Fred M. Eckel RPh, MS, Pharmacy Times Editor-in-Chief

A new term in health care is “value.” When used as a noun, value can mean “the importance, worth, or usefulness of something.” When used as a verb, it can mean to “consider (someone or something) to be important or beneficial.” For all of us, health care is important and most people would say that health care has value. But what does that mean in practical terms when the consumer makes a health care decision? How does cost fit into the value system at the patient level? Should cost even play a role, some might ask?

When different treatment options are available, cost is certainly a factor in a payer’s consideration. One stimulus for health care reform to cover uninsured individuals was to improve health care access. One reason offered to support this coverage was that uninsured individuals delayed seeking medical care, or used more expensive resources such as emergency departments (EDs) when finally seeking care. If we provide these individuals with health insurance, they will seek care sooner when treatment is less expensive—and they will use less expensive resources when seeking care.

In theory, this makes sense; however, it seems as if it is not working as expected. We are all creatures of habit. So, as a recent study showed, even with coverage, some people are still using the ED for health care. This problem suggests that cost of care is not part of the value proposition for some people.

Personally, it is a part of my decision-making process in most areas of spending, but my health care decisions are different. When I need care, I don’t want to or even know how to “shop around” for a less expensive alternative. At that point, I do what I have been doing in seeking care because it has worked for me in the past. It is what I know, and I want immediate help. Some suggest that if better preventive services were available, my need for immediate care would be less. That may be true, but that doesn’t change how I behave when I do have a medical problem that requires immediate attention.

Payers may also think that I should include cost as part of my medical care decisions. They put in place “prior approval” requirements or even multi-tiered formularies to try to get me or my provider on my behalf to include cost in my health care decisions. Maybe these approaches work, but it seems as if they just lead to patients and providers being frustrated with the fragmentation of the system. My personal physician recently shared with me his frustration with these efforts by payers to control costs. As providers, we end up feeling as if some administrator is practicing medicine on our patient’s behalf rather than the provider.

Cost should be part of the value equation. I accept that fact—but until I can become a truly informed patient, I don’t think I will factor cost in at the time I seek care. Unless I gain some economic benefit from including cost as part of my decision making, I don’t think I will easily change the way I seek medical care, nor will other people.

Just to illustrate my point, I recently went through an illness and ended up using 3 different health care facilities within a week for 3 different procedures. A recent 

 article focused on how hospital list prices for common procedures vary dramatically, even in the same area. Now that I am seeing actual copies of my bills, I can’t believe what these procedures cost! If I had known that there was a difference in prices that hospitals charged, I might have considered shopping around. However, when I was in pain from my gallstones, honestly, my mind was focused on feeling better, not saving money for my payer.

Yes, cost is part of the value proposition, but it needs to be in place at the system level, not at the time patient care services are provided.

Fred Eckel, RPh, MS, is the editor-in-chief of Pharmacy Times and co-editor of the Directions in Pharmacy series. He is a professor emeritus at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, and emeritus executive director of the North Carolina Association of Pharmacists.

Articles

Cost is a part of the value proposition, but it needs to be put in place at the system level. 

Achieving Value

Our editor-in-chief examines how state-level pharmacy issues and trends can go beyond state borders.

I have always said that pharmacy is local—and so it is with great interest that I took a closer look at what was happening in state pharmacy associations. Here’s what I found people were saying in the states as we strive to give pharmacy 1 united voice on a national level. Are you involved?

1. “Our profession is being redefined in many ways, and our emphasis and role in the health care delivery system as pharmacists and pharmacy technicians is evolving rapidly. This fact alone presents us with tremendous challenges...”

Change is certainly the name of the game, no matter where you practice. Groups need to focus on not just getting us through the change, but trying to advance our role as it occurs. This state association is focused on helping its members prepare for change. Are you part of an organization that is doing that for you?

2. “Successfully advancing our profession through the legislative process requires access to and the ability to influence key legislators and decision makers with monetary campaign contributions. In politics, money talks…”

Making change happen in desirable ways often requires getting involved in politics. You can do that alone, but when you do it with professional colleagues you often have more clout. Are you part of a group that is politically involved on your behalf? Are you contributing time and financial resources, too?

3. “Membership is the lifeblood of any association…and our group is already working hard to identify ways to convince more…pharmacists that they should become members of their state professional association.”

All issues in pharmacy are local, even if they have national implications. The body that focuses attention at the state level is your state pharmacy association. Are you supporting your state pharmacy organization with your membership?

4. “Our state is not alone in advancing provider status for pharmacists. Many states are tackling that same issue, as are our national pharmacy organizations. Leaders in pharmacy are collaborating on developing standards for our profession so that we can speak with 1 united voice aimed at achieving provider status. We need standards that we all can agree on in order to develop an approach for advocacy and our legislative efforts.”

