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Becker’s Healthcare Podcast
Sterling Elliott, PharmD, BCMTMS, Clinical Pharmacist Lead, Assistant Professor of Orthopaedic Surgery at Northwestern Medicine & Affiliate Faculty Member, Purdue University College of Pharmacy
00:21:06
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- [00:00]
A
Welcome to the Becker's Pharmacy Leadership Podcast. I'm Ella Jeffries, pharmacy reporter with Becker's Healthcare. Today I'm joined by Sterling Elliott, clinical pharmacist lead for the ambulatory surgery practice within Surgery and Procedures at Northwestern Medicine. In this episode, we'll be exploring how pharmacists are carving out new paths in a changing healthcare environment and the expanding opportunities for pharmacists leadership in ambulatory and procedural care. Sterling, thank you so much for joining me today. To kick things off, can you walk us through your background and your role as clinical pharmacist lead within the ambulatory surgery practice?
- [00:33]
B
Absolutely. It's, it's a pleasure to join you here on this podcast. I started out in the pharmacy world, sort of going back to school. I was working in different realms before that, including things like broadcast journalism. And I made a decision to go back to school and kind of go back to family roots. My family owned a prominent retail pharmacy in the north side of Chicago for many years. So after graduating I ended up in the institutional setting, starting out at Northwestern Medicine. I spent a few years there, ended up getting into a position where I was running the clean room before I left for Florida for a business opportunity where I sort of worked more extensively in ambulatory type settings and still spent time in hospitals there as well, and came back to Chicago in the summer of 2016. And so I've been back at Northwestern Medicine working in the surgical pharmacy realm ever since and really sort of found my focus in the area of ambulatory surgery and sort of looking at new and different ways to figure out how do you integrate pharmacists into that world and how do you optimize the care of patients in that realm.
- [01:55]
A
Awesome. Thank you for sharing your background. It's great to hear. Now from your perspective, what major shifts in today's healthcare environment are opening the door for pharmacists to step into expanded or non traditional roles.
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B
I think the American healthcare system is at this sort of, you know, really extensive crossroads here and really sort of fundamentally changing the way it operates. I mean, for a long, long time, the American healthcare system focused a lot on revenues and optimizing streams of revenues. And I think that in the last, I don't know, three years maybe, we've really seen costs just skyrocket in the American healthcare system and revenue streams at the same time start to decline. Third party payers are notoriously being more restrictive with what they'll cover and when they cover it, how much they'll pay and So I think it's really sent the entire American healthcare framework into a cost management mode. And so within the realm of American healthcare, I think the pharmacy component of American healthcare has been managing costs to optimize margins and revenues and income for a long, long time. And so I would think that the pharmacy departments all across the country could be a real resource for healthcare systems as we all move toward this chance to really make our costs sufficient so that we optimize our margins and our dividend for reinvestment for those of us that work in the not for profit sector and really sort of optimize the operating revenues that we get.
- [04:11]
A
Definitely, that's a really interesting point. Seems like those changes are going to create very real opportunities on the ground. Speaking of that, when you look at ambulatory and procedural care specifically, where do you see the biggest opportunities for pharmacists to fill gaps, take on new responsibilities, or lead initiatives that traditionally were considered, quote, unquote, pharmacy space?
- [04:30]
B
Yeah, it's a great question. And I think that really what we're looking at is the scenario where again, we talked about it, it comes right back to the previous conversation we were having, which is optimizing cost opportunities so that you maximize your revenue opportunities. And the American healthcare system is making this great move toward value based care. And it's a buzz term that we've heard bandied about, I would say, for years now. And whenever you talk about value based care, if you're having that conversation with somebody who's knowledgeable of everything that swirls around it, very early on in that conversation, you will hear complete agreement amongst the entire group that value based care means a million different things to a million different people. And we really don't know what it's going to look like or what it could look like. But to me, I think the best hope for value based care is one that prioritizes outcomes for patients and ties that to optimized revenues for those patient care events, as well as setting future payments to optimize revenues in the future. And, you know, so there's an area where I think a lot of the, the care of patients, whether it's acute or it's chronic, is ingrained in the use of drugs and the use of drugs effectively and efficiently. And so I think there's real opportunities for pharmacists and the pharmacy profession to find ways to integrate into the care stream with patients so that we can apply our knowledge and our expertise in terms of how to use these medications effectively and advise the patients and their physicians so that everybody has a successful outcome. And when successful outcomes are tied to optimal payments for events, plus minimizing penalties for future payments, there's a huge opportunity here for pharmacists and the profession of pharmacy to make a major impact on the future of the American health care system.
