Jim’s top 10 issues facing hospital & health system pharmacy in 2019
The continued evolution of antimicrobial resistance remains a top threat worldwide. Excitingly, in September, the Centers for Medicare and Medicaid Services (CMS) enacted a new rule requiring hospitals participating in its programs to establish Antibiotic Stewardship Programs (ASPs). A fully functioning ASP is a key element in a comprehensive strategy to control this serious public health threat. The rule mandates ASPs in U.S. hospitals in an attempt to improve the use of antimicrobial drugs and ultimately help address inappropriate use of these drugs, reduce risks to patients, and reduce or slow healthcare costs.
While this action is laudable, the real question for hospitals remains: “Is this just a check the box item for compliance or will hospitals invest in creating a high performance and fully functioning ASP?” From our experience working across the country, if you ask any hospital whether they have an ASP program invariably all will answer in the affirmative but not all would reach the desired level of high performance.
To create that high-performance ASP approach, Visante’s Bill Kelly and Warren Rose offer the following keys to success for 2020:
- Benchmark current antimicrobial resistance patterns with the local and regional resistance as well as similar institutions to identify the three most important opportunities for improvement.
- Develop accurate baselines and assessment of antimicrobial resistance and cost, patient lengths of stay, and organizational culture to develop an estimated return on investment.
- Obtain medical staff and organizational “buy-in” and financial support to develop an effective ASP.
- Appoint an ASP team with physician and clinical pharmacist co-chairs, including an epidemiologist, microbiologist, and infection prevention nurse.
- Standardize the order and antimicrobial use process.
- Ascertain accurate and timely computer records on antimicrobial use and cost by the hospital and by prescriber.
- Establish quarterly reporting of ASP findings and successes.
- Aggregate data on Physician Performance relative to guidelines reviewed in small physician groups monthly or quarterly.
- Create an ASP educational program for prescribers and pharmacists.
- Obtain accurate tracking of reductions in antimicrobial cost, lengths of stays for antimicrobial patients, etc.
- Select antimicrobial restrictions and conditions for appropriate use.
- Ensure careful evaluation and use of new antibiotics to maximize effectiveness and minimize the development of resistance.
Effectively curbing the growth of antibiotic resistance should be a goal for all hospitals and health systems and pharmacy should play a leading role in these efforts for 2020.
Alternative Payment Models for High-Cost Drugs
Orphan drugs, specialty pharmaceuticals, and gene therapy continue to show incredible promise for the enhanced control, “cure” or elimination of disease. However, along with these promising therapeutic advancements comes the challenge of how to pay for this entirely new class of therapy. The most recent addition to the gene therapy armamentarium Zolgensma (onasemnogene) from AveXis, a Novartis subsidiary, is a good case study.
Zolgensma is indicated for Type 1 Spinal Muscular Atrophy (SMA). This condition affects approximately 500 babies each year and currently, 80% of these babies would be candidates for gene therapy with Zolgensma. The drug is given as a single infusion with a price of $2.125M.
Considering the cost of Zolgensma from a cash flow perspective, a $2.125M upfront cost presents a dilemma for many small payers, state Medicaid providers, or self-insured employer plans or even for larger health plans that might experience multiple SMA patients.
Harvard Pilgrim in conjunction with the New Drug Development Paradigms (NEWDIG) collaborative at MIT has been working on an innovative performance based annuity payment plan for Zolgensma. This payment model is based on three key elements:
- A 5-year payment plan with a significant initial payment for the therapy (20% suggested).
- Subsequent payments are based on continued performance of the drug. If performance degrades, payments would be reduced accordingly.
- Mobility versus Portability for patient movement. Under the mobility plan payers would negotiate with AveXis to establish their payment rates. If a patient switches plans, the new plan would pick up payments at their negotiated rates.
While this pay for performance annuity model is innovative, it runs afoul of current Medicaid best price legislation. Medicaid “best price” was a policy solution enacted more than twenty-five years ago to address high drug costs and make Medicaid drug spending more manageable for states. Under the best price legislation, a drug manufacturer must offer state Medicaid programs the best price given to any other purchaser (with a few exceptions) with a mandatory rebate percent off the list price. Under the proposed pay for performance annuity model, if a patient had degraded results and a deeply discounted price went into effect this could trigger a new “best price” for everyone and no manufacturer would be willing to run this risk.
