Post on 18-Jun-2020
Pharmacoeconomics and
Management in Pharmacy IV
2012 [UNIT PH 3340] 1
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
2012 [UNIT PH 3340] 2
News review
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
NAO 2011 Report revisited (i)
• Steps have been taken to address some of
the deficiencies
• The GHPS has been converted into the
Central Procurement and Supplies Unit
(CPSU)
• Plans are in motion for the implementation of
a wide-ranging and multi-functional IT
system
3
J. Vella [PH 3340]
NAO 2011 Report revisited (ii)
• The situation whereby tenders were re-
issued or bypassed by direct ordering is also
being remedied
• The main obstacles to change are fear and
deeply entrenched legacy practices that
have been built up over a period of decades
• The introduction of new approaches requires
the introduction of a new ethos and work
ethic
4
J. Vella [PH 3340]
Massive margins?!
• Generic clopidogrel 75mg tabs x 28 retails
for € 29
• Tender for state supplies was won at €
2.13!!(Summer 2012)
• A great differential between the private
market and that for publicly purchased
medicinals
5
J. Vella [PH 3340]
Fair play?
• Is such a pricing strategy morally correct?
• Should the first priority of a pharmaceutical
company be the maximisation of profits or
the provision of equitable healthcare with the
concomitant effect of a fair financial reward
as a collateral effect?
• Do such price differentials have a punitive
effect on the state system?
6
J. Vella [PH 3340]
Discussion
• Are patients forced to depend on the state
system for pharmaceuticals because of the
high pricing strategy for generics?
• Should generic drugs be granted MAs only if
pricing is substantially below that of the
current market price?
• If so what discount would be deemed
acceptable?
7
J. Vella [PH 3340]
A historical note
J. Vella [PH 3340]
The advantages of modern
medicine
• It was only in the 1830‘s that medical care
broke even with the probability of patient
survival, as opposed to no intervention at
all!
• Antimony treatments and bleedings were
commonplace prior to the 1800‘s
• Very few members of the public appreciate
how far medicine has come, and how
uncertain it still is
J. Vella [PH 3340]
Technology’s effect on survival
rates and health care spending (i)
• A working paper 1 divided HTI into three
types:
• (i) home administered, e.g.
pharmaceuticals
• (ii) Interventions with varying degrees of
value e.g. an angioplasty
• (iii) Interventions with no proven value e.g.
knee arthroscopy at a cost of $ 5,000 per op
• 1Chandra & Skinner, 2011
J. Vella [PH 3340]
Technology’s effect on survival
rates and health care spending (ii)
• Applying the rationale to cardiac
interventions, the investigators discovered
that :
• 44% of the reduction in mortality from 1980
to 2000 was due improved health behaviour
• 22% was due to Cat(i) such as aspirin and
beta-blockers, 12% Cat(ii) like angioplasty,
and 10% due to Cat(iii) interventions
J. Vella [PH 3340]
Technology’s effect on survival
rates and health care spending (iii)
• The cost of Cat(i) and Cat(ii) increased modestly
over the period under review
• Cat(iii) contributed greatly to the increase in
healthcare expenditures
• This seems to indicate that current healthcare
administrators are narrowly focused on a
paradoxical pairing of cost-cutting and an affinity
for new and attractive technologies rather then
concentrating on patient outcomes as the crux of
treatment protocols
J. Vella [PH 3340]
Is the recession increasing access
to health-care? (i)
J. Vella [PH 3340]
Is the recession increasing access
to health-care? (ii)
• It appears that patients are accessing less
healthcare services as they are being more cost
conscious
• The physical constraints on the system are being
relieved by a drop in demand
• There is a reported drop in unmet needs and
delay in access to care
• Could unnecessary interventions now be avoided?
• Are patients evaluating the actual medical and
quality of life improvements prior to care?
J. Vella [PH 3340]
Is the recession increasing access
to health-care? (iii)
• Could we apply a similar principle to the local
healthcare scenario?
