Improving drug therapy.

What are your membership's main concerns today?

Webster: Our overarching concern is that the elderly, irrespective of the care setting they reside in, need access to needed and appropriate medications. "Needed" relates to whether you treat or don't treat a disease. In other words, for pain, you give pain medication. Or osteoporosis--you treat that problem. The decision is a "yes" or "no." Increasingly, primarily because of the cost-focused nature of our health care system, providers are choosing to ignore, overlook, or just not deal with treating. Assuming you make the decision to treat, then the question becomes, "What is the most appropriate drug therapy?" In a cost-driven environment, providers are likely to use the least expensive drug without due consideration for therapeutics.

The consequences of going with cheapacillin versus gorillacillin can range from ineffective to disastrous, such as when the wrong drug diminishes a resident's health outcome or quality of life, or requires further medical interventions, either additional drugs to treat the side effects, or additional personnel to address the problems created. The newer antipsychotics have a dramatically lower side-effect profile than the older ones. But the price difference is substantial. So if you're treating dementia, which route do you go? In a cost-driven environment, you may go to a cheap drug. But expect increases in urinary incontinence, falls and fractures, and Parkinson-like symptoms. That requires extra staff time, and it's all driven by the desire to minimize utilization and the cost of drug therapy.

Congress has addressed some concerns about PPS's affect on access to drugs. What else are you lobbying for?

Webster: One initiative aims to help HCFA understand that the quality indicator dealing with nine or more medications is well-intentioned but has the wrong consequence: Some patients are having drug therapy discontinued that might be needed to treat their disease or alleviate their pain because it adds to the medication count.

So far, all the debate in Congress is about how to deliver a drug benefit to ambulatory Medicare beneficiaries without regard for the special needs of Medicare beneficiaries residing in institutional environments. Unless Congress recognizes that institutional patients have special needs as to how drugs are ordered, stored, administered, and reviewed, facilities could find themselves going to the local drug store to obtain meds for their non-Part A residents. Long term care facilities have unique needs, from the need for an on-site supply to four-times-a-day deliveries, to special packaging to reduce error and waste, to medication review procedures. Any bill must take these into account.

How has Washington responded to your efforts?

Webster: While HCFA has not yet eliminated the nine-med QI threshold, I think they have it under consideration. Our support [in Congress] is pretty broad-based in terms of 1) understanding and 2) concern.

How is the assisted living sector doing at medication management?

Webster: There are a lot of problems--from residents getting the wrong drugs to inappropriate polypharmacy, where somebody has not reviewed a patient's drug regimen, or has not observed and responded to side effects or failed therapeutic outcomes. Over time, that will be addressed--probably by increased regulatory oversight--not that I'm calling for that.

What would you suggest instead?

Webster: Providers have to recognize that drug therapy is probably the greatest technology that we have available today for preventing illness, disability, and death in the geriatric population. With that in mind, they have to make sure that technology is utilized to its best advantage. That means doing something other than simply saying, "Oh, that's the resident's doctor's responsibility." Providers have a responsibility to see that residents comply with their drug regimens.

How is the push for wellness programs going?

Webster: Pretty dramatically. If you're assisted-living based, wellness is intrinsic to your mission. Having wellness and disease management programs up and running is absolutely key. And many wellness programs have a significant drug therapy component. They're based on the identification of latent or active disease and aggressive treatment so progression of the disease doesn't require a higher level of care.

Is consolidation in the pharmacy business a good thing?

Webster: I think so. Consolidated companies have the capital to develop the programs necessary to deliver optimal care in a cost-effective manner, from implementing new information systems to identifying preferred drug therapies to training senior care pharmacists.

Tim Webster is the executive director of the American Society of Consultant Pharmacists. The Washington, D.C.-based trade group represents senior care pharmacists, many of whom provide medication management and consulting services in long term care settings.