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The CHS organization includes 134 a liated hospi-
tals, as well as ambulatory surgery centers, some retail
drug stores and thousands of physicians serving on the
medical sta s of the hospitals. Like HealthTrust, CHS
leadership also relies on information to deal with the
chronic shortages, Fink says.
"Prior to the creation of HealthTrust's website, we
created a website that reported information from manu-
facturers about the causes of shortages and updates
on what drugs were in short supply," Fink says. "The
website provides our hospitals more background into
the reasons for the shortages. We provide links to other
websites such as the FDA, the American Society of
Health-System Pharmacists and HealthTrust, as well as
updates from our distributors and manufacturers."
They have also worked with physicians to help them
understand the nature of the problems and to find
alternatives to scarce medications. Most of these drugs
have reliable alternatives, but younger physicians may be
unfamiliar with them, Fink says. Physicians with many
years of practice experience may have used alternative
therapies and can be especially helpful in briefing other
colleagues on their use.
Where permitted by state law and with the blessing
of state regulators, CHS has facilitated loaning drugs
between facilities. "We've also told hospitals that
they need to place orders every day to have a standing
order with a vendor when a supply becomes available,"
While the prospect of fewer shortages is good news,
the renewed availability of the medications comes with
a bigger price tag for several reasons:
• The manufacturing and regulatory changes and
widespread rebuilding of infrastructure have forced
market prices upward---double- and, in some cases,
triple-digit increases for single-source generics.
• Single-source suppliers will have unprecedented
leverage in contract negotiations, which may serve
to suppress competition from smaller manufactur-
ers, Coulter says. "Competition for products that are
currently single source in the generic market must
be encouraged in some fashion to o set this and also
to protect against possible future shortages of those
materials," he adds.
• The pharmaceutical manufacturing industry will
continue to experience consolidations and departures
that will mean fewer sources for APIs and finished
products. This concentration gives large suppliers
increased leverage in negotiating prices.
Fink worries about the reliance on large, foreign man-
ufacturers of APIs. About 80 percent of API production
is done o shore; in some cases, these are only single
suppliers, which creates significant vulnerabilities.
"U.S. plants are trying to mitigate this situation by
signing contracts with secondary suppliers, if they
exist. I hope that this works, but I couldn't guarantee
it," Fink says.
These factors will continue to strain the operating
budgets of hospital pharmacies and impact patients'
bills. To counter this, HealthTrust works to contract for
longer agreements to stabilize pricing, Coulter says. The
GPO also has been favoring contracting with suppliers
that have redundancy built into their supply chain by
backing up their contracted API providers with second-
ary providers in case the main API vendor encounters a
production or delivery problem, Coulter adds.
At CHS, Fink says the organization anticipates higher
prices and looks for opportunities in other areas to o set
the increases. "We used to rely on drugs going generic
to see prices fall, but now we don't anticipate the same
kind of dramatic price drop as in the past," Fink says.
The renewed flow of APIs and finished products
doesn't mean shortages will vanish entirely, Thompson
and Coulter warn. And gray marketers will continue to
try to create illusory shortages by commandeering large
quantities of sought-after medications, they say.
Also, wholesalers no longer have the inventories to
provide a cushion against minor manufacturing blips.
This has created, and will likely continue to create,
transitory spot shortages that can lead to panic buying
and hoarding of the a ected pharmaceuticals.
Timely, reliable information can help calm shortage
fears in such cases, they say. "We will need to be very
responsible and cautious about labeling a blip a short-
age," Thompson says. "Clear, reliable and consistent
communication will be key to preventing or at least
diminishing panic buying or hoarding during a tem-
Note: The HealthTrust Annual Drug Shortages
Impact Survey (see full survey on SCRUBS' emergency
room page) focuses on standard mission-critical drugs
for which acceptable alternatives exist. (See list at right.)
It does not include specialized pharmaceuticals such as
oncology drugs or certain antibiotics, some of which
also have been in chronically short supply. •
• Calcium gluconate
• Magnesium sulfate
• Local Anesthetics---
• Medications causing
monitors this list
short drugs and
continued from page 24
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