Most pharmacists recognize that obtaining provider status is critical to the advancement of pharmacy. Although this is a professional concern, it will only happen through the political process. Have you focused your political involvement on those activities most critical to achieving our desired future? Our political success as a profession depends on our individual political actions.

5. “The Disease State Management/MTM Task Force is nearing its 10th Anniversary of advocating for the advancement of pharmacist-led patient care services…”

Our profession moves forward when we share our insights and experiences with others to develop new programs. Are you volunteering on committees to help advance your profession? Pharmacy needs to gather its members’ wisdom and insight.

6. “Every organization should have a ‘stop doing’ list. What will be on our list? This is the purpose of our annual planning session. Admittedly, it is easier to start new programs with promise than it is to put a stop to marginally effective ones.”

This insight was part of a state association president’s message as he shared the organization’s commitment to strategic planning. Are you engaged in a strategic planning process for your own practice—or even your own life? As we take on more things, we have to be willing to let go of old, less successful activities. As your professional activities change, what have you stopped doing? As these quotes from 6 different state pharmacy associations reveal, much is happening in pharmacy at the state level. As I’ve attended meetings of the National Alliance of State Pharmacy Associations, I’ve learned that association executives are dedicated leaders trying to help their state pharmacists not only survive but thrive. Often they do that without even having the majority of the pharmacists in their state as members.

If that applies to you, consider becoming a member. Some say, “I just don’t have time, so, therefore, I will not join.” My response is that our membership contributes funds to help sustain the organization’s program. So, until you have the time, at least contribute your finances. 

One United Voice

A recently released online study conducted in 8 countries suggests that patient attitudes about privacy in health care may be changing. More than 70% of the respondents said they are receptive to using toilet sensors, prescription bottle sensors, or swallowed monitors to collect personal health data. A personalized health care regimen based on a genetic profile was preferred by 66% of the respondents. Trusting the results of personally administered tests as much as or more than if they came from a doctor was accepted by 53% of respondents to this study, “Intel Healthcare Innovation Barometer,” conducted by Penn Schoen Berland for Intel.

Another interesting result was that 57% of the respondents believe traditional hospitals will be obsolete in the future. Although I have been suggesting this will occur as we watch hospitals morphing into health systems in our local communities, such a suggestion might seem out of step with our observed reality. Commenting on the survey results, Eric Dishman, Intel Fellow and general manager of the company’s Health and Life Sciences Group, stated “Most people appear to embrace a future of health care that allows them to get care outside hospital walls, lets them anonymously share their information for better outcomes, and personalizes care all the way down to an individual’s specific genetic makeup.” He went on to say that “Care must occur at home as the default model, not in a hospital or clinic.”

Although we are not there yet, my recent experience with the health care system suggests that hospitals are not necessary in most situations for good health care to be delivered.

Here’s my story. I woke up on a Sunday evening with the worst upper gastrointestinal (GI) pain I have ever experienced and had some vomiting. The pain subsided as it seemed to progress down my GI tract. Although I felt lethargic that week, I was able to work, thinking I had a viral GI event given to me by my grandchildren. However, by the next Saturday evening, I felt some pain and thought it might be a kidney stone.

That Sunday afternoon, I visited my family physician’s urgent care facility, where the physician assistant diagnosed a possible kidney infection and prescribed an antibiotic. I thought I was starting to feel better but got a call from my doctor’s office informing me that my pancreatic enzymes were elevated and I needed to have an ultrasound performed. That revealed gallstones in my bile duct.

The next day, I had an appointment with a surgeon who ordered a magnetic resonance cholangiopancreatography (MRCP), which occurred the next morning. Before my surgeon could remove my gallbladder, she needed me to have an endoscopic retrograde cholangiopancreatography to remove the stones in my bile duct. Because it wasn’t an emergency, that procedure did not get done until the following Monday morning.

Three days later, I had my gallbladder removal, and I was able to teach my Sunday school class 3 days later. I was back at work that Monday, 3 weeks after my initial bout with pancreatitis. Through all those events, I was treated as an outpatient. Although my MRCP was done in a hospital outpatient department and my surgery was done in a facility that could have kept me overnight, I had no need for a hospital to receive any of the care I received.

The survey respondents suggested that hospitals will be obsolete in the future, and my own recent health care experience validates this observation. As I lecture on the future of health care, I suggest that hospitals will become a place you go to die because they will only be needed for trauma care after a severe injury when the patient’s situation is life threatening.

I learned a few other things through this episode. There are a lot of very caring health professionals who do their jobs very well. When you are hurting, you care more about your provider’s bedside manner than the credentials they possess. There may be a lot of problems with the US health care system, but when it works well, it is the best.

When I came back to work after my health care experience, I felt as if I had been given a new beginning. May you view 2014 as an opportunity for your own new beginning. 

