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Roles of University Community Pharmcies in Pharmacy Services and Pharmacy Clerkship Training

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Abstract

The focus of pharmacy practice has changed over the decades from product-oriented to patient-centered care as

pharmaceutical care. Many major pharmacy education institutes have embraced pharmaceutical care as the primary

focus of pharmacists' activities and felicitated the reality work experiences in practice setting of their own university

drugstore for their students. This study was co-operated by the Pharmacy Network in Health Promotion program

(PNHP), it aimed to evaluate customer satisfaction with the service received and pharmacy students� opinion of the

pharmacy services and their satisfaction of the clerkship training. The pharmacy students who had each received

training at one of 11 university community pharmacies were surveyed via a questionnaire to determine their opinion on

the competency of the pharmacy services and the pharmacy clerkship training. Customers completed a questionnaire to

determine their satisfaction with the services provided. Eleven universities participated in the study; 397 customers and

244 pharmacy students in 4th-5th year, majority were female (62.7%) and mean age 23.7 years old (SD 3.44), completed

the questionnaires. Customers were satisfied with the pharmacy service, pharmacist manner, environment in all areas

except transportation. Only 2 university drugstores were located in urban and easy to visit. All students were satisfied

with the competency of the services provided. The highly satisfaction scores to the clerkship training were high.

Relation between trainers and resources in drugstore were satisfied. However, satisfaction with home health care

services and collaborative work with other health care organizations were rated as fair. The professional pharmacy

services provided were focused on rational drug use and acceptable to customers and pharmacy students. Further

development in the clerkship training should be encouraged with emphasis on the home health care services and the

collaborative work with others. Results were similar in each university drugstore.

Keywords: community pharmacy, pharmacy clerkship training

9

ABSTRACT

While the majority hospitals in developed countries have their out-patients fill their

prescriptions at any local pharmacy stores, the out-patients in Thailand still fill their prescriptions

with pharmacy department in the hospital. With normally large crowd of the state and teaching

hospitals, patients have to wait a long line to get diagnosed and yet another long line to have

their prescriptions filled. The pharmacy department not only works tirelessly to serve both in- and

out-patients, but also provides drug use related consultation to physicians. Moreover, the

department has to keep a massive pharmaceutical inventory in various places in order to

effectively distribute medicine to various wards in the hospital. These require enormous amount of

work, labour, and expertise which results in a huge hospital budget spending and difficulties in

management. In order to ease hospital burden and ensure quality of healthcare, a model of

having out-patients filled their prescriptions at local pharmacies, Hospital-Pharmacy Network

Model, is proposed. The model will reduce the work loads in hospital and wait time while increase

the healthcare quality. The network model was developed by analysing cost-benefit of all parties,

and allocated to each party by employing rebate contract to the model. Initially, patients under

the universal coverage were selected. Data was obtained from the hospital’s electronic database

and 10 local pharmacies. Vender Managed Inventory (VMI) also needs to be implemented to

ensure efficiency. The success of proposed model implementation will be great benefit to

healthcare in Thailand.

KEYWORDS

VMI, supply chain, healthcare management, dispensing prescription at pharmacy, rebate contract

Chirawan Opornsawad1 and Rawinkhan Srinon, PhD2

Department of Logistics Engineering, School of Engineering

University of the Thai Chamber of Commerce,

Bangkok, Thailand

Email: [email protected], Email: [email protected] 2

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1. INTRODUCTION

The concept of dispensing prescription medicines at the pharmacy (community pharmacist) has been applied in

developed countries for many years. To fill their prescriptions, patients bring the prescription from the hospital to local

pharmacy and the pharmacist will fill their prescriptions and explain how and when to take each prescription

medication. One of the reasons that is to reduce the duplication of the pharmacist for having to management both the

out- and in-patient pharmacy department’s (OUT-PATIENTS pharmacy) inventories on top of the drug monitoring

and consulting However, the most important reason is that patients will benefit more from dispensing at pharmacy.(

