soccerfreak

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I wanted to see what everybody thinks about opening up a Coumadin clinic at this time. I'm a rounding pharmacist in the ICU/OR/ER units and the hospital that I work for is located in the downtown Chicago area. We have a mostly elderly patient population and with the extra pharmacists that we just hired I believe that now I can open up a coumadin clinic.

There is always the question of how long will coumadin clinics last with the emergence of oral direct thrombin inhibitors such as dabigatran.

Any input would be helpful since I want to bring this up to my director and the hospital administration
 

Its Z

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so who and how are you going to bill for your service and who will pay for the service? and what exactly will you do in the clinic and where would youget patients from?
 

MindOverMatter

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I really don't think it's the right time to invest in something like this with direct thrombin inhibitors and factor Xa inhibitors just starting to make their way into the market. But hey, what do I know? I'm just a lowly p4.
 
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soccerfreak

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so who and how are you going to bill for your service and who will pay for the service? and what exactly will you do in the clinic and where would youget patients from?
Who - medicare/medicaid/private insurance and how? That is still up for grabs. I assume it would be through the billing department. I don't think that getting the financial commitment from administration is going to be difficult and patients would be referred from inside the hospital.
 
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soccerfreak

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I really don't think it's the right time to invest in something like this with direct thrombin inhibitors and factor Xa inhibitors just starting to make their way into the market. But hey, what do I know? I'm just a lowly p4.
Direct thrombin inhibitors and anti-factor Xa drugs have been around for a hefty time now. Or maybe I should open up a cholesterol management clinic or something similar?
 

MindOverMatter

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Direct thrombin inhibitors and anti-factor Xa drugs have been around for a hefty time now. Or maybe I should open up a cholesterol management clinic or something similar?
DTIs have been around for the treatment of HIT, but not indicated for such wide spread disease states as atrial fibrillation, VTE treatment/prophylaxis, etc. These new indications are literally game changers in the anticoagulation world.

Yes, we don't know what post-marketing data will uncover, and we might see things like the hepatotoxic effects we saw with ximegraltan, but only time will tell for that.

I was just stating that I personally wouldn't put any money into anything to do with Coumadin at this point.

Have you ever thought about just being a pharmacist for now until you have a better grasp of the field? We can't all be investment gurus like Z right out of the gate ya know.
 

Praziquantel86

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If you start a Coumadin clinic, then yeah, you're making a mistake. A full-service anticoagulation clinic, however, then you might have something with the right payor mix and provider/hospital backing.

The new orals are going to have very different dosing based on indication (DVT treatment, A-fib, etc.), renal impairment, hepatic impairment, etc. This is really an opportunity for pharmacy to grab the bull by the horns and make themselves a necessary component of the patient's care. I don't know how many people have the wherewithal or the drive to do it, but the opportunity is there.
 

mustang sally

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Don't you think people will still be on warfarin for a long time because of cost reasons? That's what I was led to believe, but I'm just a really lowly P3...
 

Its Z

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I'm a rounding pharmacist in the ICU/OR/ER units and the hospital that I work for is located in the downtown Chicago area.
So you're a clipboard pharmacist. What exactly do you do when you round? And you round in OR...doing what? Monitor anesthesia gas flowrate and MAC? How do you justify your salary. I'm not picking on you. I'm sincerely curious about what you do since non-distribution clinical pharmacist model went out the window 20 years ago unless you're paid by a school as a faculty.

Ok, so you want to set up a coumadin clinic. First, you will need to know how to bill and code for the service. And I'm assuming your hospital will be the provider yet medicare, medicaid, and private insurance don't simply reimburse pharmacist for monitoring INR.. certainly you can charge a lab fee (INR) which can be reimbursed. You will also need physicians to signoff on the change in warfarin dosing.

Hospital will need to provide some real-estate for an outpatient visit area. Then you will need to run a pro-forma... pharmacist FTE is about $150,000 per year including the benefits. Which means, every hour the clinic is open, it needs to generate a gross income of minimum $72 per hour. Wouldn't it be cheaper to use an RN to run the clinic?

Who's going to receive the referrrals, bill, set up appointments...basically run the office?

Return on Investment for this sort of clinic can vary.

I opened a coumadin clinic in 1997 at a hospital. I was only able to bill for INR which was reimbursed at $25... and I probably saw between 25 ro 30 patients a week. But I crammed that in 2 days..part time. I was also the clinical coordinator so my salary was well justified.

Your new pharmacist..what's his/her role???

Sounds like an inefficient pharmacy operation, brah.
 
