The pharmacist as an administrator

Administration and management are facets of the pharmacy profession that often disregarded, or at least relegated to a footnote at the end of minor credits, within the context of pharmacy undergraduate courses. They are, however, vital skills within our multiple-disciplinary mindset, especially in the context of the Maltese Islands.

One must consider that amongst most pharmacists that enter the field of community practice, most are required to carry out the duties of professional pharmacist and shop manager. These duties require as a bare minimum a working knowledge of administrative functions and procedures.

This point of argument is also relevant outside the area of community practice, as in the running a state owned pharmacy, or the management of the budget and expenditure of a pharmaceutical distributor. Such duties still impose the supposition of the knowledge of money and people management. Even though one might argue that management and administrative duties do not fall within the remit of a pharmacist's core responsibilities, one would be short-sighted and very blinkered not to recognize the possibilities, both from a career-ameliorating aspect, and also from that of personal satisfaction, that could be realized with the addition of management and administrative skills to the pharmacist's already broad knowledge base.

One might even argue for a greater focus at undergraduate level on such matters, and the possibility of a post-graduate specialization in healthcare administration, possibly in co-operation with the faculty of management and accountancy. Integrating a high level of functionality and versatility into the pharmacist's repertoire of skills will set up future graduates on a better footing for professional and personal success in the long haul.

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Generic medicines in Malta

The low market penetration and the consumer's lack of information about generic medicine products was highlighted by a survey carried out last year by the Malta Medicines Authority, from which it transpired that over 80% of the general population had no idea what generic medicines really meant.

This is of great import to the general discussion on the very hot topic of medicine prices, as price variations in generic and branded products can be substantial, especially when one considers that a considerable amount of new products have been introduced to the Maltese market in the past year.

Below is an unpublished opinion piece written last year on the subject. The link to pdf file is here:http://www.stsimonpharmacy.com/Docs/In%20defence%20of%20the%20Pharmacist%20II.pdf


Generic Medicines and lower prices!

Most members of the public do not have a clear idea of what the term generic constitutes when applied to the context of medicinal products. This short article aims to correct this lack of information, and also provide points on how a Maltese consumer can obtain the therapeutic benefits provided by modern medicines whilst saving on expenditure.

A generic medicinal product is a version of a previously patented (that is protected by a monopoly licence) medicine, that is identical to it in composition and action. In most cases the generic product is cheaper than the originator product. Locally, one can draw comparisons between the prices of generic paracetamol(€ 2 per 100) and the branded version(€ 1.61 per 24).

A generic version is just as safe and effective as the originator and passes all the minimum quality requirements that are demanded by the European Medicines Agency (EMEA), and also the Malta Medicines Authority. Maltese legislation allows brand substitution of prescribed products unless the physician expressly prohibits this on the script. In certain cases a pharmacist is morally obliged to point out the availability of cheaper alternatives to the patient, as the savings can be substantial. For example, in the case of a particular proton pump inhibitor (for stomach acidity), the variance between the originator and generic for a six-month prescribed course from Mater Dei General Hospital is a whopping € 277!

Not all generic drugs provide savings of the magnitude described above, and in certain cases the difference may not be significant enough to warrant changing brand, especially in the case of chronic medication and elderly patients. However it is imperative that the patient is aware of the existence of equivalent and cheaper alternatives, as this will increase the access of the general public to pharmaceutical treatment and lead to a better quality of life. No patient should object to paying a high price for a newly discovered and cutting edge drug treatment; on the other hand, it is every patient’s and Maltese citizen’s right to have access to the same treatment at much reduced prices once the monopoly period of manufacture has expired.

All patients have the right to demand the existence of an alternative medicine, and if this is available, take the decision on whether or not to migrate to a more cost-effective healthcare solution. The role of the pharmacist is to point out the existence of such alternatives, and provide professional and unbiased advice on the best treatment option to be chosen, as cheaper is not always necessarily better!

Hoping for the best?!

The recent public announcement by the Minister of Health, The Honourable Dr. Joe Cassar, regarding an expansion of the number of diseases included under Schedule V is to be applauded. To those uninitiated in the myriad complexities of the Maltese state-run healthcare system, any disease listed under Schedule V of the Medicines Act is considered to be chronic and therefore any citizen of the Maltese Islands suffering from a disease classified as such, is entitled to free, unlimited treatment, at least with respect to pharmaceutical care. Also announced were an increase in the number of patients entitled to free glucose testing kits and replacement strips.Read the full article here: http://www.timesofmalta.com/articles/view/20111012/local/reform-of-free-medicines-system-announced.388858.