ElTayeb, 2004; Eronen, 2005) Hospital pharmacists are responsible for monitoring the use of drugs that are more

complicate and the essential ones of the health professions team to improve the effectiveness and safety of treatment to

patients.Concept of hospital-pharmacy network is that it is a network of hospital and qualified community pharmacies which allow patients to fill their prescriptions at qualified local pharmacy. Detail of the proposed network model will

be further explained in the following section. Under the hospital-pharmacy network concept, it helps reducing burden

of the hospital’s warehouse management which requires a lot of resources, man power, areas, the expense of care and

maintenance and the document management. In addition, the hospital-pharmacy network concept is one way to lessen

congestion in the hospital which can cause repeated infections and dissatisfaction of the long waiting time for out-

patients pharmacy. For the benefit of patient’s care in hospital, hospital pharmacists will have more time to study and

improve the skills of rational drug use leads to safety, save and treated effectively. That means the raising of the quality

of care for the hospital.

The direct benefit for the patients is that they will not have to wait in a long queue for receiving the drug at the

out-patients pharmacy; the patients will have more time to clarify all questions with the community pharmacist. The

community pharmacist is not in a rush to explain all side effects and related symptoms to the patient, so the patient will have better understanding on how to take the drug and their affects.

Without appropriate network model, the out-patients in Thailand still have to fill their

prescriptions with pharmacy department in the hospital. In order to alleviate hospital burden and

ensure quality of healthcare, a model of having out-patients filled their prescriptions at local

pharmacies, Hospital-Pharmacy Network Model, is proposed. The model will reduce the work loads

in hospital and wait time while increase the healthcare quality. Although, Hospital-Pharmacy

models have been proposed, but none has incorporated rebate contract in the model. The

framework of the proposed network model in this study was developed by analysing cost-benefit

of all parties, and allocated to each party by employing rebate contract to the model. Initially,

patients under the universal coverage were selected. Data was obtained from the hospital’s

electronic database and 10 local pharmacies were interviewed. Vender Managed Inventory

(VMI) also needs to be implemented to ensure efficiency. There also is a case study of one of the

major teaching hospital in Thailand. The rest of the paper is organized as follows: Literature Review;

Proposed Hospital-Pharmacy Network Model, Case Study, and, Conclusions and

Recommendations.

2. LITERATURE REVIEW

Presently, the Thai health insurance system is divided into three major schemes as follows,

Civil Servant Medical Benefit Scheme – CSMBS, Social Security Scheme – SSS, and The Universal

Coverage Scheme – UC. CSMBS is coverage for officers and employees of government workers or

retirees. The family is entitled to reimbursement of medical expenses from this scheme. Comptroller

general’s department is responsible for the CSMBS cost. The second system, SSS is for private

11

employees which both employer and employee monthly deposit required money to the Social

Security fund. And, the health coverage comes from this fund. The third system , UC is to expand to

cover the rest of population whom is not under CSMBS and SSS including uninsured persons (N

Ranoong, 2004). The people under the UC do not have to pay for medical expense; the

government will pay per capita to the hospital. Therefore, the government are responsible for both

CSMBS and UC.. The proportion of people under the CSMBS:SSS:UC is 4.96:9.61:47.56 respectively.

In 2009, the number of visits of out-patients service under UC is 140.70 million times, or 79.6 percent

of the total out patient service. The top three out-patients UC disease is respiratory (27.52 percent),

pain (26.45 percent) and chronic (16.23 percent) diseases which can be treated at the primary

care level. (Kantamara, 2009) Since UC is the largest health insurance, under the UC patient was

studied and proposed as patient model of the hospital pharmacy network.

Wittayasaksitpan (2001) conducted a survey of public opinion on dispensing medicines at

the pharmacy under the government’s universal coverage healthcare showing that 76.7 of

percent respondents agree with this concept expecting reduced the waiting time (83.9 percent),

shorter time in hospital (67.4 percent) and received more advice from pharmacist. It was further

presented those respondents who do not want to visit pharmacy network because they are

concerned about quality of medicine (57.1 percent), standard of the dispensing (52.7 percent)

and presence of pharmacist in the open hour (34.1 percent). This survey revealed the public

acceptance on dispensing medicines at the pharmacy but it requires pharmacist to provide

better quality. This survey established that the waiting time in hospital is still unsatisfactory although

hospitals have been trying to improve the time continuously. Moreover, the respondents also gave

weight to received advice completed from the pharmacist; this implies that the pharmacy service

was not satisfactory in terms of dispensing in hospital. Additional, from a latest survey of health and

hygiene of the Thailand’s National Statistical office in year 2007, 25.69 percent of unhealthy Thais

decided to consult the community pharmacist. The high percentage of people visiting pharmacy

demonstrates the sense of the reliability, convenience or easy to access for Thais. Although they

cannot reimburse their medical bills occur at pharmacy with their National Health Insurance

coverage, they still choose to visit pharmacy.

