Investing in pharmacy residency programs - What's the value ...

Engaging the C-suite to Advance Pharmacy Practice Providing quality patient care through progressive pharmacy practice Investing in pharmacy residency programs - Whats the value for Institution A? Institution A Pharmacy Residency Program 290 residents since 1963 Recipient of ASHP Foundation Pharmacy Residency Program Excellence Award for producing leaders in the pharmacy profession 16 Current Institution A Residents M.S./Residency in health-system pharmacy administration 8 administrative residents (4 junior, 4 senior)

Pharmacy practice residency (PGY1) 4 hospital residents 1 community resident Medication systems and operations residency 1 MSO resident (2 year program) Specialty residencies (PGY2) 1 critical care resident 1 transplant resident External Funding Cost Reduction & Avoidance Education & Scholarship Pharmacist Recruitment, Development,

& Satisfaction Benefits of Pharmacy Residency Programs for Institution A Health New Business & Service Growth Quality, Compliance & Service Provider Satisfaction External Funding Graduate medical education: Medicare pass-through funds Federal

(PTF) available for Governmentaccredited PGY1 pharmacy residency programs Other State and national pharmacy associations professional project (research) grants Pharmaceutical industry grants Ex: Medicare Pass Through Funds* Cost Item Direct Costs Resident Salary + benefits Travel Residency accreditation fee Tuition & related expenses

Teaching time Program director Director administrative time Preceptor teaching time Preceptor administrative time Preceptor travel Total direct costs Indirect costs Calculation ($) (38,300 + 20% benefits) x10 4 programs 9,000 x 4 admin residents NET COST 459,600 8,605 4,725 36,000 (20% of salary + benefits)

(5% of salary + benefits) (25% of salary + benefits) x10 (5% of salary + benefits) x10 41,300 10,325 312,000 62,400 2,125 937,080 (30% of total direct costs) 281,124 Total educational costs Anticipated Medicare reimbursement Cost ($) 1,218,204

Medicare pt load (35.6%) x total educational costs $433,681 (1,218,789-433,889) $784,523 *Assumes 10 PGY1 pharmacy residents with a 35.6% Institution A Medicare patient Cost Reduction All residents are responsible for completing one or more drug cost reduction projects each year* On average, each project reduces drug costs by $40,000 Total annual cost reduction = $1,280,000 *Administrative residents complete three cost reduction projects per year, all others complete one per year Cost Avoidance Online staffing as clinical pharmacist

12 hours/week avoids 0.3 pharmacist FTE 0.3 RPh FTE (salary + fringe) = $41,184 1 resident FTE (salary + fringe) = $46,800 Avoids $650,000 in pharmacist FTE per year 88% of the cost of a resident is covered by their staffing component alone Cost Avoidance School of Pharmacy (SOP) lectures SOP lab teaching assistants Monograph preparation

Medication use guideline revisions PSN follow-up Site visit coordination Health Link go-live and upgrade assistance Audits Drug contract analyses Advertising, training, and relocation fees* *Average of 2 to 4 Institution A -trained residents are hired onto staff each year!! Improved Provider Satisfaction Nurse satisfaction Resource for questions: drug interactions, compatibilities, administration rates, ect. Aid in communication with MD/PA/NP Assist in assuring patient doses are available to the nurses at the appropriate time Assist in changing the dispensing location of medications for more timely administration of first doses Change dosing times to standardized times to reduce time demands on nurses Continuing education seminars Improved Provider Satisfaction

Physician satisfaction Dose medications to avoid complications Contact prescriber regarding abnormal lab values and cultures found while monitoring patients Knowledgeable about Institution As drug formulary and therapeutic alternatives Drug expert for clinical rounds Modification of inappropriate drug orders Increase through-put and efficiency Continuing education seminars Improved Quality and Service Patient care Enhance pharmacists capacity and effectiveness with patient care rounding, clinical monitoring, medication reconciliation and patient teaching Resource to research best way to manage very complex patient cases Compliance (audits, projects) CMS TJC Third party billing audits

Detailed follow up on ALL PSN reports Improved Quality and Service Enhanced achievement of external pay for performance quality indicators Improved reimbursement for pay-for-performance and future accountable care organization measures Increased reimbursement for medication therapy management (MTM) services in Institution A ambulatory pharmacies Leads to direct revenue from payers (Navitus, Unity, Group Health, etc) via patient teaching and care management Improved Quality and Service Recruitment of future (well-trained) pharmacists Community service and professional activities Enhance capacity of staff Formulary review Drug policy development Opportunity for externally funded projects