This is a step in the right direction, as Malta has often been criticised by other members of the European Union on the grounds that a number of chronic, debilitating diseases were being excluded from state-provided care systems, and thus discriminating against those afflicted by them.

What is, on the other hand, a worrying fact, is that no statistics whatsoever have been presented to back up the manner in which this increase in the disbursement of funds is to supported. Whether there is to be an increase in the budget allocated to pharmaceutical care, or there are to cuts in the same said budget, or in other areas of the global healthcare budget, remains to be seen. From an observer's point of view, these are the questions that need to be answered, and soon, as any improvements to the public healthcare system need to be sustainable and approached with  long-term benefits to the patient in  mind.

Money is not the prime mover for long-lasting corporate success

Contrary to economic theory, it has always been my gut feeling that enduring companies are built on more than just a simple quest for the augmentation of financial assets. The possibility of constructing a framework that enables profits to be generated whilst at the same time contributing to the general good of both the local and also international society might seem fanciful, but it is not as far fetched as one might think. In fact, a recent article published by the Harvard Business Review, supports this point of view:http://hbr.org/2011/11/how-great-companies-think-differently/ar/pr.

Read this article and then be prepared to alter forever your conceptions of how a business, whether it is yours or not, should be run. Ingraining the principles which underpin human decency and enable the co-existence of the whole of humanity, into the fabric of a company's make-up can only lead it upward. Profits and financial stability will follow automatically as an effect of, rather than as the reason for,  the company's existence.

Drug Shortages - Not just a local issue!

Below is a summarised version of an article published by Reuters. It highlights problems present in the pharmaceutical market in the United States, which is the most competitive in terms of product availiblity and early launch to market for innovative therapies, and also the most costly, worldwide.

(Reuters) - Two years into an escalating shortage of life-saving cancer drugs, regulators and lawmakers are still unable to identify why it is happening, let alone how to solve the problem.

Hospitals and doctors across the country are postponing care or using second-best or more costly alternatives. The shortages have also forced delays in clinical trials for cancer, which use these drugs as a baseline to test the effectiveness of novel therapies.

In the balance are hundreds of thousands of patients, and potentially millions, who may not get the full care they need.

"Anybody who is sure they know the answer to this question is probably kidding themselves," said Peter Lurie, a senior adviser in the Food and Drug Administration (FDA) Office of the Commissioner, who works on public health issues, including drug shortages.

"There appear to be multiple factors that are playing in it and it's very difficult to identify which one is most important," Lurie told Reuters.

Drug shortages have been around for years in the United States, but they were previously intermittent and largely temporary, pharmacists and doctors say. They have shot up in a very short time, with a record of over 200 scarce medicines this year alone, up from 56 in 2006, according to FDA data.

Health providers say the companies who make these drugs, long sold in generic form, have a diminishing interest in ensuring a strong supply. After a wave of consolidation, only five to seven companies produce 80 percent of these medicines, and stricter reimbursement policies have cut into the profits.

In a July survey of 820 hospitals by the American Hospital Association, more than four-fifths of hospitals said they had to delay treatment and more than half could not provide patients with the recommended drug for their disease. Sixty-nine percent of patients had to settle for a less effective drug.

The non-profit Institute for Safe Medication Practices (ISMP) has reports of at least 15 patients dying from drug shortages since last September. In the most high-profile case, nine patients died from contaminated IV fluid in Alabama this past March, when the typical supply was unavailable.

Of the 140,000 patients diagnosed with colorectal cancer each year, about 80,000 are expected to rely on typical treatments such as fluorouracil or leucovorin, both currently in short supply, said Nancy Roach, a board member at the patient group Fight Colorectal Cancer.

The government is trying to create a better notification system for shortages, which could address some of the most immediate issues for patients.

Senator Amy Klobuchar, a Democrat from Minnesota, along with Robert Casey, a Democrat from Pennsylvania, introduced a bill in February that would force drug companies to inform the FDA about looming shortages. The FDA said early notification helped it prevent 99 shortages so far this year.

But the bill does little to prevent shortages in the long-term. "People aren't in agreement on how to solve it in the long term, and not a lot of bills are going through Congress," Klobuchar told Reuters.

The FDA began tracking drug shortages closely in 1999. Over a decade later, they have only gotten worse. Sterile injectables such as the cancer drugs, make up the lion's share and accounted for 132 out of 178 shortages in 2010.

Most are generic and have been around for years, meaning profit margins are lower.

The FDA can explain the immediate causes of the shortages -- in 2010, over half of them came from product quality and "significant" manufacturing problems such as metal shavings found in vials or fungal contamination, said Sandra Kweder, deputy director of the FDA's Office of New Drugs.

