A changing health care environment: Its impact on UCSF graduates' practice patterns and perceptions

American Journal of Pharmaceutical Education, Fall 1998 by Sauer, Barbara L, Koda-Kimble, Mary Anne

Rapid penetration of managed care in California earlier this decade prompted the UCSF School of Pharmacy to embark on an intensive review and revision of its entry-level PharmD curriculum. To help insure that the School continues to provide students with the competencies needed to practice over a professional lifetime, we assessed the external environment and invited feedback from employers and alumni. This included surveying graduates from 1980-1994 to determine how managed care had impacted their practice patterns and perceptions of the profession. Of the 1,453 graduates mailed the questionnaire, 754 (52 percent) responded. Relative to a previous (1988) survey, fewer graduates were practicing in hospitals (46 vs. 62 percent) and community pharmacies (13 vs.18 percent). Twice as many (42 vs. 20 percent) were employed in ambulatory clinics, health maintenance organizations (HMOs), home infusion pharmacies, and other practice settings. Fewer reported performing traditional administrative functions (48 vs. 59 percent). Most had positions with multiple functions: 83 percent were involved in direct patient care and 60 percent initiated or modified drug therapy per expanded scope of practice laws in California; 74 percent participated in drug distribution or dispensing; and 57 percent performed administrative duties requiring clinical skills. One-half had a specialized practice, but only seven percent were formally certified. A majority of respondents (74 percent) indicated that recent changes in health care delivery had altered their job responsibilities to a moderate or great extent, but they were evenly split between viewing these changes as positive or negative. Graduates generally remained satisfied with their education and were optimistic about the profession. Although managed care has created a stressful working environment, our graduates are finding new opportunities to use their clinical expertise.

INTRODUCTION

The shift to a managed health care delivery system is forcing dramatic changes in the practices of health care providers in the United States( ). The driving force for these changes has been an unremitting escalation in the cost of health care without an apparent link to necessity or quality. Consolidation and integration of health care delivery systems, preferred providers and independent practice associations, point of service plans, gate-keepers, capitated payments, co-payments, best-practice guidelines, and carved-out services are just some of the strategies that have been used to achieve savings in health care costs.

Pharmacists have not been immune to these changes(2). As payers have encouraged medical groups to shift their care from the more expensive hospital environment to ambulatory settings, those in hospital practice have been affected by institutional mergers, downsizing secondary to decreased patient census and declining clinical revenue, and an increased use of computerized and robotic equipment. Hospital stays have shortened and many patients who previously would have been hospitalized for longer periods are now receiving care in intermediate-level facilities or at home. Community pharmacists have also been affected by pressures to cut health care costs. Carved-out pharmacy benefits have resulted in decreasing reimbursements for prescription dispensing. Diverse formularies, reimbursement schemes, and dispensing policies have increased the complexity of the dispensing process. To gain efficiencies, large chain drugstore companies have merged, mail order pharmacies have expanded, and automated equipment and technology have been exploited to improve the efficiency and accuracy of the dispensing process. Many independent community pharmacies, unable to compete in this environment, are going out of business.

California has been at the forefront of the managed care revolution and is expected to remain a bellwether for the future(3-5). It has been estimated that more than 70 percent of insured Californians are enrolled in a managed care plan, compared to 40-45 percent nationally(3). The most recent data (1996) indicate that the Pacific region, which includes California, leads the nation in HMO penetration, with over 42 percent of the population currently enrolled(5).

The unstable situation created by a rapidly changing health care environment in the early 1990s was making it increasingly difficult for faculty of the School of Pharmacy at the University of California at San Francisco (UCSF) to establish and maintain clerkship training sites. Adjunct practitioner faculty, who were finding themselves being asked to do more with fewer resources, found it challenging to accommodate students. Historically, the School had been integrally involved in managing and delivering pharmaceutical services within an academic health center. The advent of managed care potentially threatened its mission because resources that traditionally had supported professional education declined precipitously, including patient census, clinical staff, and clinical revenue. UCSF pharmacy students began to worry aloud about how changes in health care delivery would affect their education and professional opportunities as they observed the struggles of their clinician teachers navigating an uncertain environment. Students directly experienced the pace of change as their assigned clerkships evaporated within days to weeks of their scheduled rotations, and they saw a turnover in faculty as clinicians left what was once a stable, secure academic world for other employment opportunities.