Jason Poquette is the director for outpatient pharmacy services at Saint Vincent Hospital in Worcester, Mass., and an APPE preceptor for the Massachusetts College of Pharmacy. Contact him at Jason.pharmacist@gmail.com.

Jason Poquette, RPh

 continues to rise, with the front-runners like CVS Specialty and Accredo generating more than $30 billion in annual revenues in 2018 alone. By 2020, industry experts believe specialty drugs will account for 50% of U.S. spending on pharmaceuticals. 

Health systems and hospitals have been watching this trend and are entering the specialty drug dispensing industry. According to an analysis by Adam Fein of Drug Channels, “about one-quarter of all accredited specialty pharmacy locations are owned by hospitals, health systems, physician practices, and providers’ group purchasing organizations.”

But revenue alone is a rocky road on which to build the case for a health system specialty pharmacy. Margin pressures have forced several significant players to exit the market. Premier Inc. recently announced its decision to move away from the specialty pharmacy business. 

Health systems need to think strategically about how they design and implement specialty pharmacy programs. Those with access to 340B pricing may be lured into believing that the profits are virtually guaranteed; however, increasing political pressure and focus on this model, and legislation to reduce 340B reimbursements to hospitals, may require a new approach. 

The case for a successful health system specialty pharmacy model is built on the foundations of service and savings. Here is where health systems can offer value that often cannot efficiently be supplied by traditional mail-order specialty pharmacies. 

Part of the service advantage of a health system specialty pharmacy is a result of the convenience of being able to dispense directly to patients who are already at the hospital to see their providers, have blood drawn, or are there for outpatient treatment. Well designed specialty pharmacy workflows can provide an efficient way to dispense these medications to patients while they wait for their appointment or procedure. 

This service also allows health systems to use their best clinical staff to provide face-to-face counseling with patients about the use of specialty medications either within the individual clinics, during infusions, or in counseling rooms on-site. 

The cost of specialty pharmaceuticals continue to rise, and health systems need to think about ways they can help payers manage costs as well as care. By working closely with hospital providers and patient electronic medical records, health system specialty pharmacies can save money for payers by quickly discontinuing or delaying medications. 

There is an opportunity for hospitals to think about partnering with payers around outcomes-based pricing models where margins can be tied to tangible goals for patient success. Readmission prevention services for high-risk patients can also be used to help care for these patients in comprehensive, efficient ways. These and other creative approaches are more efficiently managed by a hospital outpatient specialty pharmacy.

The real winner of a health-system-based specialty pharmacy program are the patients, who will receive end-to-end care of their chronic illness or disease. By putting patient needs first and revenue second, hospitals can create value-based models for specialty pharmacy that are good for patients, payers, and providers.

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By 2020, industry experts believe specialty drugs will account for 50% of U.S. spending on pharmaceuticals.

Health System Specialty Pharmacies Enhance Services and Savings

First, do no harm. We’ve all heard these words from the Hippocratic Oath. But from the sounds of it, we might not be listening very well. A shocking 2016 report out of Johns Hopkins indicates that medical error is now the third leading cause of death in the United States. While all of these fatalities are not medication-related errors, many are.

Medication errors can happen in any setting, but I am especially sensitive to the challenge of preventing errors in a retail pharmacy where there are so many competing priorities and constant distractions. My advice, therefore, is especially aimed at my brothers and sisters on the bench.

Preventing errors has to become the very flavor and language of your pharmacy. When you travel, you learn about different cultures by immersing yourself in their language, food, customs, and style. Visitors to your pharmacy should likewise get a sense that “safety” is your custom, the way you live and move. You do this by talking about it frequently, sharing examples, telling stories, and being a champion of error-prevention yourself.

believe the training programs in most of our organizations are inadequate for the demands of a busy, distracting retail pharmacy. Sure, we expect our personnel to have a baseline drug knowledge. But where we fall short are the computer-training, problem-solving, communication-techniques, and people-skills needed to efficiently work together as a team. Untrained people get flustered and then make mistakes. Well-trained people work more efficiently. Good training brings all the parts together. And this requires an investment in great trainers and training programs.