Chalongsuk R. (2007) compared the primary care service in chronic disease between

pharmacy and primary care unit under the UC scheme in Thailand by select a local pharmacy for

experiment. The selected pharmacy is responsible for dispensing the prescription medicines from

the study hospital and then interviews the opinion on satisfaction in service of patients and the

value of the clinical laboratory when receiving the prescription medicines at pharmacy. The result

was 74.3 percent of patients were satisfied and the value of clinical laboratory of the patients did

not differ from patients receiving the medicines at the hospital. Tundee, W. (2002) studied

pharmaceutical care and prescription refill for Type 2 diabetes mellitus patient in Mahasarakharm

University’s pharmacy in Thailand. This study showed the significant increasing in physical function,

role physical, mental health and vitality in the intervention group. Moreover, the overall of

medicine cost is reduced and increasing in convenience to patients as well. (Khumsikiew, 2009)

The concept of dispensing prescription medicines at the pharmacy (community pharmacist) is

under the integrating health service system concept. This means the public health service model

that includes a variety of services provided by various service agencies with the coordination of

relevant agencies, which pharmaceutical service at pharmacy store is an important service-

related health services that the people use it regularly (Ratanavichitsilp, 1998). The integration of

pharmacy as part of the healthcare system to expand services to cover more people has been

studied in a corner of the user or patient’s perspective, the provider's perspective and the payer’s

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perspective. It was additionally suggested that the cooperation established a network of hospitals

and pharmacies will need to consider service, financial, and management arrangements. There

are two main issues to consider such a system to organise the network. And, a good system

designed so that it provide good practice, flow of service, flow of information, flow of fund and

flow of goods. The network will lead to improvement of pharmaceutical care, quality care, and

support the healthcare reform concept. In addition, the integrated health system concept was

presented including pharmacy in the propose model. The pharmacy network may be the

independent pharmacy, chain pharmacy or hospital owner pharmacy. Arkaravichien (2009)

studied the perspective of senior executives of universal coverage health insurance and director

of the hospitals in terms of the possibility to including the pharmacy to the national health

insurance system. The majority of opinion that it is possible to incorporating the pharmacy is a part

of the national health insurance system but the standard of practice and the quality of service will

acceptance by the national health insurance first. In addition, the main issue is to find the answer

to the payment as compensation for pharmacy services. Moreover, all executives believe that

incorporating the pharmacy into the health insurance system will increase the accessibility of the

patients to another dimension of health care. However, every partner must make the patient get

the most benefit. Kessomboon (2010) studied the impact from incorporating pharmacy into the

universal health coverage scheme in case of stable diabetes and hypertension. They found that

the cost of dispense on prescription drug item is betten 22-47 Baht while according to

Kesornsomboon (2008) that was 25 Baht.

Costae (2004) explored the activity flow and information system for dispensing medication of

a one of the biggest hospital in Brazil. The hospital has own pharmacy in the hospital area,

prescription will be sent to the pharmacy to provide medication and sent back to the hospital by

manual process. Problem is always an extremely delay and error. The study presents a new

information system for the distribution of meditation both in hospital and between hospital and

pharmacy. Trimongkol (2008) found that when the VMI system is implemented in hospital, the fill

rate increases 6-10 percent. Kritchanchai and Krichanchai (2010) studied on Vendor Managed

Inventory (VMI) in Thailand healthcare industry to improving operational efficiencies and reducing

cost whereas continuing to improve quality of care. VMI is a concept of sharing information

among partners related to vendor decision in replenishment that will benefit to improve supply

chain performance by decreasing inventory-related costs and increasing customer services. They

presented a model for implement VMI in a big one of state-owned hospital in Thailand. However,

their concept is still a concept that receiving prescription medicines from out-patients pharmacy

within the hospital under VMI concept. In addition, Trimongkol (2008) also studied the inventory

management under VMI concept in 2 hospitals in Ayutthaya province, Thailand. The vendor is the

government pharmaceutical organization (GPO) which is the main source of supply medicine for

government hospitals nationwide. Terms of contract price in this study is trading at a fixed price for

unlimited quantities and use the fax or internet to send the on hand stock and financial statement.