Senators Cassidy (R) and Warner (D) have introduced legislation under the Patient Affordability, Value and Efficiency Act to address this issue and create a pathway for a pay-for-performance approach. However, given the current issues being addressed by Congress, the likelihood of this bill moving forward in a timely fashion would seem to be questionable at best.
As therapy continues to advance with exciting new modalities on the horizon, equally innovative payment models must be created to ensure affordability and access to these new treatments and this will be an increasing challenge in 2020.
Sadly, drug shortages once again make the Top Ten list. Due to a myriad of factors the U.S. continues to struggle with hundreds of key drug shortages at any given point in time. This was underscored by the recent vincristine shortage, with vincristine being a “repeat offender” on the shortage list. These drug shortages continue to challenge hospitals and health systems to be able to provide critically needed medications for patients as well as to address the additional costs associated with managing these shortages. Although the issue of drug shortages continues to be reviewed by Congress and the FDA, there is no immediate resolution on the horizon for 2020 and hospitals would be well advised to continue to formalize and budget for their own shortage risk mitigation strategies and programs.
At the request of 31 U.S. senators and 104 U.S. congressional representatives, the FDA led an inter-agency Drug Shortage Task Force to examine the issue and provide recommendations. A comprehensive report from the task force was generated and the full version of this report is available on the FDA website at http://www.fda.gov/media/131130/download
The report identified three root causes for drug shortages:
- Lack of incentives for manufacturers to produce less profitable drugs.
- The market does not recognize and reward manufacturers for “mature quality systems” that focus on continuous improvement and early detection of supply chain issues.
- Logistical and regulatory challenges make it difficult for the market to recover from a disruption.
The report also recommends several enduring solutions to address drug shortages, which include:
- Creating a shared understanding of the impact of drug shortages on patients and the contracting practices that may contribute to shortages,
- Developing a rating system to incentivize drug manufacturers to invest in quality management maturity for their facilities, and
- Promoting sustainable private sector contracts (e.g., with payers, purchasers, and group purchasing organizations) to make sure there is a reliable supply of medically important drugs.
Also, the report describes legislative proposals in the President’s FY2020 Budget and planned FDA initiatives to prevent and mitigate shortages that look at improved data sharing, risk management, lengthened expiration dates for drugs, and internationally harmonized guidelines for a pharmaceutical quality system.
While all of this is certainly a step in the right direction there is still a considerable amount of change that must occur if drug shortages are to be effectively mitigated and controlled. One very interesting project involves the creation of a new 503B entity that will also include API manufacture in the U.S. Bringing API production back from overseas could be a major step in improving shortages but this would not be likely to provide any immediate 2020-shortage relief. For 2020, hospitals should continue to recognize the importance and impact of drug shortages and create and fund formal programs to address and mitigate drug shortages.
Alternate Purchasing and Contracting Strategies
As drug costs continue to escalate, total U.S., prescription drug spending will top half a trillion dollars by the end of 2020, and strategies to flatten that cost curve are becoming increasingly important. Traditional “price point” negotiations for drugs will not be effective in helping to address this challenge. Also, the study from NORC at the University of Chicago on rising drug costs demonstrated that while the overall cost of drugs is increasing rapidly, there is a disproportionate amount of that increase that manifests in hospitals, making this of even greater concern. While there may be some relief from rising drug costs from government initiatives, the likely impact for 2020 will be minimal.
More interesting are some of the evolving alternative purchasing strategies that could have a much larger 2020 impact.
- Contract Grouping Model. This is predicated on the concept of grouping different products and product types together to produce a larger aggregate spend with a company across a broader portfolio and thereby lower overall costs for the portfolio. This includes mandatory bundles where a hospital must purchase the entire bundle to get the reduced pricing on the entire portfolio. This approach often includes both pharmacy and supply chain items. Focused bundles, while still mandatory, are based on a smaller more focused portfolio which may or may not include supply chain. Flexible portfolios where the hospital can structure their own custom portfolio with pricing commensurate with total aggregated volume seem to be the most popular approach to contract grouping with hospitals.
- Value or Risk-Based Contracting. This approach for population health management is grounded in simple math. Healthcare organizations that exceed total medical spending targets for these contracts effectively absorb a penalty. Those that keep expenses below targets create savings they can keep. This approach is focused on outcomes of therapy and associated “value” produced by those outcomes and is a data-driven model that requires a true partnership between drug manufacturers and hospital systems. While attractive in theory the major challenge is the required agreement on defined outcomes and the ability to access the required data to support outcome capture and analysis.
