James Jorgenson, RPh, MS, FASHP, is a pharmacy expert recently named to Cureatr's Strategic Advisory Board, which is providing expertise, insight, and guidance to the company's management. Jorgenson is the chief executive officer of Visante, where he leads national and international programs for medication management improvement in the United States, United Kingdom, and Canada. His more than 30-year career includes pharmacy oversight of large health systems and their network associations as well as academic leadership in graduate pharmacy education.
Q: What do you see as the main contributors to shortcomings concerning medication management?
James Jorgenson: The biggest contributor to suboptimal medication management is inaccurate information about patients' medications and patients themselves.
Optimizing medication management starts with having a correct list of the patient's current medications as they move through and across the healthcare continuum. Also important is gaining access to the medication outcome data you need to effectively manage a patient's therapy, such as lab values. Then you must consider the time required to effectively educate patients on their medication regimen and help them remove any barriers to full adherence.
Typically, this process is tremendously fragmented. When you consider that approximately 25% of hospital 30-day readmissions are driven by medication-related problems and that for every dollar we spend on prescription medications, there's an equal or greater amount wasted on ineffective medication management, suboptimal medication management is a huge issue, but also a huge opportunity.
Q: What role can or should information technology (IT) play in helping improve medication management?
JJ: IT is essential to effective medication management. As healthcare starts to further embrace big data, with rapidly increasing varieties, volumes, and velocity of healthcare information, it's really imperative that we have IT that can cull and analyze the data to produce more and better actionable information for pharmacists and all other healthcare givers engaged in end-use processes.
Additionally, the impact of artificial intelligence and machine learning will be major future factors as we consider how best to apply IT to support optimal medication use.
Q: How important is granting provider status to pharmacists?
JJ: While it would be nice to be able charge for pharmacy cognitive services, the accelerated adoption of value-based care will continue to guide pharmacy more toward outcomes-based reimbursement instead of traditional fee-for-service models. As such, provider status would be most important in terms of allowing pharmacists to use their capabilities and knowledge to their fullest and work to the top of their license.
As medicine continues to become more complex, the days when a physician could be aware of everything going on with their patients are rapidly disappearing. I believe effective care delivery is now a team sport. Physicians are the quarterback of the team, but the rest of the team is comprised of a group of highly skilled experts. Pharmacists should be the medication therapy experts on that team. Provider status would help to remove some of the significant barriers to fully utilizing pharmacist resources and give them greater credibility amongst fellow healthcare providers.
As an example: My company, Visante, has an office in London, so we get to practice in the United Kingdom. The country has taken the step to create a consultant pharmacists class where these individuals receive extra training, but they have full prescribing authority and don't need to work under traditional protocols. These pharmacists work hand-in-glove with their physician and nursing colleagues to deliver a significantly enhanced level of care.
This is just one example of an existing model that could be adapted here in the United States.
Q: How do you view telepharmacy and its value in today's healthcare delivery system?
JJ: The concept of telepharmacy always made sense to me from a resource-utilization perspective. I was the pharmacy executive associate dean at the University of Utah, and I believe we created one of the first telepharmacy programs in the country. Many of the rural counties in the state lack ready access to pharmacies. Most of them generally have some clinic operations available for patient care, but when patients would need to fill and pick up a prescription, this would require a long drive to get to the nearest pharmacy.
We put automated dispensing machines in many of the clinics and then linked them back to a central hub in our main outpatient pharmacy. We also established a video link. We were able to receive the prescription, fill it remotely, release the prescription at the clinic where staff could barcode it as the verification, and then we could council the patient live via the video link.
That was well before its time. Considering the current pandemic, the use of telehealth and telepharmacy makes even more sense. We're seeing the successful execution of remote order entry and verification, remote medication reconciliation, remote counseling and education, and remote dispensing being used routinely.
Pandemic or not, I think this will become the new normal. After the pandemic subsides, we're not going to go back to the old ways of delivering many of these services.
Q: What have been some of the most significant pharmacy trends and advancements in 2020?
JJ: The pandemic and economy have dominated 2020. But I’ve witnessed pharmacy, along with all other caregivers, step up and work together to continue to provide excellent care across the country in the face of challenging conditions.
When you look at the hospital market, most hospitals and health systems had an extremely bad second quarter. Everyone is now scrambling to make up the revenue shortfalls. While pharmacy has often been an undervalued and underutilized resource in many hospitals and health systems, that's changing.
