Every Hospital Needs an Outpatient Pharmacy

Community pharmacies do a lot to improve the health of the communities that they serve, such as providing immunizations, medication therapy management, prescription synchronization, and smoking cessation programs. However, what is often under-appreciated is just how much community outpatient pharmacies located within hospitals can do to save lives and health care costs, as well as improve the financial situation of health systems. It should be standard practice for all hospitals to have outpatient pharmacies, just as they have infection control, inpatient pharmacies, and laboratory services.

Much of the talk within health systems centers on 30-day readmission reductions, patient satisfaction and quality scores, and population health management, a sort of catch-all phrase that focuses on improving access to care and creating programs, often from an analysis of big data sets, to keep large numbers of people under the organization’s care healthy. Two drivers for this relatively new focus are that 1) there is a shift away from the fee-for-service model to the bundled payment model, where a health system might get the same amount of money to take care of the patient, no matter what happens to them, and 2) hospitals are being penalized for readmission rates that are higher than the national average. In addition, patient satisfaction and quality scores are made publicly available for consumers to use when choosing a place to receive care. Penalties are calculated as a percentage of total Medicare reimbursement and can be a few percentage points, which for most hospitals means millions of dollars in lost revenue if they are penalized. Because of this, any department that can reduce readmissions and improve quality is worth more in avoided penalties and reduced expenses than they ever will be in departmental net revenue.

Unfortunately outpatient pharmacies are not often given the priority that they need to reach their full potential. In the area I work, for example, a health system has sold its outpatient pharmacy to a chain, another has closed its outpatient pharmacy, and a third has never, as far as I know, had an outpatient pharmacy. Still another, where I work, has thankfully maintained control of its outpatient pharmacy program.

One study observed that 25% of patients being discharged never even pick up their first month of medications.¹ Others have put the figure even higher.² I have seen a variety of reasons that this is the case, including financial issues, lack of insurance coverage, the hospitalist choosing a non-preferred product, and transportation issues. These problems are best solved within the hospital and prior to the patient going home.

It has been and continues to be my vision for outpatient pharmacies to be truly decentralized and integrated fully within the hospital, much like inpatient pharmacies. Many outpatient pharmacies, including ours, run meds to beds programs that deliver discharge medications to a patient’s room prior to them going home. We also not only run coupons proactively, which many community pharmacies do, we also are able to work directly with the team on the floor to ensure coverage prior to going home. For example, I work closely with our inpatient diabetes education team, and they often will call me up just to find out which basal or mealtime insulin is preferred by the insurance company. I might run a test claim for Levemir, get a rejection, then run another one for Lantus, where I get a paid claim. They can then take that information to the hospitalist so that there are no problems getting it filled. Our case managers fax prescriptions down almost daily just to get a price quote for discharge medications. With no access to an outpatient pharmacy, this is clearly not possible.

We also have a host of other programs, including a medical-supply program, where we deliver bath sponges, walkers, sock aids, etc., to the room along with medications for orthopedic-surgery patients; an oral nutrition supplement program, where we sell and deliver dietician-ordered nutritional products to encourage the patient to use them after being discharged, which has been shown to reduce readmissions; and a de-prescribing program, where we have worked with health system physicians and counseled patients to reduce the combination prescribing of benzodiazepines and opioids. Most recently, I have worked with our case management, diabetes education, and nursing teams to create a standardized workflow for us to refer patients without insurance or primary care to appropriate community clinics and to make it easier for the case manager to identify and make an appointment for the patient at the right clinic. I have also represented community pharmacy on quality committees, which is an important perspective.

Doing all this does take significantly more staffing than most outside community pharmacies and so is of course much less profitable on paper. However, considering all that it does, a hospital cannot afford to not have an outpatient pharmacy that is integrated within a health system. If a health system is truly to improve quality and satisfaction, reduce readmissions and push population health management forward, then outpatient pharmacy is an indispensable member of the team. It is time that every health system consider making one a part of theirs.

References

1. Fallis BA, Dhalla IA, Klemensberg J, Bell CM. Primary medication non-adherence after discharge from a general internal medicine service. PLoS One. 2013 May 2;8(5):e61735. doi: 10.1371/journal.pone.0061735.

2. Leguelinel-Blache G, Dubois F, Bouvet S, et al. Improving patient’s primary medication adherence: the value of pharmaceutical counseling. Medicine (Baltimore). 2015;94(41):e1805.

doi: 10.1097/MD.0000000000001805.