• Introducing a form of co-pay or prescription fee
might reduce wastage and unnecessary usage of
free state medical and pharmaceutical services
• Prescribing limits for physicians could also enable
a quantification of trends within the system
framework
• An element of cost-consciousness must be
inserted, otherwise excesses will persist
J. Vella [PH 3340]
The cost of ageing (i)
J. Vella [PH 3340]
The cost of ageing (ii)
J. Vella [PH 3340]
Bad news!
J. Vella [PH 3340]
Financial implications
• No decrease in CVS admissions means that
there is no improvement in quality of life and
resources employed
• More effort to enforce prohibition and
increased health promotion required
• A recent commentator argued for the
outright banning of tobacco and its
classification as an illegal drug
J. Vella [PH 3340]
More bad news!
J. Vella [PH 3340]
More bad news!
• Malta in figures 2012 published by the NSO
J. Vella [PH 3340]
Mortality 2011
J. Vella [PH 3340]
Vioxx in the news again!
J. Vella [PH 3340]
A planned aberration
• The company knowingly promoted the drug
for an unapproved indication, and set aside
funds for damage settlements
• A case of premeditated damage limitation
• In certain cases the FDA has bowed to
pressures from ‗big pharma‘ to approve
NME
• The financial stakes are enormous
J. Vella [PH 3340]
Obesity again!
J. Vella [PH 3340]
Champions, of the flab?
• Maltese men are the fattest in Europe!
• Maltese women are second to the UK
• We make the top of the list for the wrong
reasons
• More awareness of the potential dangers
must be created, from an early age
• A tax on fatty foods? Introduced in Denmark
J. Vella [PH 3340]
Discussion points
• Should obese people be forced to pay a
surcharge on medicines they get free, if
they are the sequelae of their own
negligence?
• Should healthy and lifestyle conscious
individuals have to pay for other‘s
indiscretions?
• Could future health systems measure vital
statistics and insurance be paid
accordingly?
J. Vella [PH 3340]
The irony of life
• A recent study found that a drop in the price
of foodstuffs in high-income countries was
related to an increase in consumption and
obesity-related morbidity
• A case of too much or too little, as exhibited
in the previous examples
• It is expected that rates of obesity will rise
further as basic food prices keep dropping
J. Vella [PH 3340]
Vaccines are big money(i)
J. Vella [PH 3340]
Vaccines are big money(ii)
• Research is costly
• Few specialised companies, high barrier to
entry
• Pfizer acquired Prevenar through its
acquisition of Wyeth
• 175,000 cases and 6,000 deaths per year in
the US
• Vaccines eliminate their own need over
time!
J. Vella [PH 3340]
HCP Euro Diabetes Index
J. Vella [PH 3340]
More money does not make
for better outcomes!
• Denmark and the UK head the standings
• The UK has by far the best outcomes, but
lags behind in the number of podiatrists
• Denmark needs to improve in Prevention &
Outcomes
• Both countries spend as much as Greece
and Finland
• Malta is in 20th place(but tops in obesity)
J. Vella [PH 3340]
The Cardiac index
J. Vella [PH 3340]
More money DOES make
for better outcomes!
• This is not the case for cardiac outcomes
• The top three countries in per capita
spending top the cardiac care index
• There is also no correlation between the
availability of drugs such as clopidogrel and
statins and the prevalence of heart disease
• Malta ranks 15th
2012 [UNIT PH 3340] 35
A comparison of vital
statistics: Malta & the US
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
David & Goliath
• At first glance the comparison might seem
ludicrous
• A country of close to 300 million should
definitely win hands down when placed side
by side to one with 400,000 individuals
• First thoughts and certain ingrained
misconceptions are however deceiving, as
we shall see
36
J. Vella [PH 3340]
Population
37
J. Vella [PH 3340]
GDP per capita(in 2009 PPP
international $)
38
J. Vella [PH 3340]
Health Exp per capita(PPP Int $
2008, WHO)
39
J. Vella [PH 3340]
Health Exp as a % of
GDP(2000/2009)
40
J. Vella [PH 3340]
Health Exp as a % of GDP over
time (US)
41
J. Vella [PH 3340]
Life Expectancy at birth
42
J. Vella [PH 3340]
Once again prosperity = long life!
