will have to work with the FDA, the federal government, and other professional healthcare organizations.³

Burnout. Burnout, a preexisting problem that was only exacerbated by COVID-19, continues to hound pharmacists and technicians. Shortages of the latter and the increased workload associated with the undersupply of drug have increased burnout.^4,5 To mitigate it, pharmacy leadership must pursue the following strategies:

•Ensure that sufficient staff is available to perform the work that needs to be done.

•Create a workplace culture that fosters camaraderie, collegiality, and interpersonal relationships.

•Increase technician salaries so they are commensurate with the work being performed.

•Minimize staff, especially technician, turnover as much as possible.

•Promote flexible work schedules and work-life balance.

•Use incentives and rewards whenever appropriate.

•Provide counseling and other employee assistance and support as needed.^4,5

Even after implementing these actions, however, meaningful improvement in this area may be quite challenging.

340B drug pricing program in peril. The 340B program faces challenges from 18 drug manufacturers.⁶ If it is significantly altered, the consequences will be devastating for 340B hospitals that rely on these savings to support care for underserved patients. Pharmaceutical companies have imposed restrictions on 340B discounts when drugs are dispensed at community pharmacies, including requiring that claims data be provided to a designated vendor to access 340B discounts at contract pharmacies and allowing only a single-contract pharmacy to access 340B pricing if the hospital does not have an in-house pharmacy that can dispense drugs purchased under 340B.⁷ Since the end of 2021, the estimated annualized impact of restrictions on 340B hospitals has more than doubled, to a median of $2.2 million for disproportionate-share hospitals, rural-referral centers, and sole community hospitals, and to $448,000 for critical-access hospitals.⁷ Challenges to the legality of these restrictions are being played out in the courts, with the federal government continuing to advocate for a 340B program that preserves its original intent. It is imperative that 340B hospitals prepare a community benefit report detailing the use of its 340B savings as well as patient impact profiles demonstrating how the program positively affects their care. These documents can have a significant impact when advancing the cause on Capitol Hill.

White bagging. White bagging is not going away but is, in fact, increasing in frequency. For health-system pharmacies, it can lead to problems with finances, patient care, regulation, and safety.⁸ The drugs targeted by white-bagging programs are frequently expensive chemotherapy agents and other specialty medications. The ASHP has developed recommendations for states to consider when developing white-bagging legislation.⁹ Several states have been successful at getting legislation passed to address this issue.¹⁰ From a hospital perspective, the goal should be to allow white bagging when it is the only option to care for a patient and failing to do so would result in a negative outcome. Furthermore, hospitals should fight for the ability to buy and bill for these medications themselves.¹¹ Such efforts are needed at the national and state levels to oppose payer-mandated white bagging.¹² It is important to engage with and educate both the government relations group within an institutio —so that it can, in turn, educate state legislators—and the managed care contracting team, which is, after all, negotiating payer contracts.

Opportunities

Hospital at home. The pandemic greatly increased hospitals’ interest in moving patient care out of the facility, in large part to help alleviate capacity overload. Although not a new care model, many health systems and hospitals have recently implemented or are in the process of implementing the hospital-at-home (HAH) model, under which acute care is provided at a patient’s home for conditions such as asthma, cellulitis, heart failure, and pneumonia that historically would have required admission.¹³ Care is typically a combination of in-person visits and telehealth monitoring by various health care providers, including pharmacists. As of September 30, 2022, the Centers for Medicare & Medicaid Services (CMS) had approved 114 systems and 256 hospitals in 37 states for the Acute Hospital Care at Home initiative (AHCaH), which began in November 2020.¹⁴ Hospitals can request a CMS waiver for 2 participation conditions that allow care to be given at home but reimbursed as if provided at the hospital.¹⁵ Institutions receive full payment for patients’ Medicare Severity Diagnosis Related Groups. The concern exists, however, that the CMS waiver for the AHCaH program may not continue once the public health emergency (PHE) expires. Our hospital is discussing the HAH program with other payers to assess potential interest. However, as previously stated, HAH programs were in place and successful before the AHCaH was established. Hospitals considering an HAH program should have a pharmacist on the senior committee charged with its implementation who can take the lead on all aspects of the program relatedto medications.

Telehealth. Over the past 2 years, pharmacists have embraced telehealth so as to continue providing care. As defined by the Department of Health and Human Services, telehealth is the “use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration.”¹⁶ Telehealth can be performed via the internet, the telephone, streaming media, store-and-forward imaging, and videoconferencing.¹⁷ Due to the pandemic, CMS authorized telehealth waivers that eliminated some of the limitations previously in place, like the requirement for an in-person visit before transitioning to telehealth. Care of patients via telehealth during the COVID-19 PHE was so successful that CMS, commercial payers, and state policy makers indicated they wanted to continue using it.¹⁸ The ASHP recently released a Statement on Telehealth Pharmacy Practice that “advocates for telehealth utilization in suitable functions of pharmacy operations and patient care to improve patient outcomes, expand access to health care, enhance patient safety, achieve effective cost of care, and interact with other health care team members.”¹⁸ Reimbursement for pharmacist-provided telehealth services, however, has been difficult to obtain because pharmacists are not considered health care providers under Medicare Part B. Therefore, the ASHP is working toward having pharmacists recognized as reimbursable health care providers by all health insurance plans, including Medicaid and Medicare, although it is cognizant that intermediate steps may be needed before this occurs.¹⁸ The bottom line is that telehealth is here to stay, so it is imperative that the pharmacy profession take a leading role in its refinement.

