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Hospital pharmacy: bleeder or feeder?



In the past, a bleeder was known only as a blood vessel cut during surgery that required clamping. Lately, however, hospital management has introduced the term ‘bleeder’ for a cost centre and ‘feeder’ for a profit centre. A bleeder needs attention or has to be cut away (and not by a surgeon but by a board of directors!). So if your department is considered to be a bleeder, you are challenged to turn it around, make profit and turn it into a feeder. What position does hospital pharmacy have in this discussion? Read more in the contributions from several colleagues.
Paul PH LeBrun
PharmD PhD
Hospital Pharmacist and Clinical Pharmacologist,
Central Hospital Pharmacy,
The Hague,
The Netherlands
The cost of medical care is a major issue in The Netherlands, as it is elsewhere. Managers review hospitals more and more for their economic value. The principle of return on investments is considered to be a synonym, if not a panacea, for efficiency.
Historically, the hospital pharmacy has been considered to be a cost centre for a hospital. It has no influence on production and thus does not add money to the budget. On the contrary, in the eyes of many mangers, it claims part of a rapidly decreasing budget.
Medicines will always be needed in therapy, of course, but what is added value in the hospital pharmacy and can we prove that it has added value at all? If so, how can we improve the added value? There are several possibilities, two examples of which are presented below.
A solid and coordinated purchasing policy saves money, especially when efforts are combined. In The Netherlands, hospital pharmacies work together in groups to negotiate best value for money. A major opportunity could be a swap to using biosimilars instead of originals. The hospital pharmacist can play a key role in this process and thus demonstrate their added value. At the same time, hospital pharmacists can initiate the evaluation of new therapies with expensive drugs. To date, this has been done in the case of the TNF-alpha inhibitors in several hospitals, resulting in major cost savings.
The reconstitution of medicines is a high-risk process. In The Netherlands, 95% of the handling is done by nurses on the wards. It has been demonstrated that, when this process is taken over by the pharmacy, it improves safety and saves money. In more and more hospitals, the hospital pharmacist is now taking the initiative and coordinating the reconstitution process. Product knowledge and experience with risk evaluation constitute the ideal combination of optimisation, increased safety and increased cost effectiveness.
Looking at the future, hospital pharmacists have to be more creative. They should strive to be more cost effective, by cooperating with those parties involved, by setting up commercial activities and by demonstrating the added value of medication safety, not only from a clinical point of view but also through demonstrating economic savings.
By daring to create a lean organisation, it is through demonstrating its added value that the hospital pharmacy can be a feeder for the hospital.
Martin J Hug
Director of Pharmacy
University Medical Centre,
Freiburg, Germany
Ever since Germany adopted the Diagnosis Related Groups System (G-DRG), concerns were raised that, from then on, treatment in hospital would result in an economical disaster. In fact, within the G-DRG, only a fixed flat fee will be paid for each individual case, mostly independent of the patient’s total length of stay. It is apparent that, under these circumstances, the combined costs for medicinal products and services matter more than ever. Patients requiring expensive drugs might possibly mean a financial loss for the respective hospital if cost control is not vigorously enforced.
In this particular setting, hospital pharmacies play a major role. Trained to keep costs down by negotiating the best price for medicines, German hospital pharmacists have prevented the cost for drugs from having a negative impact on their institution’s budget. At the same time, they have developed tools to monitor the use of innovative and therefore expensive drugs. For these products, the G-DRG offers the possibility for additional reimbursement, but only if the costs can be attributed to the individual case. Nowadays, many pharmacies document the costs for the more expensive drugs on a case basis and submit this information directly to their hospital’s administration. Another side effect of the G-DRG, however, is the trend to treat more and more patients in ambulatory care. In this setting, hospital pharmacies play yet another important role.
Drugs administered in the outpatient clinic may be provided by the hospital pharmacy, which, in turn, bills the costs for the medication directly to the insurance companies. Revenues generated by this system increase the overall profit of the respective hospital. While all these services have demonstrated the making of cost control more transparent while at the same saving money for the hospital, they do require more skilled staff in the pharmacy. It is a challenging task for each pharmacy director to explain to his administration the need to invest in infrastructure and personnel in the pharmacy. It is therefore mandatory to document the pharmacy’s efforts undertaken to keep the hospital’s budget at bay.
Michael Scott
Head of Pharmacy and Medicines Management,
Northern Health and Social Care Trust,
Antrim, UK
In the United Kingdom, the hospital pharmacy service has changed very significantly over the last twenty to thirty years, from a product-based distribution system to a very much more patient- centred clinical service.This has been facilitated by enabling technologies, such as robots and e-procurement solutions, which have allowed such change to occur in an efficient manner.
This change has generally been implemented in an overarching manner by programmes variously termed pharmaceutical care, medicines management and (most recently) medicines optimisation. Thus, the hospital pharmacy service is now predicated on the principles that safety and quality will drive health gain and economy.This is exemplified in procurement by the development of a clinician-driven evidence-based process, to meet service need at best value for healthcare resources. In addition, in relation to aseptic requirements, for example, the ability of production units to provide ready-to-administer items and the use of dose banding with regard to cytotoxic agents have all helped to achieve greater efficiency for the health service.
The role of hospital pharmacy in clinical trials and greater involvement in both research and service development has led to improved patient care and as well as income and enhanced capacity for the service.
However, the greatest developments have been in the patient-centred re-engineering of medicine procedures and processes. This includes the role of the pharmacy team at admission, with comprehensive medicines reconciliation, robust inpatient monitoring of medicines use (now further enhanced with pharmacist prescribing), high-quality discharge, incorporating good communication with primary care colleagues, and better multidisciplinary working with both medical and nursing staff. All these actions and  numerous others have been evidenced to show that hospital pharmacy is definitely a feeder, as there is a positive return on investment of the order of 5–8-fold but, most importantly, that it is achieved by the provision of a safe, high-quality service to patients.
Anna Carollo
PharmD PhD MS
Hospital Clinical Pharmacist,
ISMETT Hospital, Palermo, Italy
Hospital Pharmacists are challenged to fulfill, in modern healthcare, their historic role as professionals who, working with physicians, hold patients’ well-being as their foremost concern. Advances in biomedical science and technology and drastic increases in the cost of care have changed the way medical care is organised, delivered and paid for. The future of medical care depends on whether professionalism survives or succumbs to the profit motive and whether, faced with increased competition and restricted funding, care-givers will sustain the ethic of providing care to all who need it. Clinical pharmacists can best improve the quality of care by dedicating themselves to rational drug therapy. Drug-use evaluation in hospitals must increasingly demonstrate patient benefit, not just cost savings. Clinical pharmacists can improve the prevention of adverse drug reactions by more timely dissemination of drug information to physicians.
Clinical pharmacists should be assertive in identifying non-rational prescribing trends. Clinical pharmacists’ responsibility for therapy will expand and the future will require clinical pharmacists to distinguish between efficiency in providing quality services and narrow economic motivations. Wise choices will help to ensure pharmacy a full partnership in patient care.

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