43
J. Vella [PH 3340]
Physicians per 100,000 pop.
44
J. Vella [PH 3340]
Malta in 2000 WHO rankings
45
J. Vella [PH 3340]
Why?
• The 2000 WHO health system rankings were
revealing!
• Malta placed 5th whilst the US placed 37th
• This, regardless of the great disparity in
resources deployed
• All the more so intriguing since there are
obvious deficiencies in the Maltese system
46
J. Vella [PH 3340]
Not how much but how!
• The deployment of resources is critical
• In the Maltese Islands our primary care
system is well developed
• Citizens have easy access to physicians
who can take timely decisions on whether to
dismiss, treat or refer
• The number of deferred hospitalisations is
low
47
J. Vella [PH 3340]
A different approach
• This is not the case in the US
• Primary care has developed along different
lines
• The uninsured are only begrudgingly
afforded the mandatory emergency care
• Often the same patients turn up elsewhere in
a worse condition, and now costing more to
treat
48
J. Vella [PH 3340]
Multi-layered care systems
• On both countries, the patients, prescribers,
dispensers, and purchasers of
pharmaceutical care are distinct
• This leads to a level of disconnect
• The value of the intervention is not passed
along the treatment chain
• This leads us to the need to introduce value
into HTA and pharmaceutical care structures
49
2012 [UNIT PH 3340] 50
Healthcare expenditures in a
local and global context
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
The public health system and
pharmaceutical care
J. Vella [PH 3340]
J. Vella [PH 3340]
Increasing healthcare
expenditure(i)
J. Vella [PH 3340]
Expenditure vs GDP
J. Vella [PH 3340]
Increasing healthcare
expenditure(ii)
• The figure for the Maltese Islands per capita
is € 185, or around $ 249 at today‘s rates
• This does not take into account PPPs
• If purchasing power parities are taken into
account, then the figure would be $313 per
capita (2009 fig, from UPenn CIC)
• After adjusting for variation, it still emerges
that spending in Malta is 1/3 that of the US
J. Vella [PH 3340]
Increasing healthcare
expenditure(iii)
J. Vella [PH 3340]
Increasing healthcare
expenditure(iv) (PPP adjusted)
J. Vella [PH 3340]
Increasing healthcare expenditure
(v)
J. Vella [PH 3340]
Increasing healthcare expenditure
(vi)
J. Vella [PH 3340]
A few definitions (i)
• GDP – Gross Domestic Product, which can
be defined as the total market value of all
final goods and services produced in a
country in a given year, equal to total
consumer, investment and government
spending, plus the value of exports, minus
the value of imports
• A commonly quoted figure
J. Vella [PH 3340]
A few definitions (ii)
• GNP – Gross National Product includes all
that is encompassed by the GDP plus any
goods manufactured abroad by entities
owned by nationals of the said country
• Gross as opposed to the Net Domestic
Product, which is the GDP minus the
depreciation of the capital national stock
J. Vella [PH 3340]
A few definitions (iii)
• Recession is officially defined as two
consecutive quarters of negative GDP
figures
• An important economic indicator, together
with the Rate of Inflation, unemployment
figures and expenditures in various vital
public sectors
• Politics has a lot to do with spin and ‗feel
good‘ factors!