The result of the study is the reducing of stockpile and the expired products.

S.M. Disney et. Al. (2003) studied the impact of vendor managed inventory on transport

operation and showed the possible transport cost saving in both short term and long term. VMI in

practice eliminates customers’ needs to manage inventory and takes off one duplicate process in

the supply chain. As a result, VMI brings focus on cost effectiveness over the entire supply chain,

from manufacturing, inventory storage to transportation, and attempts to coordinate inventory

replenishment and transportation in such a way that the cost is minimized over the long run

(Campbell, & Savelsbergh, 2004). Optimal supply chain performance requires the execution of a

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precise set of actions. Unfortunately, those actions are not always in the best interest of the

members in the supply chain, i.e., the supply chain members are primarily concerned with

optimizing their own objectives, and that self-serving focus often results in poor performance.

However, optimal performance is achievable if the firms coordinate by contracting on a set of

transfer payments such that each firm’s objective becomes aligned with the supply chain’s

objective. Various contracts have been proposed to coordinate the supply chain by aligning

objectives of the supply chain members. Majority of supply chain concept focuses on a few

popular contracts such as buy back (Pasternack, 1985), quantity flexibility (Tsay, 1999), revenue

sharing (Cachon and Lariviere, 2005), quantity discount (Tomlin, 2003), sales rebate (Taylor, 2002).

Wong (2009) presented two-echelon supply chain with a single supplier serving multiple retailers

with the sales rebate contract under VMI concept. The results demonstrate that when the sales

rebate contract combines with the VMI mechanism, the supply chain achieves perfect

coordination that retailers can make price decisions to maximize the aggregate chain profit.

3. PROPOSED HOSPITAL-PHARMACY NETWORK MODEL

Changing from dispensing prescriptions with pharmacy department in the hospital to fill prescriptions at any

local pharmacy, a sequence of steps is as follows; the physician in hospital write a prescription medicine then patient

brings the prescription to a local pharmacy which is a member of the network, the pharmacist dispenses the medicines

and keeps the prescription for reimbursement from hospital. The importation regarding information management, there

should be at least a central database for all parties to verify the authenticity of the prescriptions and the healthcare

coverage certain patient is under.

In this model, we propose 3 parties in the Hospital-Pharmacy Network model that are

hospital, central department and local pharmacy stores. This change is a simple model that UC

patients just receive the medicine at the convenience local pharmacy stores of the hospital

network without having to pay upfront. The hospital would either setup or outsource the out-

patient medical dispensing related management to a unit called central department. The central

department acts as a hospital-pharmacy network’s distributor who also manages of the qualified

local pharmacies to dispense medicine to patients. The central department is responsible for

providing a network of pharmacies and managing medicines to supply chain. It is responsible to

coordinate between the hospital and the local pharmacies, to be the supply chain management

centre, to be the auditor, to be the public relations and to support other works such as technical

work, seminar, etc. The central department should possess ability to coordinate between the

medical services, understanding the context of hospital and pharmacy services, and capabilities

to manage finances. Due to the budget constraint and the constraints of the professional in

understanding the hospital pharmacy system, the central department should be an organisation

that already exists, it might be a community pharmacy association (Thailand) which is a

pharmacist own association and pay a key role on the pharmacy certification. The other possible

alternative is a combination between related parties with a minimum cost of administration or

outsourcing to an existing potential wholesaler. For the local pharmacies which are private

enterprise, the pharmacist must expect the compensation that they satisfy. In this model, the

pharmacist must receive the return no less than before being part of the network. The local

pharmacies also gain advantage from more traffic in the shop besides they also get more return

while required investment increasing only slightly. However, pharmacy should get suitable fee for

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dispensing or other form of compensation. For the quality control, the pharmacies must be

certified by the Pharmacy Council and qualified as quality pharmacy.

