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Haven't been around for a while. Busy at work, had a health problem, then there is family and kids, and just...stuff. Just accepted an offer to be the DOP of a mid-sized hospital known for its quality care. Woke up early this morning, can just see myself 5 years ago at this time, working on the residency research project in the dim pharmacy basement late into the night. So much has changed so fast. In a month, life will be crazy busy again trying to get up to speed at my new post.
While I'm here, I want give some insight into Long Term Acute Care (LTAC) pharmacy, some of the reasons why I left a hospital for it, and why now I'm leaving it now for a hospital.
LTACs are specialty hospitals where patients need prolonged inpatient care. The average length of stay of an LTAC patient is around 25-30 days. The common conditions, are respiratory failure requring a ventilator, osteomyelitis, stage 4 decubitus ulcers, endocarditis. As such, the severity of illness (acuity) is lower than ICU, but higher than med/surg floor. A background in infectious diseases and/or critical care allows you to excel with this patient population. Those are my forte, and the drug cost per patient day (PPD) went down by almost 50% while mortality rate decreased, the CEO was overjoyed and treated me very well and generously. With bonus, the pay was over $170K last year. The job load wasn't overwhelming. In fact, not having ER and surgery (contracted out to the host hospital), made meeting regulatory compliance significantly easier, allowing me plenty of time to do clinical and fine tune financials. I see LTAC has an wonderful opportunity for new residency trained pharmacist who love clinical pharmacy and less redtape.
So why am I leaving? The major reason was I'm pessimistic about the long term outlook.
CMS has changed the reimbursement dramatically to cut cost, greatly restricting the types of patient that will qualify for the higher LTAC reimbursement schedule. This means bulk of the current LTAC patient population will be reimbursed on the lower IPPS schedule (the typical hospital payment). I can see this will drive several things: (1) the existing LTACs will fight over the fewer higher paying patients, many will close their doors simply because there isn't enough to go around, and cannot survive on taking mostly IPPS patients. (2) even those LTACs that survive will likely need to take a good portion of patients on IPPS, eating into their margin. Since IPPS payment is around 6 days hospital stay, there will be more admission and discharges, early into late at night. LTAC pharmacy are not usually 24 hours, and with a lowered reimbursement, increasing pharmacy FTE to extend hours operation will be tough, even remote pharmacy may be too costly of an option. Many other departments need additional staffing as well, such as admissions, case management, medical records. (3) IPPS patients will need different meds and need them quickly (patient comes in on Friday, you can't order a med and wait for it to come in on monday if he's only here 6 days total). And with the new Drug Supply Chain Security Act (DSCSA) in place, loan and borrow meds become a major hassle, I know some community hospital simply refusing to do that outside of their own system. So this will necessitate expanding the formulary, inventory, both of which cost big bucks.
CMS provided a 2 year phase-in period, where patients who no longer meet LTAC reimbursement is payed on a blended schedule, so as to avoid jumping off a cliff. After 2 years, the blended payment is set to go away, but here is a chance that it will be renewed. I don't blame the CMS too much. The US healthcare system is unsustainable in it's current form. CMS is trying to cut hair where it can, and it just was LTAC's turn. What's sad to me is that it's death by a thousand cuts, as no amount of hair cut here and there is going to save the system in the end.
LTAC is a good place to learn how to run a hospital pharmacy. Knowledge of everything from dispensing, clinical, administrative, legal and compliance can be learned here. And because has only few people on staff, you can shape the pharmacy to fit your style easily, and has much less politics. 2 years ago, I would recommend it to any new residents or hospital pharmacists who have had at least 2 years experience, who might wanted to try out or learn management. Now, I would still say it's a good place for these same younger pharmacists who has ambition and is tolerant of career risks. Those who has a family, wanting high job security may want to wait 2 years to see who survives.
While I'm here, I want give some insight into Long Term Acute Care (LTAC) pharmacy, some of the reasons why I left a hospital for it, and why now I'm leaving it now for a hospital.
LTACs are specialty hospitals where patients need prolonged inpatient care. The average length of stay of an LTAC patient is around 25-30 days. The common conditions, are respiratory failure requring a ventilator, osteomyelitis, stage 4 decubitus ulcers, endocarditis. As such, the severity of illness (acuity) is lower than ICU, but higher than med/surg floor. A background in infectious diseases and/or critical care allows you to excel with this patient population. Those are my forte, and the drug cost per patient day (PPD) went down by almost 50% while mortality rate decreased, the CEO was overjoyed and treated me very well and generously. With bonus, the pay was over $170K last year. The job load wasn't overwhelming. In fact, not having ER and surgery (contracted out to the host hospital), made meeting regulatory compliance significantly easier, allowing me plenty of time to do clinical and fine tune financials. I see LTAC has an wonderful opportunity for new residency trained pharmacist who love clinical pharmacy and less redtape.
So why am I leaving? The major reason was I'm pessimistic about the long term outlook.
CMS has changed the reimbursement dramatically to cut cost, greatly restricting the types of patient that will qualify for the higher LTAC reimbursement schedule. This means bulk of the current LTAC patient population will be reimbursed on the lower IPPS schedule (the typical hospital payment). I can see this will drive several things: (1) the existing LTACs will fight over the fewer higher paying patients, many will close their doors simply because there isn't enough to go around, and cannot survive on taking mostly IPPS patients. (2) even those LTACs that survive will likely need to take a good portion of patients on IPPS, eating into their margin. Since IPPS payment is around 6 days hospital stay, there will be more admission and discharges, early into late at night. LTAC pharmacy are not usually 24 hours, and with a lowered reimbursement, increasing pharmacy FTE to extend hours operation will be tough, even remote pharmacy may be too costly of an option. Many other departments need additional staffing as well, such as admissions, case management, medical records. (3) IPPS patients will need different meds and need them quickly (patient comes in on Friday, you can't order a med and wait for it to come in on monday if he's only here 6 days total). And with the new Drug Supply Chain Security Act (DSCSA) in place, loan and borrow meds become a major hassle, I know some community hospital simply refusing to do that outside of their own system. So this will necessitate expanding the formulary, inventory, both of which cost big bucks.
CMS provided a 2 year phase-in period, where patients who no longer meet LTAC reimbursement is payed on a blended schedule, so as to avoid jumping off a cliff. After 2 years, the blended payment is set to go away, but here is a chance that it will be renewed. I don't blame the CMS too much. The US healthcare system is unsustainable in it's current form. CMS is trying to cut hair where it can, and it just was LTAC's turn. What's sad to me is that it's death by a thousand cuts, as no amount of hair cut here and there is going to save the system in the end.
LTAC is a good place to learn how to run a hospital pharmacy. Knowledge of everything from dispensing, clinical, administrative, legal and compliance can be learned here. And because has only few people on staff, you can shape the pharmacy to fit your style easily, and has much less politics. 2 years ago, I would recommend it to any new residents or hospital pharmacists who have had at least 2 years experience, who might wanted to try out or learn management. Now, I would still say it's a good place for these same younger pharmacists who has ambition and is tolerant of career risks. Those who has a family, wanting high job security may want to wait 2 years to see who survives.