J. Vella [PH 3340]
An example (i)
J. Vella [PH 3340]
An example (ii)
J. Vella [PH 3340]
The American paradox, again! (i)
J. Vella [PH 3340]
The American paradox again! (ii)
• Better survival rates in breast and colorectal
cancers
• Higher rates of admission in asthma and
COPD
• Primary system is underdeveloped due to a
shortage of physicians
• Administration costs are 2.5x the OECD
average
J. Vella [PH 3340]
Annual Expenditure on health in
the Maltese Islands
J. Vella [PH 3340]
Pharmaceutical expenditure in the
Maltese Islands
• € 36.5 million in 2003
• € 76.4 million in 2010
• A sharp increase, more than double in 7
years
• Has the quality of care increased?
• Are final patient health outcomes improved
or are we simply increasing treatment
without keeping an eye on the effects?
J. Vella [PH 3340]
New Medicines Increase Longevity They Account for 40% of Increase in Life Expectancy
Data source: Lichtenberg8
0.120.23
0.30
0.570.45
0.76
0.56
1.07
0.62
1.37
0.70
1.65
0.79
1.96
0.0
0.5
1.0
1.5
2.0
2.5N
um
be
r o
f Y
ea
rs I
nc
rea
se
d L
on
ge
vit
y
1988 1990 1992 1994 1996 1998 2000
Increase in Longevity Due to
New Drug Launches
Total Increase in Longevity
J. Vella [PH 3340]
Note: Total health care expenditures for 2004 were $1.9 trillion.
* Now revised to Structures and Equipment
** Now revised to Government Public Health Activities
Data source: U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services,
Office of the Actuary6
Research and Construction*
Personal Medical Equipment
and Nonprescription Drugs
Nursing Home and Home
Health Care
Net Cost of Private Health
Insurance, Administrative
Costs, and Public Health
Programs**
Hospital Care
Prescription Drugs
Doctors, Dentists, and Other
Professional Services
Health Care Costs: 1965–2004 US
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$1,800,000
$2,000,000
'65 '70 '75 '80 '85 '90 '95 '00 '04
Do
lla
rs (
in M
illio
ns
)
J. Vella [PH 3340]
Therapeutic shift from inpatient to outpatient care with drug therapy Direct-to-consumer (DTC) advertising and consumer demand Existing drugs — expanded applications and more aggressive treatment guidelines New drug ―improvements‖ and ―new markets‖ Price inflation Demographic shifts
Reasons Implications
Why more spending?
More users
More prescriptions per user
More expensive mix
Higher unit costs
Spending on healthcare is increasing annually in the Maltese Islands
J. Vella [PH 3340]
Factors increasing expenditure (i)
• Individually these factors are
understandable...
• Together they produce a kind of ―Perfect
Storm‖ effect
• EXAMPLES:
• Inpatient to outpatient shift - primary
treatment of ulcers used to be gastric
resection surgery; now surgery is very rare
J. Vella [PH 3340]
Factors increasing expenditure (ii)
• DTC advertising- Claritin captured 80%
market share supported by extensive Direct
To Consumer advertising
• Expanded applications and more
aggressive treatment guidelines
• e.g Asthma and allergy drug Singulair now
approved for treatment of allergic rhinitis;
J. Vella [PH 3340]
Factors increasing expenditure
(iii)
• Pre-mid ‗90s guidelines for treating high
cholesterol targeted >222, current
guidelines target > 150 (I.e., ‗more people
qualify for treatment‘)
• New drugs - we can treat diseases today
that we couldn‘t treat before - hepatitis,
Aids, MS, renal dialysis (e.g., Cerezyme to
treat Gaucher‘s disease costs $450k/year)
J. Vella [PH 3340]
Solutions to increased costs
• Paradoxically increased investment in
