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