- Risk-based Partnership Model. This approach requires a partnership based on a defined portfolio of services with an upside in sales for the supplier and guaranteed savings for the hospital. This model would be most relevant for a major supplier like a drug wholesaler. A health system might provide a much longer contract period in exchange for a guaranteed approach to margin enhancement through defined programs for expense reduction, revenue maximization and creation of new revenue sources. This approach might also consider a “gain share” opportunity for the defined supply partner.
- Central Service Center Model. Many larger health systems are exploring the option of becoming their “own GPO.” This approach is predicated on the recognition that the largest GPOs are still relatively small purchasers on the list of major drug purchasing entities in the U.S., and pricing between major GPOs is not significantly different to add enough value. Health systems are considering establishing central service centers for contracting and distribution for member hospitals. In this mode,l wholesaler engagement can also be variable up to and including complete elimination of wholesaler use.
- Hospital Owned Drug Manufacturing – CivicaRx Model. This approach originally developed in response to continuing drug shortages and rising prices with the creation of a non-profit generic injectable drug manufacturing company owned by member hospitals. The focus is on ANDA opportunities with generic drugs in shortage situations and generic drugs with high costs. The Civica approach provides one price for all buyers regardless of size or volume. Initial operations will rely on contract manufacturing but future operations will include full owned manufacturing capabilities
- Securitization Model. Securitization is the process of taking an illiquid asset and through financial engineering, transforming it into a security. This approach is predicated on aggregating significant volumes within a class of drugs ($1-2B). It focuses on multi-source options with equivalent therapeutic impact and requires total commitment from participants to move market share based on an aggregate decision. This model assumes market share movement is large enough to positively impact stock prices for the “winning” product/company. In addition, stock price appreciation creates value for investors and this security value is shared back among member purchasers. The theory is this approach can produce a much larger financial return than traditional price point negotiation and contracting
- 503B Model. Most hospitals and health systems purchase a significant amount of compounded sterile products provided by “Voluntary Outsourcing Facilities” – 503B providers. Many systems are exploring the creation of an “owned” 503B operation to service member hospitals at a lower total cost. Alternatively, systems are also exploring making a formal investment in a commercial 503B operation to provide better control of product selection and pricing without having to make a significant capital investment to build their own 503B operation. The larger GPOs are also players in this market providing “private label” products for members.
For 2020, I don’t believe that any single alternative strategy will be enough to significantly flatten the drug cost curve but a combination of alternative strategies may be worth exploring.
Sterile Compounding/USP 797/800
With the delay in implementation of the revised USP Chapters <795> and <797> along with the new Chapter <825> and the likely move to early 2020 implementation, this again makes the Top 10 list.
The implementation delay is a result of USP considering appeals for the following three topics under USP <795> and <797>:
- Beyond-use date (BUD) provisions in both chapters,
- Removal of the alternative technology provision from USP Chapter <797>, and
- Applicability of both chapters to veterinary practitioners.
Chapter <825> is also under appeal in terms of compounding from sterile substances and the applicability of <825> within the radiopharmaceutical regulatory context.
It would appear the majority of state boards that have already adopted <797> will wait for the release of the revised chapter and will not move forward with revisions to their rules & regulation until the new chapter is finalized with no pending appeals. However, since General Chapter <800> is not subject to any pending appeals, it will become official on December 1, 2019. It is important to note that during the postponement and pending resolution of the chapter appeals, USP has stated that <800> is informational and not compendially applicable. Nonetheless, some states will be enforcing <800> in its current form as of December 1. Sites should look to their state regulating bodies for guidance.
I would recommend operating under the assumption that this is likely to be a short delay and pharmacies should take full advantage of the “extra time” and be ready to demonstrate full compliance to the revised and new Chapters <795>, <797>, <800>, and <825> in short order for 2020
Evolution of Central Service Centers
For 2020, I anticipate continued M&A activity and growth of health systems. One of the primary drivers of system expansion is the opportunity to leverage economies of scale and reduce waste and duplication of effort across supply chain processes. Consolidation and centralization of inventory along with standardization of ordering and receiving processes through the creation of a consolidated service center (CSC) is a concept receiving more interest and attention.