Expanded Pharmacy Services Every major new Institution A pharmacy initiative is powered by a pharmacy resident project Second year administrative residents complete a rotation with the VP of Professional Services to help advance goals of senior leadership. Expanded Pharmacy Services wi t ha W e ll w n do

e 2000s 2010s xt? 1990s 2000s 1980s 2000s 1970s 1980s Advancements in patient care 1960s 1970s services Innovation in core pharmacy services New pharmacy business development Expansion of clinical services into ambulatory

and alternate sites Drug policy and managed care pharmacy program development Implementation of fully automated medication use process Electronic medical record Innovative pharmacist roles New business ventures Resident Projects 1960s 1970s

100% unit dose dispensing Complete IV admixture system Fully computerized pharmacy order entry/ distribution system Pharmacist-managed drug information center Pharmacist-managed medication administration record for inpatients 1970s 1980s Med histories, reconciliation, discharge counseling for all patients Pharmacist participation on patient care rounds Pharmacokinetic dosing services Decentral pharmacy service in all areas from 0700 to 2300 and

around the clock services for critical care areas Resident Projects 1980s, 90s, 2000s Pharmacists participate in >20 ambulatory clinics Integrated ambulatory pharmacy network throughout Dane County 13 pharmacies Inpatient and in-home hospice services Pharmacy management consultative services for hospitals in rural communities 1990s 2000s Developing, implementing, maintaining, and monitoring policies related to the use of pharmaceuticals with in Institution A Initiation of several external pharmacy contract services Manage pharmacy benefit for Unity Coordination of technology assessment programs Centralized robot

Automated dispensing cabinets Barcode medication administration software at point of care Smart IV infusion pump Medication carousel Resident Projects 2010s (What will we do next?) Practice model and professional staff advancement through development and implementation of the pharmacist career ladder Decision support expansion to maximize evidencebased care Operational efficiency improvement New technologies (IV Robot, etc) Integration of pharmacists on primary care teams Pharmacist Recruitment, Development, & Satisfaction Recruitment Feeder-system for new and vacant positions More costly to recruit, orient, and train outside candidates

Attract highly skilled candidates best RPhs want to precept residents Development Training of new hires technicians, interns, and pharmacists Satisfaction Promotes workplace energy, practice reflection, innovation, and company dedication to quality improvement Resident projects enhance workplace experience Education and Scholarship Residents are required to provide education to doctors, nurses, and pharmacists Precept pharmacy students Faculty-resident collaboration on scholarly efforts

Show me the Money Pharmacy Residency Program Return on Investment (ROI) Analysis Expense for Current 16 Residents Expense Item Salary and Benefits Travel Tuition Accreditation fee Recruitment Total Expense Cost $734,400 24,585 72,000 5,175 2,185 $838,345

External Funding for Current 16 Residents Funding Source Commercial Supporter grant Medicare PTF Total Direct Income Funds ($) 40,000 442,604 $482,604 Cost Reduction for Current 16 Residents Drug Cost Reduction Project*: Resident Type Administrative PGY1 MSO PGY2 Total

Calculation 3 projects/yr x $40,000/project x 8 res 1 projects/yr x $40,000/projects x 5 res 1 project/yr x $40,000/project x 1 res 1 project/yr x $40,000/project x 2 res Total Cost Reduction ($) 960,000 200,000 40,000 80,000 $1,280,000 Cost Avoidance for Current 16 residents cont Cost Item HL go-live assistance Medication audits Med rec assessment Drug contract analysis Position advertisement*

New RPh training* New RPh relocation fee* Staffing Calculation Cost ($) 50 shifts/yr x 4 hr/shift x $66/hr 13,200 8 audits/yr x 15hr/audit x $66/hr 7,920 10/res/yr x 0.3 hr/asmt x $66/hr x 16 res 3,168 5 analyses/yr x 15hr/analysis x $66/hr 4,950

2 ads/position x 2 positions/yr x $5000/ad 20,000 2 RPh FTE/yr x 40hr/wk x 8wks x $66/hr 42,240 2 RPh FTE/yr x $4,000/relocation fee 8,000 ~12hr/wk x 52wk/yr x $66/hr x 16 res Subtotal 646,272 $745,750 *********continued on next slide********** Cost Avoidance for 16

residents Cost Item Calculation Cost ($) Institution A SOP lectures $300/lecture x 5 lectures 1,500 Institution A SOP lab TAs 40hr x $66/hr x 5 res 13,200 $30/CE credit x 25 RPh/tech attendees x 11 res 8,250