But these reasons fail to address why these problems have gotten so much worse, officials and industry analysts said.

Industry consolidation and lower inventory levels could exacerbate the problem, leaving less slack in the system to deal with shortages when they arise, the FDA said.

The agency has also blamed an increasing number of production issues on older facilities that need to be renovated as manufacturers in the low-margin generic market avoid investments in maintenance. Makers of sterile injectables Teva, Hospira and Bedford Laboratories, part of privately-held Boehringer Ingelheim, have all had manufacturing issues in the past few years, shuttering production on multiple drug lines.

The FDA also acknowledges some manufacturers may have less financial incentive to make older, cheaper generic drugs. In 2010, 11 percent of shortages were due to companies that stopped making a certain drug, usually for business reasons.

Manufacturers are loathe to make a connection between the financial incentives and producing older medicines. Several, including Teva Pharmaceuticals and Hospira, say they are building new facilities as a back-up for future shortages.

The industry lays part of the blame with the FDA. The Generic Pharmaceutical Association (GPhA) said the agency has become more focused on enforcement in the past three years, shutting down factories for smaller problems that would have been dealt with less drastically in the past.

They include creating a national stockpile for emergency injectables -- just like for vaccines -- or offering tax incentives for manufacturers of low-cost but life-saving products. But those are unlikely to gain favor as the U.S. government is scrambling to cut costs and reduce the national debt, lawmakers and industry players said.

The International Monetary Fund and the U.S. Department of Health and Human Services are both investigating the issue, and a Government Accountability Office report is due to come out in November, according to a congressional staffer.

In the meantime, doctors like Steven Abrams, at Texas Children's Hospital in Houston, work to make sure newborn infants with intestinal damage have enough calcium and phosphates.

These essential minerals - manufactured by APP Pharmaceuticals, a company in the Fresenius Kabi Group, and Hospira - have been in short supply since April, Dr. Abrams said, forcing him to ration treatment to those most in need.

"Our task is to continue to advocate for long-term solutions," he said. "And the second is to manage this problem day to day. That's just what we have to do, ... to make sure the babies get the medicine they need."

(Reporting by Ann Yukhananov; Editing by Michele Gershberg and Tim Dobbyn)

A small step forward?!

The meeting held at the Westin Dragonara Resort last Tuesday the 11th for pharmacists, under the auspices of the Malta Pharmaceutical Association (MPA) should be viewed as a step in the right direction. The reason for the get together was the recent change in the pharmacy course structure and final degree awarded, as explained in the post previous to this.

Some of the attendees expressed their reservations,  both about the fact that the new structure could negatively affect their standing, and also about the fact that they were not familiar with the rasion d'etre of the MPA.

From the initial tangible facts available, it seems that the opportunity to obtain a high quality post-graduate degree such as the M.Pharm., on a part-time basis and tailored to the needs of a very busy and hectic professional an personal life, is one not to be passed up. This statement is to be taken in the light of the fact that the requirements, yet to be formulated and open to a certain amount of constructive discussion, are to be reasonable and take advantage of the possibilities for distance-learning and also contain the opportunity to integrate current and past work experience into the credit structure.

Some discussion was held about the need for another body, apart from those already in existence, to represent pharmacy professionals in Malta.

What is required now is a well conducted exchange of views by all pharmacists so as to enable a consensus to be reached on the M.Pharm. issue, and then use the momentum and unity gained thus far to confront the various other serious issues facing our profession.

To be Pharm or to M Pharm!

Last week's announcement by the University of Malta that the Department of Pharmacy has now amended the courses offered to include a BSc in pharmaceutical sciences ( a four year course) and a Master in pharmacy as a fifth following year, with this final year required to be able to obtain a public warrant to practice in Malta, has caused much discussion.

Recent graduates of the five year pharmacy course are up in arms at the fact that the course to be followed for the attainment of the Master in pharmacy is seemingly identical to the one followed by them. They are asking to be granted the opportunity to complete any missing credits and be granted the Master degree. The senate of the University of Malta is yet to provide feedback on the situation, or at least its pronouncements have not been widely disseminated.

Even though it is in the interest of all us pharmacists to  find a speedy resolution to this problem, such events have revealed the many divisions within the local group of pharmacists. Whether we be community pharmacists, medical representatives, academics, non-practicing or a mixture of some of the mentioned roles, it is high time that we came together as a cohesive unit to face the many intricate problems faced by our profession.

It is imperative that the whole of the local pharmacist community takes a stand on the issue, after a measured discussion on the subject.