- [07:05]
A
For sure. I definitely agree on that. And kind of going a little bit deeper, what are some of those specific patient benefits you anticipate from pharmacists taking on these roles?
- [07:14]
B
Well, I think, for instance, I, we see that in diabetes, in areas like diabetes and in areas like cardiology. Some of my, my colleagues are working in the ambul regulatory settings and they're helping the physicians and their patients optimize their blood glucose levels and optimize their, their outcomes. And oftentimes optimizing outcomes in chronic disease states like that means that patients are having fewer acute admissions for events where their health has declined. And that is leading to fewer high cost encounters that are reimbursed at a level that's not, you know, that's not in line with the costs that it takes to help somebody get through that. And so that's one area. And then very often payments can be tied to how well your patients perform in the aggregate, not necessarily in acute settings. So there's an opportunity. Those are opportunities that we know of in my world in which I work in the acute surgical realm in an ambulatory setting. One of the major components of post operative care is pain management. And how do you do that effectively? And the answer in America right now almost always includes the use of opioids because they work. But they also, as we know, come with a lot of consequences that we have to be very, very cognizant of. And so I think that there's a real opportunity. That's what I'm trying to start forging here. For pharmacy and for pharmacists like me and others who would want to come on board and help me and join me and figure this out would be how do we effectively teach patients to manage their pain so we minimize their use of opioids? Because a lot of reimbursement issues are tied to 30 day readmissions and patient reported outcomes. And one of the major things that drives patient reported outcomes is their perception of the pain after surgery. And so I think pharmacists and pharmacy in general has a great opportunity to leverage that. And that's really what I'm trying to build.
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A
Mm, for sure. Those are great examples. Thank you so much for sharing. Now kind of switching gears a little bit. You know, stepping into new spaces isn't always simple. As these roles expand, what barriers or misconceptions still stand in the way of pharmacists practicing at the top of their license? And how do you think leaders can address them?
- [10:16]
B
Yeah, I think let's talk misconceptions first because I think that those used to exist within the health systems and I think those have largely been broken down within the health systems. There was a time where pharmacists were calling out, let us join you, let us help you, let us be a part of this. And there was resistance from physicians and nurses and mid level practitioners thinking that the pharmacy could potentially encroach on some of their realms. And I think what's been learned is that that's not at all what's happening, because the nature of how healthcare gets measured and assessed and how those measurements and assessments and those results get applied to revenue is driving things in a direction nobody's happy with. And I think there's been this general perception that pharmacists and pharmacy in general can add to the optimization of that. So the misconception within the health system is not there, but I think it exists outside. I think that a lot of patients still see the top of mind vision of the pharmacist and as somebody in a branded piece of clothing in a retail setting moving their medication. And certainly those folks exist and we need them and they're a crucial part of making sure that the appropriate drugs get to the right patients in the right way. And that should never go away. But I don't think patients realize the other contributions. And then I think too that the government mechanics out there, legislatures at the state and federal levels, don't yet recognize or have mechanisms in place to recognize pharmacists and the profession of pharmacy as a crucial component of the work that gets done for patients. So those are misconceptions. Now, what are the barriers? Well, the barrier, sort of the primary barrier, I think emanates from the misconception that we were talking about at the legislative level, which is that there needs to be a commitment to establish pharmacists as a viable source of patient care in the American healthcare landscape. So that when it does, the principal barrier, which is cost relative to reimbursement, can be really pushed back on hard, because that's the key barrier. The key barrier is that there are very few elements of the legal and regulatory components of the American health care system that mandate that a third party payer, the insurance carriers, cover the costs of pharmacists intellectual services that they provide to patients. And while there's tacit agreement amongst all the members of the American healthcare system that pharmacists do do that and that there'd be nothing wrong with paying for that, there's nothing motivating the payers to do so. And until they're motivated, they're not going to because they just see it as a cost outlay. But in fact, a small cost outlay to a pharmacist to join in the process to help optimize the care of patients when it comes to the way medications are used could lead to far fewer high cost, high reimbursement events that take place as a consequence. So I really think that's the critical barrier that we're facing now.