Flexible workplaces. The pandemic also provided an opportunity for health care to reevaluate its belief that most procedures must be performed onsite. Historic concerns about remote work included questions about worker productivity and the feasibility of performing certain functions at home. However, studies have demonstrated that pharmacists can be more productive when working from home and have higher job satisfaction, suffer less burnout, and call out less frequently.^19,20 Many pharmacist and technician duties—like chart review, acquisition of drug preapproval, order entry and verification, follow-up calls, and the provision of drug information—can be accomplishedwith just a computer and a phone. Staff often prefer amix of onsite and offsite work. In our department, we have successfully implemented a hybrid model for the pharmacy information technology team, preauthorization technicians, and specialty pharmacists and technicians.

It is inevitable that some of these challenges and opportunities will still be with us in the New Year. However, it is also a given that 2023 will bring its own set of challenges and opportunities.

References

1. Pharmacy technician shortage survey findings executive summary. American Society of Health-System Pharmacy. March 2020. Accessed October 19, 2022. https://www.ashp.org/-/media/assets/pharmacy-technician/docs/Technician-Shortage-Survey-Exec-Summary.pdf

2. Severity and impact of sterile injectable drug shortages. American Society of Health-System Pharmacy. Updated March 2022. Accessed October 19, 2022. https://www.ashp.org/-/media/assets/drug-shortages/docs/ASHP-Sterile-Injectable-Drug-Shortages-March2022.pdf

3. Improving the quality and resilience of the United States healthcare supply chain. American Medical Association, American Society of Anesthesiologists, American Society of Health-System Pharmacists, Association for Clinical Oncology, and the United States Pharmacopeia. Accessed October 19, 2022. https://www.ashp.org/-/media/assets/news-and-media/docs/Healthcare-Supply-Chain-Recommendations

4. McQuade BM, Keller E, Elmes A, et al. Stratification of burnout in health-system pharmacists during the COVID-19 pandemic: a focus on the ambulatory care pharmacist. J Am Coll Clin Pharm. 2022;5(9):942-949. doi:10.1002/jac5.1672

5. Yamamoto K. Avoid burnout during times of uncertainty. Pharmacy Times. May 13, 2022. Accessed November 3, 2022. https://www.pharmacytimes.com/view/avoid-burnout-during-times-of-uncertainty

6. Protect patients. Stop 340B cuts! 340B Health. Accessed October 17, 2022. https://www.340bhealth.org/newsroom/stop340bcuts/

7. Contract pharmacy restrictions represent growing threat to 340B hospitals and patients: survey results. 340B Health. Accessed October 17, 2022. https://www.340bhealth.org/files/Contract_Pharmacy_Survey_Report_FINAL_05-05-2022.pdf

8. Traynor K. White bagging a growing concern for health systems. American Society of Health-System Pharmacists. March 22, 2021. Accessed October 17, 2022. https://www.ashp.org/News/2021/03/22/White-Bagging-a-Growing-Concern-for-Health-Systems

9. ASHP’s model white bagging legislation. American Society of Health-System Pharmacists. Accessed October 17, 2022. https://www.ashp.org/advocacy-and-issues/key-issues/other-issues/additional-advocacy-efforts/ashps-model-white-bagging-legislation 

10. Snyder B, Feild D. An overview of white bagging: the effect on systems and potential strategies. HOPA News. 2021;18(3). Accessed October 17, 2022. https://www.hoparx.org/hopa-news/volume-18-issue-3-2021/practice-management

11. Fein AJ. White bagging update 2022: hospitals battle to boost buy-and-bill. Drug Channels. September 21, 2022. Accessed October 17, 2022. https://www.drugchannels.net/2022/09/white-bagging-update-2022-hospitals.html

12. ASHP stands opposed to payer-mandated white bagging. American Society of Health-System Pharmacists. March 17, 2021. Accessed October 17, 2022. https://www.ashp.org/News/2021/03/18/ASHP-Stands-Opposed-to-Payer-Mandated-White-Bagging?loginreturnUrl=SSOCheckOnly

13. Hawkins BA. Executive summary of the meeting of the 2022 ASHP commission on goals: optimizing hospital at home and healthcare transformation. Am J Health-Syst Pharm. 2022;79(21):1945-1949. doi:10.1093/ajhp/zxac216

14. Approved facilities/systems for acute hospital care at home. Centers for Medicare & Medicaid Services. Updated September 30, 2022. Accessed October 15, 2022. https://qualitynet.cms.gov/acute-hospital-care-at-home/resources

15. Acute hospital care at home individual waiver only (not a blanket waiver). Centers for Medicare & Medicaid Services. Accessed October 15, 2022. https://qualitynet.cms.gov/acute-hospital-care-at-home

16. FAQs on telehealth and HIPAA during the COVID-19 nationwide public health emergency. US Department of Health and Human Services Office for Civil Rights. Accessed October 16, 2022. https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf

17. Telehealth in your pharmacy practice. American Pharmacists Association. June 1, 2020. Accessed October 16, 2022. https://aphanet.pharmacist.com/sites/default/files/audience/APhACOVID-19Telehealth0620_web.pdf

18. Begnoche BR, Butler CD, Carson PH, et al. ASHP statement on telehealth pharmacy practice. Am J Health-Syst Pharm. 2022;79(19):1728-1735. doi:10.1093/ajhp/zxac188

19. Kusoski C, Polley S, Kennerly-Shah J. Coronavirus 2019 work-from-home productivity of inpatient and infusion pharmacists at a comprehensive cancer center. 2022;62(3):877-882. doi:10.1016/j.japh.2021.11.02

20. Shaw G. As COVID-19 comes and goes, is remote work here to stay? Pharmacy Practice News. January 19, 2022. Accessed October 15, 2022. https://www.pharmacypracticenews.com/Operations-and-Management/Article/01-22/As-COVID-19-Comes-and-Goes-Is-Remote-Work-Here-to-Stay/65872