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The President's Discount Card Proposal and Implications for Patients in the Institutional Setting

What is Institutional Pharmacy?
Institutional pharmacy describes the range of services provided by pharmacists to residents of nursing homes, hospitals or hospice environments. In their role as medication therapy experts, institutional pharmacists take responsibility for their patients' medication-related needs; ensure that their patients' medications are the most appropriate, the most effective, the safest possible, and are used correctly; and identify, resolve, and prevent medication-related problems that may interfere with goals of therapy. Institutional pharmacies are a necessity for the long term care facility, the hospital and their residents, and are often required by law to provide 24 hour a day, seven day a week service.

How is Institutional Pharmacy Different from Retail Pharmacy?
In addition to providing round-the-clock delivery service, there are numerous qualities that differentiate institutional pharmacy from other pharmacy. Institutional pharmacy, for example, provides prescription drugs in individually packaged blister packs (known as single-unit-dose packages or "bingo cards") so that health care workers can easily and safely provide patients with their proper medication and dosage. Its round-the-clock ability to deliver drugs permits, IV's and other necessary drugs to the institutional setting saves lives and money by reducing the need for avoidable emergency room visits. Institutional pharmacists also provide "med-carts" and "e-carts" (drugs on consignment to the nursing home to be used for emergencies). Unlike retail operations, institutional pharmacies also continuously check patients' drug interactions to avoid possible duplication of treatment or adverse reactions. In this way, institutional pharmacy is a principal defense against medical errors and ensures the highest quality of patient care.

Other Functions of Institutional Pharmacy.
Institutional pharmacists counsel patients, provide information and recommendations to prescribers and caregivers, review patients' drug regimens, present in-service educational programs, and oversee medication distribution services -- all in addition to providing medication. Institutional pharmacists also provide a wide range of other services to seniors, including pain management counseling, pharmacokinetic dosing services, intravenous therapy, nutrition assessment and support, and durable medical equipment.

Why is Institutional Pharmacy so Important to Institutional Facilities and Patients?
Nursing home requirements mandate rigorous attention to pharmacy administration. Only institutional pharmacies provide 24-hour pharmacy to long term care facilities, often avoiding the unnecessary transfer of nursing home patients to hospitals for emergency drug needs. Additionally, institutional pharmacists individualize the packaging of prescriptions for nursing home residents and develop treatment profiles of their patients to avoid improper medication or medical error by caregivers. Most nursing facilities do not provide the economic scale to support hiring in-house pharmacists and they cannot rely upon retail "drop and run" pharmacies to meet regulatory requirements. Given the Administration's commitment to strengthening the quality of care for nursing home residents, attention must be given to reducing medication errors and minimizing drug interactions. Without the specialized programs and attention to dispensing, packaging and documentation provided by institutional pharmacies, an increase in adverse patient outcomes will almost certainly result.

The President's Plan May Make Sense for Retail Purchasers of Drugs, but Does Not Work Well for Residents of Nursing Homes and Hospitals. Residents of nursing homes and hospitals have special pharmacy needs due to their unique circumstances. In specific, residents of nursing homes and hospitals depend on specialty pharmacy services which include "unit dose" packaging, medical carts, e-carts, 24 hour availability, drug interaction consultations, advice about generic options and prevention of medical errors. Under the current healthcare system, these services are provided attendant to the provision of drugs by consultant pharmacists.

The Mechanics of the President's Plan May Not Translate Well for Institutional Patients.
The President's Drug Discount Card plan operates under the assumption that participating Medicare beneficiaries purchase their own drugs and are in a position to make decisions concerning their drug plan options. In reality, however, very few seniors in nursing homes, hospitals or hospice environments are in a position to purchase their own drugs, choose between competing plans or make the most basic decisions concerning their health care. In addition, many of these patients are physically or mentally incapable of making or acting upon their own decisions. Thus, the President's plan to provide new purchasing options does not translate effectively to this specialized patient population. Moreover, an unintended consequence of the President's plan may be unnecessary complexity and confusion. Of particular concern are dual eligible beneficiaries who require Medicare and Medicaid coverage.

The Drug Discount Card Proposal May Have Unintended and Deleterious Effects on Nursing Home and Hospital Patients.
If the President's plan is extended to include residents of nursing homes and hospitals, patient care will suffer. Patients will be encouraged to purchase their drugs from PBMs and other bulk sellers who cannot provide the individualized single-unit-dose delivery system, rather than through consultant pharmacists who provide important health care services. Some types of drugs (such as emergency IVs) cannot be delivered by PBMs within the time frames necessary. The disparate delivery systems could also cause confusion in the institutional setting should different patients receive their drugs in differing packaging and from differing sources. Given that the "point of purchase" in long term care facilities is the nursing home itself, rather than the retail counter, and in light of the specialized care that nursing home patients require, a drug discount card system cannot adequately recognize and account for the special life saving and cost saving benefits of utilizing specialty pharmacists for institutional patients.

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