Given the significant growth in drug spend for health systems, pharmacy as either a stand-alone CSC entity or in combination with Supply Chain is a logical element for consideration in any central service considerations. From our experience supporting health system CSC development, there is no “one size fits all” approach to creating these CSC models. The size and scale and combination of services should be tailored to the individual needs of each organization to produce the greatest return on investment.
In terms of pharmacy, the following areas can be considered for CSC opportunities:
- Drug Distribution Services
- To what extent will “insourcing” apply to wholesaler, GPO, and direct contracting?
- How much will be centralized versus decentralized and how will oversight be conducted?
- Investment Buys – how will this be coordinated relative to:
- Drug Shortages
- Market place “deals”
- Drug Storage – Systems and technology required?
- Drug Distribution – Logistics?
- Controlled Substances
- Fulfillment & Prescription Services
- ADC Replenishment
- Kits & Tray Preparation
- Repackaging (Low Unit of Measure to Bulk)
- Non-sterile Compounding
- Sterile Compounding
- 503A Operations
- 503B Operations
- Infusion / Home Infusion Services
- Remote Medication Order/ Prescription Entry & Verification
- Ambulatory Prescription fulfillment
- Central Rx Mail Order
- Central Rx Refill Operation
- Specialty pharmacy
- Support Services
- Pharmacy Call Center Activity
- Prior Authorization Management
- Refill Authorization Management
- Ambulatory Formulary Management
- Indigent Patient Support Program
- Patient Care Telepharmacy Support
- Medication Therapy Management
- Chronic Disease Management
- Transition of Care Follow-up
- Pharmacy Call Center Activity
- 340B Program Considerations
- Implications/challenges for a Centralized Services Center (CSC) with a 340B “mixed house”
- Elements needed for a successful Health System-wide 340B program
- IT/Split billing system considerations for a CSC based 340B program
A CSC, while presenting a multitude of potential economies, also requires a considerable investment in space, equipment and personnel resources. Organizations considering a CSC option should very carefully assess these needs and investments against a potential ROI and other organizational opportunities.
Drug Cost Control
With election season in full swing, a major point of emphasis for virtually all candidates from all political parties is control of prescription drug prices, which are outpacing all other elements of U.S. healthcare in terms of cost increases. This issue seems to be one of the few bipartisan areas of agreement in what is otherwise shaping up to be a highly contentious election based on partisan political party affiliation. While there will be voluminous amounts of opinions on needed healthcare reform in 2020, I expect little actual action, which is why healthcare reform itself doesn’t make the list. However, drug cost control has the potential to see changes.
Hospitals and health systems should pay close attention to the variety of plans being put forward, including:
- Prescription Drug Price Relief Act (Senator Bernie Sanders and Representative Rho Khanna). This legislation would require the Secretary of Health and Human Services to make sure that Americans don’t pay more for prescription drugs than the median price of the following five countries: Canada, the United Kingdom, France, Germany, and Japan. If pharmaceutical manufacturers refuse to lower drug prices down to the median price of these five countries, the federal government would be required to approve cheaper generic versions of those drugs, regardless of any patents or market exclusivities that are in place.
- Prescription Drug Pricing Reduction Act (Senators Chuck Grassley and Ron Wyden). The Act aims to lower the price of prescription drugs by capping out-of-pocket drug costs for Medicare Part D participants and requiring pharmaceutical companies to justify drug price increases to the Department of Health and Human Services. A Congressional Budget Office review estimated that the bill would lower government spending by $85 billion over 10 years and save Medicare beneficiaries $27 billion in out-of-pocket costs and $5 billion in premium spending over the same period
- Lower Drug Costs Now Act is Speaker Pelosi’s bill to reduce drug costs. The primary element this bill would allow Medicare to negotiate lower prices on as many as 250 of the most expensive drugs per year and apply those discounts to private health plans across the U.S. The bill also includes a penalty on drug manufacturers that refuse to negotiate or fail to reach an agreement with the U.S. government, starting at 65% of the gross sales of the drug in question. A preliminary Congressional Budget Office analysis showed Pelosi’s plan would save Medicare $345 billion over 10 years.
- Affordable Prescriptions for Patients Act (Senators Cornyn and Blumenthal) would eliminate drug companies’ anti-competitive use of patents to protect prescription drugs and prevent generic and biosimilar competition from coming to market. The bill is designed to encourage competition and give patients greater access to prescription drugs at a cheaper cost without stifling innovation or infringing on patent rights.
