quinta-feira, outubro 27, 2011
Enquanto em Portugal se continua a perder tempo com pseudo-problemas comezinhos e anacrónicos, nos EUA há quem discuta aquilo que realmente interessa e que provavelmente estaremos também a discutir daqui a 10 anos.
Mão amiga fez chegar à caixa de correio do Efervescente esta interessante reflexão da médica Terry McInnis (que, não por coincidência, saiu no ACCP Report de Outubro de 2011). Para ler, analisar e guardar:
Mão amiga fez chegar à caixa de correio do Efervescente esta interessante reflexão da médica Terry McInnis (que, não por coincidência, saiu no ACCP Report de Outubro de 2011). Para ler, analisar e guardar:
Written by Terry McInnis, M.D., MPH
Editor’s Note: Dr. Terry McInnis is President of Blue Thorn, Inc., a health care management consulting company. She is a board-certified physician in preventive and occupational medicine and has an extensive background in health policy and program administration, including her most recent position as Medical Director for Health Policy and Advocacy for GlaxoSmithKline US. Dr. McInnis co-chairs the Center for Public Payer Implementation for the Patient Centered Primary Care Collaborative (www.pcpcc.net) and co-leads the PCPCC Medication Management task-force together with Linda Strand, Pharm.D., Ph.D., and ACCP Associate Executive Director C. Edwin Webb. Her email address is tamcinnis@bluethorninc.com.
I am a physician. Although arguably the practice of medicine is an art, by no means is it a “free-hand” art practiced at the whim of the artist on the canvas of a complacent patient. The diversity of our patients’ experiences, expectations, and beliefs paired with the wonderful complexity of the human body in various degrees of health and disease all demand a level of systemization in our approach to practice. If we as practitioners are to meaningfully engage our patients in optimizing their health, we must have an orderly and evidence-based process to apply our “art.” Even with all of the knowledge of various diseases, symptoms, and signs, without an effective and efficient approach to reveal the various degrees of health and disease in a particular patient the knowledge is worthless. Thinking back over 25 years to my medical school days the familiar approach remains in place today—chief complaint, history of present illness, review of systems, past medical history, etc., including the SOAP format (Subjective, Objective, Assessment, Plan) for our documentation system. Clinical decision support tools, reminders, and electronic medical records (EMRs) have helped to embed this rigor. This was and is a systematic approach, used to try to ensure that important details and clues are not missed and are then adequately addressed and communicated with the patient and other providers. The practice of “pharmaceutical care” demands the same rigor and systemization to truly take its rightful place as a provider-based discipline in a whole-patient approach. What I mean by this is that it is easy to answer a specific question, such as, are there any drug-drug interactions occurring with this patient? A pharmacist can compile a medication list for medication reconciliation or review the INR level and suggest dosage changes of warfarin. Even the familiar question people hear from their car windows at the drive through or across the dispensing counter at the cash register as they are handed a bag of medicines and asked “do you have any questions about your medications that you want to discuss with the pharmacist?,” is easily and readily answered. All of these questions are important and at times are the questions to be answered. But this is not the practice of pharmaceutical care1 whereby all of the medications being taken are systematically reviewed with the patient in the context of the disease state for which the medications are being used. Comprehensive medication management2 involves optimizing the medications in an attempt to achieve the clinical goals of therapy for each disease state in a patient-centric approach. This practice must be orderly and fully understood by the profession and is essential to the successful discovery and resolution of drug therapy problems that are preventing patients from reaching these goals. The practice must be documented, communicated, evidence-based, and reiterative—in short, the practice requires a systematic approach. Dr. Linda Strand, Distinguished Professor Emeritus of the University of Minnesota. School of Pharmacy, recently commented after her keynote in Reykjavik, Iceland for the Nordic Social Pharmacy Conference to an international audience3: “Pharmacists are coming together, however, for the very first time for the purpose of defining a common professional practice. It is becoming apparent to everyone, perhaps those outside of the profession sooner than for those inside the profession, that unless a common, scientifically-based and professional patient care practice is understood, implemented and practiced by all pharmacists around the world, there will be no place for this service in future health care systems. This is still a revelation to many pharmacists, and yet, is the starting point for marking real progress in establishing a valuable contribution to the ethical care of patients.” Closer to home, in a recent article in Pharmacy Times addressing the role of pharmacists in coordinated care models, Professor Fred Eckel4 stated: “As these newer models (accountable care organizations/patient-centered medical homes) become more common, will the pharmacist become a member or will others provide the patients’ drug therapy needs? The answer to this question will impact pharmacy’s future significantly. I am concerned that too many pharmacists are spending too much energy holding onto the current dispensing practice model instead of investing time and money to establish this new practice. What advice would I give to those working on the incorporation of pharmacists into the PCMH and the ACO? It would be to make sure you position pharmacists to take care of the patient.” I believe that these two elements—a professional, standardized practice and the evolution of the pharmacist as a practitioner “taking care of patients” as part of the patient-centered medical home or ACO team—are equally critical. This systematic approach embodied in a common professional practice of pharmacy will unleash the full power of the appropriate use of the phenomenal medications that we have to improve health for patients and simultaneously lower our total healthcare costs in collaboration with physicians and other team members! Then we as a society will realize the true value that pharmacists can play by applying the full-force of their pharmacology knowledge in this clinical role. My keynote address at the National Leadership Roundtable held earlier this year at the University of Maryland School of Pharmacy, which was co-sponsored by ACCP, included my conviction (it was actually the title of the keynote!) that “pharmacists can be the most transformative force in improving health for patients and reducing costs—but will they?” You cannot practice this level of care while you are behind the counter dispensing medications. The skill set to effectively interview and interact with patients as a trusted clinical pharmacist in making drug therapy recommendations, while having the confidence and respect of the physicians and prescribers with whom you are collaborating, will demand a systematic and evidence-based approach to identifying and resolving drug therapy problems that undeniably adds value to the outcomes of the patient’s care. Simply suggesting therapeutic or generic switches (which do not change clinical status), pointing out a drug-drug interaction, or compiling a list of the medications a patient is taking, can be done by other caregivers—and often times, easily available computer software. Will you take your knowledge of pharmacology to the level of applying it to practice by making the more difficult recommendations such as suggesting based on the evidence, an additional drug be added, a change of dosage, or a different drug prescribed which resolves a drug therapy problem that you have systematically found and documented, based on the evidence and your professional knowledge, to actually improve patient outcomes and safety? Are you prepared to consistently practice at the absolute top level of your license and scope of practice? For pharmacists, I believe that you have come to one of the rare crossroads that will define the future of your profession. You will either take your place as providers of care, or your numbers will dwindle as most dispensing activities are replaced by robotics and pharmacy technicians. I am a physician, and I say our profession and the patients that we serve need you “on the team” as clinical pharmacist practitioners. But, will you truly join us? References: 1 Pharmaceutical care practice is fully described in the following textbook: Cipolle R, Strand L, Morley P. Pharmaceutical Care Practice—The Clinician’s Guide, 2nd ed. New York: McGraw-Hill, 2004. (The third edition is pending publication.) 2 Comprehensive medication management is defined and described in the Patient-Centered Primary Care Collaborative Resource Guide: The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Available at www.pcpcc.net/files/ 3 Linda Strand, Pharm.D., Ph.D., is Vice President of Professional Services at Medication Management Systems (www.medsmanagement.com), and the comments can be found on her July 8 blog (http://blog.medsmanagement. 4 Fred Eckel, R.Ph., M.S., is a professor at the UNC Eshelman School of Pharmacy and formerly an executive director of the NC Pharmacists Association. The article appeared in Pharmacy Times (http://www.pharmacytimes.com/ |
domingo, outubro 16, 2011
Um texto brilhante de Nuno Pacheco, jornalista do Público:
PS - será que mesmo os imbecis que defendem o acordo não percebem que um momento político em que é particularmente evidente que perdemos a soberania económica e política é o menos indicado para se perder a soberania linguística? Ou, de um modo mais oportunista, o adiamento da entrada em vigor do AO por mais 50 anos não seria uma boa medida de contenção orçamental?
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PS - será que mesmo os imbecis que defendem o acordo não percebem que um momento político em que é particularmente evidente que perdemos a soberania económica e política é o menos indicado para se perder a soberania linguística? Ou, de um modo mais oportunista, o adiamento da entrada em vigor do AO por mais 50 anos não seria uma boa medida de contenção orçamental?
quinta-feira, outubro 06, 2011
Uma das vantagens de acordar de madrugada para embalar bebés é que assim podemos ver a evolução da "actualidade noticiosa". Foi interessante perceber que o tema "Steve Jobs" só se tornou relevante a meio da manhã noticiosa. Até às 7 da manhã, nem uma nota de rodapé...!
quarta-feira, outubro 05, 2011
O Estado Vigil é um blog recente (mas da autoria de três pessoas com uma enorme experiência) e que se tem dedicado ao acompanhamento dos momentos conturbados que se vivem no sector da saúde.