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soccerfreak

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So you're a clipboard pharmacist. What exactly do you do when you round? And you round in OR...doing what? Monitor anesthesia gas flowrate and MAC? How do you justify your salary. I'm not picking on you. I'm sincerely curious about what you do since non-distribution clinical pharmacist model went out the window 20 years ago unless you're paid by a school as a faculty.

Ok, so you want to set up a coumadin clinic. First, you will need to know how to bill and code for the service. And I'm assuming your hospital will be the provider yet medicare, medicaid, and private insurance don't simply reimburse pharmacist for monitoring INR.. certainly you can charge a lab fee (INR) which can be reimbursed. You will also need physicians to signoff on the change in warfarin dosing.

Hospital will need to provide some real-estate for an outpatient visit area. Then you will need to run a pro-forma... pharmacist FTE is about $150,000 per year including the benefits. Which means, every hour the clinic is open, it needs to generate a gross income of minimum $72 per hour. Wouldn't it be cheaper to use an RN to run the clinic?

Who's going to receive the referrrals, bill, set up appointments...basically run the office?

Return on Investment for this sort of clinic can vary.

I opened a coumadin clinic in 1997 at a hospital. I was only able to bill for INR which was reimbursed at $25... and I probably saw between 25 ro 30 patients a week. But I crammed that in 2 days..part time. I was also the clinical coordinator so my salary was well justified.

Your new pharmacist..what's his/her role???

Sounds like an inefficient pharmacy operation, brah.
Let me clarify a little. I round in the ICU and on some of our floors. I do the ICU/floors one week and the OR/ER next week. In the OR I monitor medication use such as preop antibiotics, Tran acid, post op orders, integrilin use in cath lab, etc. I also round on another floor. With all of that, it still leaves plenty of time to do other things, some of which might be discharge counseling of the patients, attending codes, or opening up a coumadin clinic. The OR position is a relatively new one, opened up last week so we're still trying to figure out where a pharmacist can best intervene. The new pharmacists that we hired opened up more time for me so we're trying to figure out how we can best utilize this extra help.

If we were to open up a coumadin clinic, it would only be 2 days a week maybe around 3-5 hours. The office would be run by me with the extra time that I have available now.

Physician signing off would not be a big problem since all of what occurred during the visit would be sent to the physician the very same day.
 

njac

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I wanted to see what everybody thinks about opening up a Coumadin clinic at this time. I'm a rounding pharmacist in the ICU/OR/ER units and the hospital that I work for is located in the downtown Chicago area. We have a mostly elderly patient population and with the extra pharmacists that we just hired I believe that now I can open up a coumadin clinic.

There is always the question of how long will coumadin clinics last with the emergence of oral direct thrombin inhibitors such as dabigatran.

Any input would be helpful since I want to bring this up to my director and the hospital administration
whywould you give up a clinical ICU/ED position for a freaking coumadin clinic??? That sounds horrible!

I'll take your ED from, it's cool.
 

Its Z

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Let me clarify a little. I round in the ICU and on some of our floors. I do the ICU/floors one week and the OR/ER next week. In the OR I monitor medication use such as preop antibiotics, Tran acid, post op orders, integrilin use in cath lab, etc. I also round on another floor. With all of that, it still leaves plenty of time to do other things, some of which might be discharge counseling of the patients, attending codes, or opening up a coumadin clinic. The OR position is a relatively new one, opened up last week so we're still trying to figure out where a pharmacist can best intervene. The new pharmacists that we hired opened up more time for me so we're trying to figure out how we can best utilize this extra help.

If we were to open up a coumadin clinic, it would only be 2 days a week maybe around 3-5 hours. The office would be run by me with the extra time that I have available now.

Physician signing off would not be a big problem since all of what occurred during the visit would be sent to the physician the very same day.
Congratulations on securing a position that's strictly "clinical." Your worst nightmare is if you have an administration change, he/she will bring in consultants to run a workflow analysis for clinical, financial, operational, and regulatory compliance and efficiency.

Since your OR rounding is new, I assume you have created and pulled the baseline SCIP/Core Measure compliance rate for antibiotic selection, cut time, and discontinuation compliance then monitor it going forward to ensure improvement can be seen through your effort and time. Then report your findings to your DOP and the hospital admin.

Same thing with Cath Lab.. hope you have the baseline Integrillin and/or GP IIb/IIIa utilization/purcahse per case or adjusted patient day and monitor the changes in order for you to track your time is well spent. Of course this outcome should also be reported back to your DOp and the hospital admin.

Same approach should be taken with the Warfarin clinic. The revenue should be able to justify the office space, pharmacist time, and lab time. Along with improved clinical outcome of the patients, it difinitely needs to make financial sense. Of course I would keep a close monitoring on the changes in ER admission due to elevated INR.