- Secretary Azar and President Trump also continue to work on their “Blueprint to Reduce Drug Costs” although to date very few elements of this plan have been realized e.g. the failed attempt to force drug manufacturers to include their prices in TV ads and the failed attempt to eliminate rebates as part of the overall US drug pricing strategy.
Drug pricing remains a very contentious and complex issue for all elements of the U.S. healthcare community, and hospitals and health systems should very carefully evaluate the impact of any proposals to ensure that there are no unintended consequences such as negative impacts on 340B status or current revenue streams.
External Market Disruptions
U.S. healthcare continues to be challenged with escalating access, quality, and cost issues. To be successful in this environment requires transformational change initiatives, which by definition means changing the traditional way of thinking about service delivery. Changing processes and systems to achieve incremental improvements will not be enough to keep pace with the rapid rate of change facing U.S. healthcare.
One of the more anticipated changes has been the entry into the healthcare market of Amazon in partnership with JP Morgan and Berkshire Hathaway. These three corporate heavyweights partnered to launch Boston-based Haven Healthcare. Haven’s mission is to “work with clinicians and insurance providers to address issues like making primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable.”
There has been a lot of speculation on exactly what this healthcare entry strategy might involve. Amazon’s acquisition of Pillpak has signaled their interest in the mail order pharmacy market and the opportunity to capitalize on the low customer satisfaction ratings and customer experience that patients have with traditional mail order pharmacy. PillPack recognized that the problem of medication overload is a big one. Approximately 32 million Americans—10% of the population—are on at least five different prescription drugs. Studies have demonstrated that half of all Americans on medications don’t take them properly, adding $100 billion a year to U.S. health care costs. To support better medication adherence, PillPack provides patients their prescription drugs by mail order (nothing new there), but instead of sending all Drug A in one bottle and Drug B in another, medications are sorted together into clear plastic wrappers printed with the date and time at which they should be taken.
The idea of prepackaging medications by dosage before they even reach the patient isn’t something new. This is very similar to what many hospitals have been doing for several years with inpatients and goes back to the old Baxter ATC-212. In 2006, researchers at Walter Reed Army Medical Center demonstrated that by putting medications in blister packs they increased the proportion of people who took their medicine (from 61% to 97%). This approach certainly adds more competition to the market but also creates another opportunity for hospital‑based programs that are already familiar with this technology and approach from the inpatient side of the business and could easily adapt this for outpatients.
Also, in support of creating innovative models of accessing primary care both “live” and using online tools, Amazon Care was launched in September as a pilot in the Seattle market. Amazon Care provides a mobile app that enables employees to access virtual and in-person healthcare services. Amazon contracted with Oasis Medical (private practice) to provide in-home care for any of the company’s 60,000 Seattle-based employees. Amazon Care also provides applications for a video visit with a doctor, nurse practitioner, or registered nurse for advice, answers, diagnoses, treatment or referrals, as well as “Care Chat,” a text chat app that connects employees to a clinician for health advice and answers. Amazon’s “Mobile Care” facilitates nurse home visits to collect lab samples, perform some testing (such as tests for strep throat), administer common vaccines, or perform physical examinations. And Courier Care allows meds to be delivered to their homes. This platform would seem to open up many more pharmacy related opportunities as well and is also a model that many hospitals and health systems are exploring.
Amazon could also leverage its acquisition of Whole Foods to enter the retail pharmacy market via the grocery store route, but currently, their number of stores is significantly limited and this would likely pose little threat to the current market. There is also the potential for Amazon to get into the business of selling pharmaceuticals and compete with the wholesale drug market given their distribution capabilities but this also seems a less likely direction. The bottom line for 2020, however, is that non-traditional drivers of healthcare innovation like Amazon/Haven will continue to push the market forward toward transformational change and hospitals and hospital pharmacy operations should be paying attention.
Tragically, the opioid crisis again makes the Top 10 list for 2020. Despite increased concerns and attention, more than 130 people in the United States die each day from overdosing on opioids. The inappropriate use and subsequent addiction to opioids remain a serious national crisis that impacts not only U.S. public health but also our economic and social welfare. The Centers for Disease Control and Prevention has estimated that the total “economic burden” of prescription opioid misuse in the United States is $78.5 billion a year and growing. This figure includes the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.