Our editor-in-chief shares a personal experience to illustrate the growing belief that traditional hospitals will be obsolete in the future.


What Role Will Hospitals Play in Health Care's Future?

Yes, I saw Watson win at Jeopardy. I have heard presentations on how Watson was being used to assure that a cancer treatment was personalized to assure best outcomes for the patient. Recently, IBM Software Solutions Group senior vice president announced in a news release that “For the first time IBM will make its IBM Watson technology available as a development platform in the cloud, to enable a worldwide community of software application providers to build a new generation of apps infused with Watson’s cognitive computing intelligence. The move aims to spur innovation and fuel a new ecosystem of entrepreneurial software application providers—ranging from start-ups and emerging, venture capital-backed businesses to established players. Together with IBM, these business partners share a vision for creating a new class of cognitive applications that transform how businesses and consumers make decisions. With this move, IBM is taking a bold step to advance the new era of cognitive computing. Together with our partners we’ll spark a new class of applications that will learn from experience, improve with each interaction and outcome, and assist in solving the most complex questions facing the industry and society.”

Of course, my first reaction upon reading this news release was to question whether this is more hype or ask if have we truly entered a new era. We have heard these types of promises before.

 focuses on health information technology. Just as Watson has opened up a whole new era of cognitive computing, we focus on the same types of developments that are happening in health care. It provides me with an opportunity to reflect on my personal evolution to become more comfortable with computers.

In many ways, I am really old school. I started working with computers when punch cards were used to program a computer—hard to believe! More than 50 years have passed since that graduate school experience, and the change in computing has seen exponential growth. People of my era were skeptical about how computers would improve our lives, and some may still be.

Recently, I was reflecting on how my approach to handling money has changed dramatically as I have become more secure with using the financial tools available. Many younger people probably wonder why I had any trouble moving from using cash or writing checks to using online payments or automatic monthly payment withdrawals. It was hard for me to quit balancing my checkbook each month and rely on my bank statement, but I have. Paying that bill or making a contribution online was hard at first, but now I do it routinely. However, I still ask for transaction receipts when I use my credit card, so I am not completely liberated.

I share this personal perspective because I think it conveys the thought that what has happened in the financial world could happen in health care when we solve the interoperability issues and achieve system connections across the health care continuum. Just think what we, as pharmacists, will be able to do when we have access to the information we need—and can share our patient outcome goals with other team members. Is such a possibility realistic in the coming years?

This question is raised by many of us who have been hearing for years how health care is changing as information connections occur. Our experience, however, is that for each step forward, we end up taking 2 steps back, often due to unintended consequences.

The articles in this issue would suggest that things are different now and that this time the promises are more realistic and, therefore, probable. One difference is how connected most people are to their smartphones today. As we learn how to harness that connectivity and use it to promote better health care outcomes, we will see improved access with better outcomes and lower cost. I believe these benefits will result in quicker adoption.

Another reason I believe things are different now is that the current system is so broken. An administrator once told me, as we talked about how to make change happen in our hospitals, that real change can occur only in 2 situations: 1) when the system is working so well that people have nothing to lose by the change, or 2) when the system is so broken that no one has anything left that they want to protect. The latter seems to be where the US health care system is today. As the articles in this issue suggest, pharmacy is being well positioned to make change happen, but more importantly, to take advantage of the change to better serve our patients.

Mr. Eckel is a professor emeritus at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He is interim executive director of the North Carolina Association of Pharmacists.

This issue of Directions in Pharmacy focuses on health information technology.

Getting Connected

A new phrase has entered the pharmacy lexicon: “transition of care.” What does this term mean and how does it affect the pharmacy community? I would like to explore these questions.

I had a conversation recently with a hospital pharmacy director who said that a great deal of her time was focused on ensuring a smooth transition in the care process, especially in medication therapy when a patient was being admitted to or discharged from the hospital. She stated that this term, “transition of care,” was just another way of expressing the goal of continuity of care—a concept she said I used to talk about when I taught hospital pharmacy. I will leave it to someone else to decide if these concepts are identical, or if “care transition” is a component of ensuring “continuity of care.”

What is obvious is that everyone, from payers, to providers, to patients and regulators, is concerned about safe and effective transitions when a patient moves from one health care setting to another. There are probably many reasons for this interest, but a major reason is that more problems occur at this juncture in the care process than any other—and these problems can be costly and dangerous for the patient. Thus, everyone is focusing attention on care transitions to save money and to keep the patient safe.

While attending a meeting recently, I asked an independent pharmacy owner how his daughter was doing now that she had graduated and returned to his pharmacy to work. She had taken one of my courses and had talked about how excited she was to put some of her training into practice in a community pharmacy. As her father responded that she was doing well, you could tell by his voice and countenance that not only was he a proud dad but he was pleased that she was bringing real innovation to their pharmacy practice.