Há dias um dos seus autores escreveu lá isto. Eu comentei assim:
Há dias um dos seus autores escreveu lá isto. Eu comentei assim:
Deixo apenas algumas notas sobre a questão do medicamento e as novas regras de cálculo da margem:
- Em primeiro lugar, trata-se, no seu essencial, do cumprimento de uma medida da Troika:
“3.61. Change the calculation of profit margin into a regressive mark-up and a flat fee for wholesale companies and pharmacies on the basis of the experience in other Member States. The new system should ensure a reduction in public spending on pharmaceuticals and encourage the sales of less expensive pharmaceuticals. The aim is that lower profits will contribute at least EUR 50 million to the reduction in public expense with drugs distribution. [Q4-2011]”
(a ANF tem razão quando se queixa de que neste sector os objectivos da Troika vão ser triplicados)
- Ficam por concretizar duas outras medidas:
“3.60. Effectively implement the existing legislation regulating pharmacies. [Q4-2011]” e “3.62. If the new system of calculation of profit margin will not produce the expected savings in the distribution profits, introduce a contribution in the form of an average rebate (pay-back) which will be calculated on the mark-up. The rebate will reduce the mark-up by at least 3 percentage points. The rebate will be collected by the Government on a monthly basis through the Conference Center of Invoices, preserving the profitability of small pharmacies in remote areas with low turnover. [Q1 -2012]”
- Em primeiro lugar, trata-se, no seu essencial, do cumprimento de uma medida da Troika:
“3.61. Change the calculation of profit margin into a regressive mark-up and a flat fee for wholesale companies and pharmacies on the basis of the experience in other Member States. The new system should ensure a reduction in public spending on pharmaceuticals and encourage the sales of less expensive pharmaceuticals. The aim is that lower profits will contribute at least EUR 50 million to the reduction in public expense with drugs distribution. [Q4-2011]”
(a ANF tem razão quando se queixa de que neste sector os objectivos da Troika vão ser triplicados)
- Ficam por concretizar duas outras medidas:
“3.60. Effectively implement the existing legislation regulating pharmacies. [Q4-2011]” e “3.62. If the new system of calculation of profit margin will not produce the expected savings in the distribution profits, introduce a contribution in the form of an average rebate (pay-back) which will be calculated on the mark-up. The rebate will reduce the mark-up by at least 3 percentage points. The rebate will be collected by the Government on a monthly basis through the Conference Center of Invoices, preserving the profitability of small pharmacies in remote areas with low turnover. [Q1 -2012]”
Chamo a atenção para um aspecto relacionado com as novas regras de cálculo das margens e que tem sido mais ou menos ignorado no espaço mediático: estas serão reduzidas em quase 50% (em valor – esta é uma estimativa pessoal e feita muito ad-hoc, considerando simultaneamente os efeitos das margens regressivas e da diminuição dos preços dos medicamentos), o que representa simplesmente o fim do modelo farmacêutico português tal como o conhecemos e vai levar a uma gigantesca limpeza de balneário no sector, com milhares de falências e inevitável entrada de novos players (o que se antevê difícil, dada a reduzida rentabilidade e elevado risco que as farmácias passarão a ter). As farmácias das pequenas localidades vão deixar de ser economicamente viáveis e o governo será obrigado a subsidiar a instalação de farmácias em algumas regiões do país para poder garantir a universalidade no acesso a medicamentos.
A ANF vai provavelmente falir ou emagrecer consideravelmente e a distribuição farmacêutica vai ter dificuldades que neste momento me parecem inultrapassáveis.
Deste modo, será inevitável implementar o ponto 3.60 a muito curto prazo, bem como produzir legislação para acelerar a substituição de farmácias falidas.
Acho, no entanto, que nada disso terá efeitos palpáveis e a única solução para continuar a garantir o acesso da população a medicamentos passará pela liberalização da instalação de farmácias, com a entrada no sector de players com redes próprias de distribuição e músculo financeiro suficiente para aguentar as margens residuais.
A ANF vai provavelmente falir ou emagrecer consideravelmente e a distribuição farmacêutica vai ter dificuldades que neste momento me parecem inultrapassáveis.
Deste modo, será inevitável implementar o ponto 3.60 a muito curto prazo, bem como produzir legislação para acelerar a substituição de farmácias falidas.
Acho, no entanto, que nada disso terá efeitos palpáveis e a única solução para continuar a garantir o acesso da população a medicamentos passará pela liberalização da instalação de farmácias, com a entrada no sector de players com redes próprias de distribuição e músculo financeiro suficiente para aguentar as margens residuais.
O ponto 3.62 é redundante e desnecessário, pois estou convencido que a poupança com as medidas agora anunciadas vai ser 4 a 5 vezes superior aos objectivos da Troika.
Haverá maior castigo para Alberto João Jardim que a vitória com maioria absoluta? Eu acho que não (e não estou a gozar). Como diz o povo, quem comeu a carne que coma também os ossos!