While government agencies such as HHS and NIH continue to work toward national approaches and solutions to this problem, any sweeping national reforms to blunt this growing concern in 2020 seem unlikely. It appears that the best approach to addressing this issue and beginning to reverse this trend in 2020 involves a focus on local communities and hospitals. While opioid addiction is a major problem, with any big problem come big opportunities and this is an opportunity for hospital pharmacy to be a leader in the effort to curb opioid addiction.
The opioid crisis is a very complex and multifactorial problem and there is no simple “one size fits all” solution. In response to the opioid crisis, a multidisciplinary approach using pharmacy, nursing, physicians, pain specialists, addiction specialists, and social services experts is a logical approach. At a high level, there are several key areas where Opioid Stewardship programs can have an immediate impact on their local community.
- Advancing better practices for pain management. Working to establish better prescribing practices for pain management using multimodal approaches to therapy is a key tactic and an area where hospital pharmacy should be a leader. Assessing opioid prescribing patterns and discharge prescription quantities to limit excess amounts of opioid entering the community should be another ongoing program approach. Stopping the potential problem before it starts and effectively controlling pain without or with limited opioid use should be a cornerstone strategy for Opioid Stewardship teams.
- Strengthening patient assessment and surveillance. Establishing consultative programs to identify chronic opioid patients in advance of situations like surgery where opioid use may occur and developing alternative therapy plans or opioid sparing treatment plans can be an effective approach for Opioid Stewardship efforts.
- Improving access to treatment and recovery services. This can include establishing an ambulatory Opioid Stewardship Clinic to help manage and effectively wean patients off opioids; educating and focusing emergency services to rapidly address overdose situations; supporting formal addiction and recovery programs; establishing formal Pain Clinic programs to more effectively manage chronic pain patients, and leveraging telemedicine programs to provide enhanced access to care for more patients can all be effective approaches.
Promoting the use of overdose-reversing drugs. Creating community education programs and ensuring that rapid and easy access to reversal agents is available to the local communities that our hospitals and health systems serve is an opportunity to help reduce overdose related deaths.
While there is certainly the need to “think nationally” about the opioid crisis to have an immediate impact we need “act locally” and hospital pharmacy can and should be leaders and champions in this effort for 2020 and beyond.
Somewhat related to the opioid crisis is the issue of drug diversion in healthcare and this also again makes the list. As more people struggle with addiction to prescription drugs, they continue to escalate drug-seeking behavior and this problem is not exclusive to healthcare providers. Hospitals and health systems need to be mindful of the potential for diversion of controlled substances by employees. This can occur for personal use or to support a family member or loved one. However, diversion can also occur for sale where prescription opioids can be a lucrative opportunity.
The impact of drug diversion for hospitals and health systems can be significant in terms of:
- Impact on patient safety. We have had numerous national reports of addicted healthcare professionals exposing patients to blood borne infections such as Hepatitis C and HIV through the use of injectable drugs where diverters first used the drug for themselves and then injected patients with the same needle.
- Adverse Publicity. Hospitals and health systems can suffer significant damage to their reputation and brand image as a result of major diversion events.
- Regulatory Penalties. Lax controls and oversight of these drugs can result in serious sanctions by entities such as the Drug Enforcement Agency or individual State Boards of Pharmacy.
- Financial Impact. In addition to the value of the drugs being diverted, hospitals with lax controls and oversight that experience drug diversions can be subject to very significant fines and monetary penalties. We have seen escalating fines and penalty amounts levied by the DEA, with several recent examples of multi-million dollar fines.
Unfortunately, while drug diversion remains a serious concern and rising problem, far too many U.S. hospitals and health systems refuse to “learn from the misfortune of others.” Too few hospitals and health systems have recognized drug diversion as the serious problem it is and has not invested in a robust program to detect and prevent drug diversion. A robust diversion program depends on the collaboration and teamwork of a multidisciplinary group with oversight for managing controlled drugs and diversion events. Since diversion is an organizational problem, the team should have members from pharmacy, nursing, anesthesia, security, accreditation, human resources, risk management, lab, environmental services, and human resources, as well as representatives from the medical staff and senior leadership. The team should be responsible for policies, procedures, staff education and training, diversion monitoring, and management of diversion events. And, most importantly, the team should have a formal line item budget and the tools and analytics needed to do the job, which should include periodic external program reviews!
Drug diversion is not going away and is continuing to increase and every hospital and health system should have a formal program in place to protect its patients and its reputation/brand to the greatest extent possible. This is another area for 2020 where hospital pharmacy can take a leadership position.