pharmaceutical care can lead to overall
reduction in healthcare costs
• This is demonstrated in the following two
slides with data from the United States
• Locally, a strong case is made for
considerable investment in obesity
prevention and diabetes education in an
effort to defray future costs
J. Vella [PH 3340]
Disease Management Program Increases
Use of Diabetes Medicines and Reduces
Total Health Spending
Data source: Cranor, Bunting, and Christensen40
Other Prescriptions
Diabetes Prescriptions
Insurance Claims
$6,096
$488
$666
$3,596
$889
$724
$3,492
$1,440
$894
$3,283
$1,572
$1,027
$2,815
$1,409
$1,170
$1,584
$1,702
$1,393
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000M
ea
n C
os
t p
er
Pa
tie
nt
pe
r Y
ea
r
(in
20
01
U.S
. D
olla
rs)
Baseline Year 1 Year 2 Year 3 Year 4 Year 5
Follow-Up (12-Month Intervals Following Baseline)
J. Vella [PH 3340]
Increased Use of Medicines Reduces Overall
Health Care Costs Mental Health/Substance Abuse (MH/SA) Spending per
Patient Fell as Drug Spending Increased, 1992–1999
Data source: Mark and Coffey39
Psychotropic Drug Spending
Inpatient MH/SA Spending
Other MH/SA Spending
$42.70
$55.20
$17.10
$24.10
$25.30
$45.60
$0
$20
$40
$60
$80
$100
$120
$140
Sp
en
din
g p
er
Co
ve
red
Lif
e p
er
Ye
ar
1992 1999
2012 [UNIT PH 3340] 78
Healthcare expenditure and
global inequalities
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
Shocking!
79
J. Vella [PH 3340]
Health inequality and social
conditions
80
J. Vella [PH 3340]
Money is important!
81
J. Vella [PH 3340]
Discussion (i)
• Research demonstrates that social inequality
leads to imbalances in healthcare outcomes
• ‗Tiered‘ healthcare systems where the
wealthy have better treatment options and
access to cutting-edge pharmaceuticals
• This is not ‗fair‘, but it is reality, even to some
extent, locally
• Administrators work to reduce this inequality,
both locally and world-wide 82
J. Vella [PH 3340]
Discussion (ii)
• http://www.who.int/features/factfiles/health_i
nequities/facts/en/index.html
• Follow the link above for a reality check
• Although our present system is inefficient,
we are privileged to have the functional
basics for a decent existence
• All the more reason to implement changes
and improve the provision of services
83
J. Vella [PH 3340]
Discussion (iii)
• It is the duty of us as pharmacy
professionals to reduce the impact of socio-
economic factors on health outcomes
• This can be done by:
• (i) improving counselling for illiterate
patients
• (ii) educating the public about lower priced
generics
84
J. Vella [PH 3340]
Discussion (iv)
• (iii) providing specific services to aid the
elderly with compliance and dosage issues
• (iv) improving interpersonal communication
skills so as to enable a more productive
patient & health professional relationship
85
2012 [UNIT PH 3340] 86
The impact of demographics
in pharmacoeconomic
considerations
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
Healthcare and demography (i)
• Literature and commentators constantly
reference demographic shifts
• Is this a chicken and egg situation?
• Is an ageing population driving up
healthcare costs, or
• Is a greater healthcare expenditure making
increased life expectancy possible?
J. Vella [PH 3340]
Healthcare and demography (ii)
J. Vella [PH 3340]
Healthcare and demography (iii)
• Increased spending leads to better
outcomes and longer life expectancy
• The gross exception is the United States
• Malta, with a figure of € 2500 has better
results than the US at € 4500!