The emergence of DTI raises another interesting point. How much money is saved by not needing to run INR vs. increase in Factor or FFP use due to bleeds. It remains to be seen.

My most curious point is why would you hire a pharmacist who does not have a defined position/role predetermined before the hire was made. It's almost like buying a bunch of building material first then deciding what to build where. You know what I mean?
 

owlegrad

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My most curious point is why would you hire a pharmacist who does not have a defined position/role predetermined before the hire was made. It's almost like buying a bunch of building material first then deciding what to build where. You know what I mean?
You know Z I had the same thought. Who hires someone without a defined role? Sounds like a nightmare job to me.
 
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soccerfreak

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You know Z I had the same thought. Who hires someone without a defined role? Sounds like a nightmare job to me.
All of the above mentioned analysis and reporting in terms of cost saving/efficiency has already began.

My duties before the other pharmacist was hired were half clinical and half staffing in central pharmacy. Our administration decided to expand our clinical role (more pharmacists rounding/antibiotic utilization/expense savings) due to a savings benefit seen in the ICU with the rounding pharmacist position, thus we decided to see where we can intervene in the OR/ER and other floors.

You are correct as to why hire someone without a defined role but I already has a defined role (just not completely now since I am full time clinical). That is why I, as well as my clinical coordinator and the DOP are trying to find out ways we can save the hospital money. Hiring the other pharmacist at this moment was definitely not the best move (Not my idea) but if the administration gives you the ability to expand you take it and run while improving patient safety, utilizing the best pharmaceutical care, and saving the hospital money.
 

Its Z

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what exactly did yall do in the ICU to save money and what cost are you measuring?
 
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soccerfreak

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what exactly did yall do in the ICU to save money and what cost are you measuring?
Sedation/ventilator management
Antibiotic streamlining
Dosage adjustments
IV to PO - although most of this gets done in central pharmacy
Core measurements - ace for heart failure/ asa for mi etc

Integrilin monitoring
Argatroban switches
Xigris prevention (innapropriate use) ~ 10,000 for this one

Chart reviews
Disease state management- you would be surprised how many patients don't get the appropriate treatment
Alternative therapy recommendations

The icu position has been there for about 6-8 months so that is relatively new too but the cost savings has already been documented

I'm just looking for other opportunities for us so we can ultimately improve patient's safety and well being. I think if we do that then this will lead to a hospitals success and I think all of you would agree with that?
 

njac

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I disagree on the being hired without a job description being a bad thing.

In my specialty there is a wide variety of practice models that people choose to practice by. If I start my own practice (which is likely) I will probably come in and establish needs and then work on a game plan to address those, rather than coming in with a set job description.
 

Its Z

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I disagree on the being hired without a job description being a bad thing.

In my specialty there is a wide variety of practice models that people choose to practice by. If I start my own practice (which is likely) I will probably come in and establish needs and then work on a game plan to address those, rather than coming in with a set job description.

I never said Job Description rather defined role. There's a difference. In your case, you will be hired to establish a program of your specialty. In that instance, your job description will simply state "establish a program...."

But you're hired for a specific purpose to perform a certain defined role.

Asking should we open a coumadin clinic because now we have extra help is not the same thing.
 

Its Z

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Sedation/ventilator management
Antibiotic streamlining
Dosage adjustments
IV to PO - although most of this gets done in central pharmacy
Core measurements - ace for heart failure/ asa for mi etc
Hopefully ASA for MI is done in the ED not ICU. What are you doing for sedation management...dosing propofol and midazolam?

Integrilin monitoring
Argatroban switches
Xigris prevention (innapropriate use) ~ 10,000 for this one
$10,000 for xigris is just 1 treatment.

Chart reviews
Disease state management- you would be surprised how many patients don't get the appropriate treatment
Alternative therapy recommendations
Why would I be suprised?

The icu position has been there for about 6-8 months so that is relatively new too but the cost savings has already been documented
How do you measure it?

I'm just looking for other opportunities for us so we can ultimately improve patient's safety and well being. I think if we do that then this will lead to a hospitals success and I think all of you would agree with that?
Well, great pharmacy department alone doesn't lead to a hospital success.. but your head is in the right place. Keep it up fella.
 

Argentium

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Don't you think people will still be on warfarin for a long time because of cost reasons? That's what I was led to believe, but I'm just a really lowly P3...
Well that's up to marketing isn't it. HEOR cost effectiveness studies from stanford have shown that pradaxa is cost effective compared to warfarin despite being 8x more expensive once you factor to QOL + ADE/DDI problems in warfarin. havent seen clinical results for xarelto but its supposed to be as good or better than pradaxa

http://www.annals.org/content/early/2010/11/03/0003-4819-154-1-201101040-00289.full?aimhp