The pharmacist went on to describe a new program which his daughter was taking the lead to implement. They had approached a large physician practice group in their community with a proposal to work with them to help manage the patient care process when their patients are discharged from the hospital to return to their home or another facility. He mentioned how receptive the medical group was to this request because they were being evaluated by how well patients did during these transitions. The doctors viewed the pharmacy help not as a cost, but as a tool to improve reimbursement. He went on to suggest that he and his daughter plan to expand this program to other practices and even the local hospital.

This type of program is not unique only to a small town in rural North Carolina, as pharmacy owners work to improve health care in their communities. Many chain pharmacies have also moved into such programs; recently, the Walgreens WellTransitions, a coordinated care program, was endorsed by the American Hospital Association.

“The Walgreens WellTransitions program will serve as another tool for hospitals seeking to reduce readmissions and support overall community wellness,” stated Anthony Burke, president and chief executive officer of AHA Solutions. “We have endorsed this program for the broad scope of services that are provided through Walgreens’ extensive network of pharmacies and pharmacy services.”

The message I hope you get from my commentary is that there is great opportunity for community pharmacy, but it will take “transformative thinking.” This idea was described by RADM Scott F. Giberson, acting deputy surgeon general, in a recent article (

 70:1601-1604, September 15, 2013). Here he says, “Transformative thinking does not mean simply thinking of a way to add more detail to what we are already doing or adding more constructs to seemingly improve an established baseline. Transformative thinking means we must also try to advance our practice, not just improve it, for the benefit of the nation’s health.”

Those community pharmacists who have become engaged in helping patients manage care transitions are engaging in transformative thinking. Are you one of these?

Our editor-in-chief explores the meaning of the term "transitions of care" and how it affects the pharmacy community.

Care Transitions

I was leading a discussion with a group of community pharmacy residents recently. We were talking about the health care transformation and how the community pharmacist will have a new and exciting role to play. As I closed the discussion, I offered this observation: “What an exciting time to begin a career in pharmacy!” It is the same message I offer to the readers of 

. You are coming into pharmacy at the beginning of a new era for pharmacists.

It is obvious that our current health care system cannot be sustained. Change is needed. That change will focus on increasing access and quality, while containing or reducing costs. That is exactly what pharmacists do. Numerous studies and demonstration projects have shown that when pharmacists get involved, costs go down while quality and patient satisfaction go up. These are the very things needed to improve our current health care system.

The fact that pharmacists are the most accessible and underutilized health care professionals is becoming well recognized. New programs to utilize the pharmacist are being proposed. Your pharmacy school curriculum is preparing you for these new roles. You are comfortable working as part of an interdisciplinary team. You will graduate with a strong knowledge base on the appropriate use of drugs. Since drugs, when used correctly, are one of the most cost-effective treatment modalities, you are well positioned to make immediate contributions.

Patients need to focus more attention on prevention and wellness. The health care system is recognizing this and is paying for preventive services. Immunizations are one area of preventive services where pharmacists will be playing a much larger role in the future—and you will be, too. The community pharmacy is becoming positioned as the neighborhood health center, in part because of immunization administration in pharmacies. Your role will become more consultative as the patient’s coach as well as the health educator for the community. Most of us went into pharmacy to give back to our communities, and now you will be able to do that in new ways.

Chronic disease is growing as people live longer. Pharmacists have demonstrated through the Asheville Project and the Ten City Challenge that we have an important role to play in helping to manage these conditions. Again, you are well prepared to undertake this role. It is for all of these reasons that I see exciting opportunities for our profession ahead.

Of course, these new opportunities are still limited, so not everyone will find an ideal job immediately. That means you will need to find a way to differentiate yourself. Some of you will do this by pursuing a residency. Others will use volunteer activity to gain new skills or improve your experiences. It really is who you know that is key to creating opportunities for yourself. Make yourself known to those who are doing the job you would like to have. Find out what they did to achieve their position. Ask them to mentor you.

Yes, I believe your future is bright, but you will have to create that future. You must realize that graduation does not mean that a great job is waiting for you. Instead, graduation means that you can now start to create that ideal job. Look at any position in terms of “How can I use this experience to help me advance in my career?”

Thinking of pharmacy as a career—and not just a job&mdash;is the place to begin. Careers evolve as we grow personally and professionally.

Sometimes we have to take risks to achieve what we want. We learn from our successes but we really learn more from our failures, so don’t be afraid to fail. For those willing to work hard, continue to grow, and take risks, the future is bright. Pharmacy has been a great career choice for me. I hope you find it is that way for yourself, too.

Pharmacy Times' editor-in-chief argues that this is a very exciting time to be entering the profession of pharmacy.