• We are more efficient at employing the
resources at hand, probably because the
public system still plays a major role
J. Vella [PH 3340]
Worldwide picture (i)
90
J. Vella [PH 3340]
Worldwide picture (ii)
91
J. Vella [PH 3340]
Worldwide picture (iii)
92
J. Vella [PH 3340]
What does this all mean? (i)
• An older population has a negative effect on
a country or region‘s finances in three main
ways:
• (i) older people require a greater quantity of
more expensive healthcare interventions,
including pharmaceuticals
• (ii) there is a smaller percentage of
productive labour force to pay for the above
J. Vella [PH 3340]
What does this all mean? (ii)
• The ratio is now 4:1 in most industrialised
countries; this is projected to drop to 3:1 in
the US and 2:1 or less in Europe and Japan
in 50 years‘ time
• This problem is also relevant to the Maltese
Islands, as the following slides demonstrate
J. Vella [PH 3340]
Demographic shifts in Malta (i)
95
J. Vella [PH 3340]
Demographic shifts in Malta (ii)
• The latest demographic survey by the NSO
illustrates the problem
• By 2050 the population will decrease to
380,000
• 24% will be aged 65+, as opposed to 15%
in 2009
• Our finances are already feeling the strain
J. Vella [PH 3340]
Demographic shifts in Malta (iii)
• Expenditure on pharmaceuticals is
increasing rapidly, and shortages will
become more frequent
• All this points to the need for a change in
the approach to the pharmaceutical
healthcare provision paradigm that is
presently advocated by administrators and
policy makers
2012 [UNIT PH 3340] 98
Suggestions for improvements
to local practice within the state
pharmaceutical healthcare
system
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
2012 [UNIT PH 3340] 99
Supply chain issues
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
Reducing local pharmaceutical healthcare
costs (i)
• Better inventory control, both in stock
management and in tendering procedure
• Distributive logistics applied locally would
make better use of the money allocated for
rolling stock
• At present, certain areas of the primary care
state system can be OOS, while others
have 2-3 months stocks
J. Vella [PH 3340]
Reducing local pharmaceutical healthcare
costs (ii)
• Minimum level systems to trigger automated
re-order procedures within the context of a
pre-determined contract would ensure less
frequent OOS
• Less frequent changes of brand will reduce
patient confusion and medication errors
• Transparent tender systems, possibly online
and e-compliant
2012 [UNIT PH 3340] 102
Care issues
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
Reducing local pharmaceutical healthcare
costs (iii)
• Focus on patient-centred care, rather than
cost control
• Build a system around a central database
architecture that revolves round the patient
and the layers of pharmaceutical care
• Various degrees of care can be applied,
according to the necessity and cost-
effectiveness of the treatment
J. Vella [PH 3340]
Reducing local pharmaceutical healthcare
costs (iv)
• Develop a set of indicators for the cost-
effectiveness of pharmaceutical care
• Set a minimum level of care and a set of
milestones to be achieved
• Take the step to e-medicine and do away
with mountains of paperwork, at the same
time reducing administrative costs
considerably
J. Vella [PH 3340]
Reducing local pharmaceutical healthcare
costs (v)
• This can only be achieved by pharmacists
taking the lead in this change
• To do so we must have the right attitude and
initiative to blend pharmaceutical care skills
together with administrative and
pharmacoeconomic techniques
• These skills can be developed by putting
our knowledge and profession into the
context in which we learn and practice
2012 [UNIT PH 3340] 106
The future for pharmacists
and pharmaceutical
healthcare administration
[John Vella B.Pharm.(Hons.) M.Sc.(Pharmacoeconomics)]
J. Vella [PH 3340]
Why must we change?
• "If you think that you can run an
organisation in the next 10 years as you've
run it in the past 10 years you're out of your
mind."
CEO, Coca Cola
J. Vella [PH 3340]
Predictions can go awfully wrong!
• "Radio has no future"
• "Heavier than air flying machines are
impossible"
• "X rays will prove to be a hoax‖
Lord Kelvin
J. Vella [PH 3340]
What is instigating change? (i)
• The evolution of the information age:
the internet, databases, globalisation
• Cost containment: healthcare providers
cannot keep increasing expenditure
without budgetary controls
• Ageing world: demographic shifts are
contributing to a greater strain on public
healthcare systems
J. Vella [PH 3340]
What is instigating change? (ii)
• Increasing public accountability:
expenditure must be justified and audited
• Increasing access to all:
healthcare for all members of a global
society
• Ethical provision:
health systems must function without
discrimination and within professional
boundaries
J. Vella [PH 3340]
What is instigating change? (iii)
• Current approaches to financial investment
and expenditures take into account the new
era of capitalism and money management
following the crash of 2008
• Healthcare and pharmaceutical services
have not been immune to cut-backs
• In fact, medicines are usually the first to feel
the force of budgeting constraints
J. Vella [PH 3340]
Why we must change!