- [14:24]
A
Definitely those are really helpful perspectives and I think a lot of leaders will appreciate hearing those. But let's bring that to life a little bit more. Can you share an example of a program workflow or initiative that you've helped build that demonstrates how pharmacists can carve out new impactful roles in care, you know, despite these barriers and misconceptions?
- [14:42]
B
Oh, absolutely. And it's the work that I do at Northwestern Medicine in our flagship location at Northwestern Memorial Hospital, when it comes to ambulatory orthopedic surgery. And this is a result of a lot of thought about what do you say to people, how do you say it, when's the best time to say it? And it's collaboration with my leaders in the pharmacy department, collaboration with my colleagues who are surgeons in orthopedic surgery and the leadership of orthopedic surgery. And everybody kind of coming together and saying, yeah, this is something really interesting and valuable that we can provide our patients that you probably just won't get anywhere else. And got a lot of lines of research that the teams and I are pushing toward. And as we do our literature research, we don't find a lot of examples of people writing up the type of thing that we're doing. Essentially what we do is on the day of surgery we'll go into patients pre op rooms. And I do this in conjunction with students that I precept from Chicagoland area pharmacy schools. And they do a lot of the work and it's great because it's a great teaching opportunity and to show them how to think about doing something differently. And we walk in there and we talk to patients and we tell them we're going to talk about your pain management experience on the first day you're recovering and afterward and the Goal here is to figure out how do you know when it's the best point in time that you may need to use one of those opioid pain pills. We set expectations about what pain is going to be like after surgery. That's a huge thing to do. And we talk to them about their other options besides the opioids, chiefly things like acetaminophen, the brand name Tylenol and the non steroidal anti inflammatories. And we've crafted it so that we can talk about the NSAIDS in terms of how do you use them effectively if the doctor wants you to use them as needed and or how do you incorporate prescribed scheduled doses. And we talk to patients about evaluating their pain not in terms of a pain score, but in terms of functionality, how are you doing with the pain and let your functionality drive whether or not you need an opioid. And we give them seven factors that they can assess and we tell them that once you know that your pain never reaches the level that you're even asking yourself those seven questions, well, you no longer have pain that comes anywhere near needing an opioid. And we teach them the importance of getting rid of it and how to find take back day events, how to find, you know, kiosks that exist that are regulated by dea. And so I think all of those things are really fascinating concept. The surgeons appreciate it and very often they'll tell me about experiences that they have with patients on post op visits who mention that they thought it was helpful, number one. Number two, one of my colleagues always says I can always tell the patients who listened to the part about the anti inflammatories because their course of progress after surgery is the best. So I think we're seeing tangible results. It's a matter of how do you bring that out to the masses now.
- [18:16]
A
For sure, it's great to hear about the work that you're doing for both pharmacists and patients. Now, thinking bigger picture, what should hospitals and health systems be doing right now to better support pharmacists as they move into expanded or non traditional roles?
- [18:30]
B
I think that what health systems need to do is what I can tell you. I know the leaders at my health system are doing, which is to listen to these ideas, to think about them, to understand the value and then to work effectively at finding paths forward for how to make this happen. Right. You know, I think one of the things in sort of looking at this and some of the conversations that I've had with folks, you know, they talk about. Certainly they talk about recognizing the importance of creating cost efficiency. But what I think we have to realize as a pharmacy profession is that the true success of this is going to be figuring out how to incorporate revenue generating activities. Whether that's partnering with physician practices to generate revenue that goes alongside time with the pharmacist, or I think very importantly, advocating for laws and legislation that recognizes pharmacists as legitimate providers of healthcare services to patients, because that will generate the ability to create revenue streams from the third party payers which predominate the flow of money through the system. And then I think too, it's being creative. In our case, we have conversations about how do we build out lines of investigation to describe the merits of what we're doing that can not only put our name out there and motivate other colleagues throughout the country to do this, but can also motivate benefactors, philanthropists who want to support innovation in healthcare to join in and provide funds to do that as well. So I think it's going to take a lot of thoughtful creativity and the willingness to have these conversations.
- [20:41]
A
Definitely. Well, Sterling, this has been such an insightful conversation. Thank you so much for sharing your perspective and experience with us. That's all the time we have for today's episode of the Becker's Pharmacy Leadership Podcast. A big thank you again to Sterling Elliott for sharing his insights on how pharmacists are carving out new paths in today's evolving care environment. Thanks for listening and we'll see you next time.