10hr/monograph x $66/hr x 10 res 6,600 2hr/revision x $66/hr x 10 res 1,320 1500 PSN/yr x 0.5hr/PSN x $66/hr 49,500 12 visits/yr x 10hr/visit x $66/hr 7,920 CE lectures Monograph preparation Med use guideline revision PSN follow-up Site visit coordination Subtotal

$88,290 Subtotal (previous slide) 745,750 Total Cost Avoidance $834,040 $ = I O R ( financial gain annual expense annual expense

)x 100 Return on Investment for Current 16 Residents Item Total Cost Cost Benefit $838,345 External Funding $482,604 Cost Reduction $1,280,000 Cost Avoidance

$834,040 Total ROI ROI $1,758,299 ($482,604 + $1,280,000 + $834,040) $838,345 = = $838,345 210% ROI Breakdown per Resident Type Resident Type* Cost per Resident ($) Financial Value

per Resident ($) Margin ($) ROI Admin (n=8) 54,937 195,761 140,824 256% PGY1 (n=5) 49,237 137,998 88,761

180% MSO (n=1) 48,637 110,964 62,327 128% PGY2 (n=2) 48,937 80,382 31,445 64%

* n= # of residents in current FY11 budget PROPOSAL Residency Program Expansion Add a permanent PGY2 oncology resident position Add a permanent PGY2 nutrition resident position Add an fifth administrative resident position for FY12 + FY13 Benefits of Oncology Resident Oncology is core Institution A service line Area of growth and expansion key pharmacy specialty area 25% of Institution A s $109 million drug budget is oncology drugs At forefront of what we can do at ambulatory clinics Hard to find and hire pharmacists with oncology specialty MD demand Services can be expanded while at the same time

lowering total costs Benefits of Nutrition Resident Program was initiated 5 years ago, but has alternated between critical care and nutrition Extremely successful program High priority of Department of Surgery for both research and practice funds 50% of nutrition pharmacists FTE Shortage of nutrition pharmacists throughout the country Services can be expanded while at the same time lowering total costs Have seen 25% growth in consistent level of nutrition service to all patients Benefits of Nutrition Resident # TNA Doses Administered at Institution A 7500 # of Doses 7000

6500 Adult Doses 6000 Linear (Adult Doses) 5500 Total Doses 5000 Linear (Total Doses) 4500 4000 3500 3000 2007

2008 2009 2010 Benefits of Administrative Resident Largest ROI (256%) Record number of exceptional applicants in 2010 Shortage of pharmacy administrators Huge leadership crisis in pharmacy profession A 2005 survey of pharmacy directors and middle managers found that 80% anticipate leaving their jobs in the next decade Services can be expanded while at the same time lowering total costs FINANCIAL IMPLICATIONS

Total Cost to Institution A Cost of 3 new resident positions Salary + Benefits + Travel = $152,810 In exchange, 0.7* clinical pharmacist FTE will be removed Salary + Benefits = $96,096 Total Investment = $56,714 *0.3 FTE for admin resident (FY12 + FY13 only) and 0.2 FTE for each PGY2 resident (permanent) Can we afford more residents? $3,000,000 $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 C t n

re r u d d A al n o iti Ad c n O tio i d lO

a n Ad & c n tio i d t u N n o riti lO a

n on ti ri t u N , nc ,& A in m d Cost Benefit Margin

Lets Compare Total ROI Cost ($) Current Additional Onc, Nutrition, & Admin Difference Benefit ($) Margin ($) ROI 838,345 2,596,644 1,758,299 210% 991,155 2,925,448 1,934,293

195% $152,810 $328,804 $175,994 Financial Financialreturn returnisisgreater greaterwith withthe theaddition additionofof oncology, oncology,nutrition, nutrition,and andadministrative administrativeresidents residents Expanding Expandingboth

boththe thenumber numberofofresidency residency positions positionsand androles rolesofofpharmacy pharmacyresidents residents will willbenefit benefitthe thepharmacy pharmacydepartment, department,the the hospital hospitaland andmost mostimportantly, importantly,our ourpatients!

patients! Questions???? Additional References Smith KM, Sorensen T, Connor KA, et al. ACCP White Paper: Value of conducting pharmacy residency training the organizational perspective. Pharmacotherapy. 2010;30(2):490e-510e. Pasek PA, Stephens C. Return on investment of pharmacy residency training program. Am J Health-Syst Pharm. 2010; 67: 1952-1957 White S. Will there be a pharmacy leadership crisis

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