• Population growth, increasing spending and
an increased level of expectancy and
accountability have placed great pressure
on pharmaceutical healthcare
administrators and pharmacists at every
level
• We must rise to the challenge by being
prepared to implement our professional
skills in a socially relevant context
J. Vella [PH 3340]
Practical Intelligence (i)
• All the pharmaceutical knowledge to be had
is useless if we cannot bring it to practical
use
• We must concentrate on developing a set of
problem solving skills, rather than becoming
simple data collectors
• Memorising quantities of data is no longer
relevant as IT has put all the information we
need at arm‘s reach
J. Vella [PH 3340]
Practical Intelligence (ii)
• Rather, our next challenge as pharmacist(s)
administrators and managers is to enable
the delivery of equitable pharmaceutical
care within the confines of the system within
which we are placed
• This concept applies both to a public and
private professional placement
J. Vella [PH 3340]
Practical Intelligence (iii)
• Dispensing duties are no longer the only
facet of our profession, but patient
counselling, social integration and the
meshing of the public and private sector
pharmaceutical systems are all part of the
pharmacist‘s remit
• This can only be achieved through a
complete re-think of our professional mind-
set
J. Vella [PH 3340]
A paradigm shift
“healthcare: a cost to be rationed” dogma to the
opposite vision: “healthcare: a service to deliver
consumer satisfaction” 1
1The Great Healthcare Paradigm Shift- Building the Largest Service Industry in Society,
Arne Björnberg, Ph.D.
J. Vella [PH 3340]
Current approach to
pharmaceutical care
• Presently the focus is on keeping costs
down to a specified limit, usually imposed
by administrators from outside the
healthcare circle
• The future is a complete reversal of this
approach
• The patient‘s health outcomes must be
evaluated along the whole cycle of care,
and a decision taken for the cheapest
holistic option
J. Vella [PH 3340]
Patient-centred care
• This is the evolution of patient-centred care
• A philosophy that is still in its infancy, but
that will form the cornerstone of
pharmaceutical care in years to come
• PE will play a central part in this change,
bringing a measure of reason and justice to
a highly-charged and emotional debate
J. Vella [PH 3340]
PE in this change (i)
• HTAs should be used to speed up access to
novel and/or cheaper technologies
• Not used as a tool for simple cost-
containment
• Existing reimbursement and pricing policies
delay patient access
• PE should be used to establish clinical and
cost-effectiveness indicators
J. Vella [PH 3340]
PE in this change (ii)
• Patients W.A.I.T. Indicator, EFPIA, May
2009 – 17 EU countries covered in the
report
• Between 47 to 90% of medicines licensed in
the last three years were available to
patients, delays in patient access to those
medicines ranged from 101 to 403 days
(beyond the 180 days mandated by EU
legislation).
J. Vella [PH 3340]
Types of Possible Remedies (i)
• Purchasing to Improve Quality/Patient Safety • Performance linked pay • Tiered networks • Strengthening primary care and care
coordination (medical homes) • Improve Efficiency (i.e., appropriate
care settings)
• Purchasing Strategies to Reduce Costs • Pooled purchasing, rebates, etc.
J. Vella [PH 3340]
Types of Possible Remedies (ii)
• Promoting Health and Disease Prevention
• Wellness Programs • Disease Management • Reducing Obesity/Tobacco Use • Positive incentives for Health
• Producing and Using Better Information
• Information Technology
• Evidence-Based Medicine