Consider that drugs are the primary treatment modality for greater than 85% of any health system's patients, they're the fastest rising expense in U.S. healthcare, they represent a major revenue source, and they are the number one contributor to medical errors in the country. When you take that all together, it is obvious that the business of pharmacy can be a major resource in helping organizations address their financial challenges while also helping to improve quality and safety.
The pandemic has certainly highlighted the issue of drug shortages. That has been a continuing problem for the last 15 years and it doesn't seem to be getting any better. It has significantly highlighted the vulnerability of the U.S. healthcare system. Virtually all of active pharmaceutical ingredients (APIs) come from foreign sources.
Specialty pharmacy programs have been increasingly providing more seamless care for complex patients while also working to help increase safety and compliance and effectively manage the high drug costs associated with that complex level of care.
Finally, the drug manufactures' assault on the 340B program, which is happening in the middle of the pandemic when the patients need that support the most, is problematic.
Q: What trends are you going to keep an eye on in 2021?
JJ: In regards to COVID-19, the complexity of vaccines and their distribution will make it very likely that the earliest we will see any kind of dent in population vaccinations is well into the third quarter of 2021. We're going to be dealing with many of the same issues through 2021 that we're dealing with now.
Another trend I'm watching is the accelerated release of high-cost specialty medications. When you look at the medications in the pipeline, probably over 60% of them would be considered specialty medications. In 2021, specialty medications will probably consume at least 50% of the total U.S. prescription drug spend but less than 3.5% to 4% of total prescription volume. That is incredibly impactful.
We're going to see continued evolution of gene therapy. We have a handful of such therapies already out now. The most recent one, Zolgensma for pediatric spinal muscular atrophy, costs around $2.5 million for a single infusion. While that therapy is hopefully effective, we still need to figure out how to pay for it.
The next therapy most likely to receive approval will be for hemophilia patients. If you have an inhibitor patient consuming $1 million worth of blood factors annually, being able to eliminate or significantly reduce that will be huge, but the price tag on that therapy might be somewhere in the neighborhood of $3 million to $4 million.
While these are fantastic developments, we still need to figure out how to come up with that cash on the front end to pay for them.
I'm excited about the continued expansion of personalized medicine and the application of pharmacogenomics so we can develop better and more tailored medication therapy regimens based on the individual patient's genetic profile and markers.
I'm watching the progress being made with bringing active pharmaceutical manufacturing back to the United States. There are number of exciting 503B operations where they are looking to create continuous manufacturing programs in the United States that will allow them to build the API from raw chemicals and then take that API and put it right into compounding drugs that might be in critical shortage situations.
Then there's the matter of the continued evolution of outcomes-based contracting. How do you most effectively manage that drug spend? It might be that you're focusing on outcomes rather than getting a nickel off a price point of a particular medication. And then there's the ability to manage the increasing cost of medications overall. We're going to soon be at well over half a trillion dollars spent on medications and that will represent at least 17% of total U.S. healthcare spend. We're going to need to figure out how to control that expense.
Finally, the United States Pharmacopeia should be coming out with its finalized enhanced standards around sterile compounding — USP 797 — as well as hazardous medications — USP 800. I believe there will be a much greater emphasis in 2021 on enhanced quality and safety standards for compounded sterile products.
Q: How do you view the role that Cureatr's technologies and services are playing in helping to improve healthcare delivery?
JJ: I think Cureatr is in a great spot. What the company does fits right into the sweet spot of better managing medications. To improve clinical outcomes, you need to have the medications right. Meds 360° gives you that important look at the correct medication profile and helps you understand how medications are being utilized, allowing all clinicians to use that information to better manage their patients' medication therapy.
You can expand that idea with the Meds 360° for populations. With the continued evolution of the accountable care model and population health management, Cureatr can take that same real-time medication data and aggregate it so that places can zero in on areas of medication-related risk across any desired patient population.
That then also provides organizations with a better ability to track the effective impact of their medication interventions and, importantly, build out analytics to help them find and focus on that 10-15% of the population that really drives 80% of the modifiable risk around medication use.
Finally, when you add in Cureatr's capability to provide telepharmacy and clinical pharmacy support, you have a company and service line that's right in the middle of the evolving care landscape.