R.Ph.s, HCFA lock horns at ASHP annual meeting
The ASHP annual meeting in Baltimore earlier this month was the setting for a showdown between health-system pharmacists and the Health Care Financing Administration (HCFA). The two groups have been at odds over proposed changes to HCFA's conditions of participation (COPs), introduced last December, that hospitals must adhere to in order to be eligible for Medicare and Medicaid reimbursement. Although the main point of contention is a requirement that would remove pharmacists from the medication-use process and allow nurses and physicians exclusive review of medication orders, pharmacists were also upset by a proposed change that calls for the establishment of a 2% medication error threshold for hospitals participating in Medicare and Medicaid.
Samuel Kidder, a pharmacy consultant with HCFA, told attendees at a roundtable discussion that HCFA staffers justify that portion of the proposed change that eliminates R.Ph.s from the medication-use process because pharmacists, unlike physicians and nurses, "are not involved with medication at the point of administration." Many pharmacists attending the discussion, however, asserted that removing the pharmacist--the health professional with the most in-depth training on medication use--would seriously compromise patient care as well as eliminate a vital link to patient safety.
When pressed by pharmacists about the professional makeup of the HCFA staff that wrote the proposed changes to the COPs, Kidder revealed that he was the lone pharmacist and that the majority of the authors on the staff were physicians and nurses. He also confirmed that it was a nurse who wrote the specific portion of the proposal calling for the removal of the R.Ph. from the medication-use process. He said he formally voiced his opposition to the proposed changes but was overruled.
"I know pharmacists can solve problems," said Kidder. Several years ago he pushed for changes to pharmacy drug review regulations in the long-term care setting that gave R.Ph.s more oversight.
ASHP has received thousands of letters from its members opposing the proposed changes to the COPs since they were published in the Federal Register in December of 1997. But Kidder pointed out that the letters had little impact because the HCFA committee viewed them as self-serving.
He went on to say that although the public comment period on the issue has expired, the best chance pharmacists have to bring about a change in the proposals is to seek as many allies as they can in nursing and medicine to support their position. He also suggested that pharmacists supply as much hard data as possible quantifying how many medication errors R.Ph.s actually prevented in a specific hospital/health-system setting as well has how many dollars they saved an institution by their intervention.
"That would be powerful information," said Kidder, who pledged to submit any such information to the HCFA staff.
Harold Godwin, director of pharmacy at the University of Kansas Medical Center in Kansas City, told Kidder that in some institutions R.Ph.s have made in excess of 300 interventions a day where they prevented a medication error or an adverse drug event. Godwin also cited data from several recent studies that claim 90% of all medication errors have their origins in prescribing.
While the packed audience included staff pharmacists and pharmacy directors appreciative of Kidder's support and sympathetic to his lone-wolf pharmacist position on the HCFA staff, they were nonetheless concerned about the timetable regarding a resolution to the proposed regulations. Kidder said it was unlikely that the issue would be resolved any time soon, acknowledging that it could take as much as six years for any changes to be made. "Don't expect to see this rule in final version for a while," he cautioned. It is estimated that HCFA has received 65,000 comments to its proposal, and just sorting through them will take considerable time.
But Gary Stein, a legal affairs representative for ASHP, reminded Kidder and the attendees that HCFA does have the ability to withdraw the current proposal entirely and start the process over again from the beginning. Kidder acknowledged that while that has happened in the past, he didn't think it was a likely alternative now.
Regarding the 2% medication error rate threshold, roundtable attendees indicated overwhelmingly that the strategy was flawed. Some ASHP officials, for example, told Kidder that HCFA should push instead for a fail-safe plan that would require U.S. hospitals to eliminate errors entirely by establishing programs to address errors from a system perspective.
In a separate panel discussion the night before the roundtable event, the HCFA proposal was attacked by a host of experts from pharmacy, nursing, and medicine. They gave numerous explanations as to why the 2% threshold and the elimination of R.Ph.s from the medication-use process were unacceptable. Panelists told Kidder that the 2% rate could, in fact, hinder error reporting and create the impression that a certain level of errors is acceptable. Teri Bair, an R.Ph. and an attorney in Texas, said that a 2% medication error threshold could also lead to incomplete reporting. Michael Cohen, president of the Warminster, Pa.-based Institute for Safe Medication Practices, said that while HCFA has strengthened its drug monitoring position for pharmacists in the long-term care setting, it is off base in regard to the 2% error rate.
Other health-care professionals on the panel gave pharmacists the support that Kidder suggested would be needed in order to sway HCFA's staff. David Bates, M.D., division of general medicine, Partners Health Care in Boston, said that pharmacy directors are "key personnel" and have to be active and aggressive in the area of medication error prevention. Linda Everett, R.N., northwest regional administrator at the Detroit Medical Center, said that she disagrees with HCFA and believes that R.Ph.s are the most qualified to coordinate the medication-use process.
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