I urge you to have a zero-tolerance policy for chaos in the pharmacy. The mantra I communicate frequently to my team is: “Busy is good, chaos is not.”
	Chaos is usually the result of one or more good people making one or more bad choices.
	For example, we might cut corners to try and speed things up to an unsafe pace. Baskets in the work flow might get disorganized. Patients might be promised unrealistic timelines, thus putting inappropriate pressure on the team. Someone might get flustered, distracted, or upset. You need a leader, ideally the pharmacist, to exude a calming influence and to insist on maintaining decency and order in the work flow steps.

I tell my pharmacists to picture themselves in a courtroom every time they verify a prescription, trying to explain to a jury why they allowed that prescription to go out. A scary thought-but we need sobering reminders of just how serious our job is.

Take a breath. Read the label carefully. Think. You must train yourself to look for all of the possible errors that may be in front of you. Is this a commonly confused drug or dosage form? Does the dosing make sense? Does the prescription seem reasonable for this patient given their age, gender, and history? There’s simply no checklist that will replace the importance of getting your head in the game. Every time. Every single prescription.

Pharmacists must cultivate a culture of safety, training to protect patients.

How to Prevent Medication Errors

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For some of us, pharmacy school was a long time ago. The painfully long nights studying, the grueling exams, the incomprehensible kinetic lectures have mostly faded into misty memories. That is probably a good thing. My school did a great job preparing me to become a pharmacist, and I’m grateful now for what felt like torture at the time.

However, after being a pharmacist for many years, there are definitely some things I know now that I didn’t know back then. To be fair, it wasn’t really the job of my university to prepare me for everything in life. As Julius Caesar put it, “Experience is the teacher of all things.” I needed to work, make mistakes, face fear and frustration, try new things and struggle a bit to learn these important lessons.

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For the most part, that is how you are going to learn them too. But maybe I can share a few things I’ve come to see as a pharmacist that I didn’t know, or fully appreciate, when I graduated from school. And maybe you will learn these things sooner than I did.

First, I have learned that your character is more important than your GPA. I’m not saying that grades and academics are unimportant. They are. Study hard and do your best on every assignment. But when you graduate into the “real world” you will be judged a lot more frequently on the type of person you are.

Heraclitus, the ancient Greek philosopher, said “character is destiny.” So I would challenge my fellow pharmacists to think seriously about the type of person you want to be. What do you want said about you when you reach the end of your career? Be that person today. This is how you develop character, leadership and success. No one carves their GPA on their tombstone.

Second, I have learned that you are going to make 

. Much of your training in pharmacy school and on rotations is about how to 

 mistakes, and rightly so. No one wakes up wanting to make an error that day. But sometimes we spend so much time talking about error prevention that we forget to think about managing our failures.

I’m not just talking about dispensing errors. I mean all of our blunders, which include careless comments, poor business choices, unintentional rudeness, sloppy work, and things we just forgot to do. I wish I had taken better notes and determined to learn from my mistakes earlier in my career. Someone once said, “your best teacher is your last mistake.” Think about that for a while.

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Third, I would say one of the things I wish I knew in school was the importance of focusing more on what I’m good at than what I’m not. School in general, and exams and rotations in particular, are very good at exposing our weaknesses. We notice what we got 

. As a result, we naturally tend to focus our attention on the things we struggle with and believe it is our job to improve in those areas. To some extent that is true.

However, the problem with that is that most of us will only ever move our “weaknesses” from “below average” to “mediocre” at best. But our strengths are another story. Focus on what you’re good at. Push yourself in that thing that you already do better than most. For me it was pharmacy management, leadership, team building, and business. I loved those things and was naturally pretty good at them. But for a long time I felt guilty about not 

 the clinical side of our profession. I got over it. And now I love my pharmacy career.

I don’t regret that it took me a while to learn some of these important career lessons. But I would regret not sharing them with others, with hopes and prayers that you learn them sooner than I did.

What one pharmacist says he wishes he’d prioritized sooner.

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