In order for the model to work, all participating party should get better benefit both in service and/or financial

wise. In the proposed model, patient will receive faster and better consulting, the hospital pharmacy will have fewer

burdens while the hospital will receive at least the same margin from selling medicine to out-patient. Additional,

pharmacy in the network should also get benefit at least the same return for dispensing the medicine, or other form of

compensation. For more efficiency system, the model in a VMI partnership should be set. VMI is an important flow

coordination scheme which integrates operations between suppliers and retailers through information sharing and

business process reengineering.

The retailers in this model are the pharmacies or drugstores. The retailers buy the medicines from the central

department that acts as a wholesaler vendor. The central department gives a period credit term while the suppliers or

distributors give more long period credit term for the central department. Figure 1 shows the way that signal for

replenishment and medicine flows. The central department is responsible to replenishment signal from hospital and

pharmacies by forwarding the signal to the pharmaceutical manufacturers or distributors. The central department as a

vendor adopts a periodic review policy to replenish inventory for each retailer and the hospital. At the starting point,

the central department first determines a base stock level and maximum inventory level for each retailer and hospital

taking the customer service level (CSL), inventory holding cost and lead time in to account. For the medical

transportation responsibility, the manufacturers or distributors should assume this responsibility to deliver medicine to

hospital and drugstores.

Figure 1: Model for Replenishment Signal and Medical Flow

For the financial contract, when the supply chain is coordinate, one of regular contract in pharmaceutical retail

industry which is consistent with the model that is the rebates contracts was chosen. A rebate is different from an order

quantity discount as it only applies to items sold to end-users. There are 3 main reasons for choosing the rebate contract

for the model. Firstly, the contract is familiar in this industry. Next, the rebate contract will give benefit to the retailers

that are really responsible. Lastly, since the price would be much cheaper than drugstore could be from manufacturers,

the rebate contract will control the volume so that pharmacy/drugstore could not greedily purchase more than the limit

of conditions.

Figure 2: Model for Financial Flow

15

Figure 2 illustrates financial flow of the proposed model. Patients under the UC Schemes could receive the

medicine in two ways; in case of emergency at Emergency room or the drug cover for use at home. Most of the out-

patient cases will obtain the medicine at pharmacy. Under the UC Schemes, patients do not need to pay for medicines

except for rare case that the medicine is not covered by the insurance. Since the hospital has enormous bargaining

power with the suppliers, the medicine purchased through the central department is always cheaper than or at least

equal to the wholesalers’. Therefore, the pharmacy in the network will has lower medicines cost or equal to that of the

other pharmacies. The payment process is pay forward to the level of vendor of each echelon.

For the model under the rebate contract, hospital and pharmacies must promise the minimum order quantity

for archiving the target to get rebate. To prevent the pharmacies to take advantage from lower medicine cost when buy

the medicine from the central department and damage the competition in the drug retail market, the central department

should also set the maximum order quantity depending on the policy of establish the central department.

The following is the proposed model for hospital-pharmacy network with rebate contract. Since the medicine

are from patient from hospital, the central department set the same wholesale price, , to both hospital and pharmacies

and set the standard price to sell to the patients at . Where, is the base-stock level of item j determined by the

central department for pharmacy i.

In this model the supplier give the retailer % rebate from the value of . Now, the transfer payment with

the rebate contract, , of the pharmacy to the central department is

(1)

Where is the order if the item and is the order of the pharmacy. When is the dispensing value at

price for pharmacy, Baht, pharmacies pay only leftover stock at the pharmacy at the wholesale price minus

the rebate of price of unit to the central department. Holding cost and purchasing cost are not including in the

pharmacies transfer payment because pharmacy have to stock these items whether they are part of the network or not.

Hospital transfer payment to the central department is

(2)

Hospital pays for every item quantities pharmacy purchased, and get the rebate of the selling price,

. That is the hospital act as the payer at the selling price in this model.

The central department transfer payment to the suppliers or distributors is

16

(3)

So the central department’s profit function not including the management fee is

(4)

Profit for all of the parties could be boosted by increasing in and . If the model increase in , it will not

only benefit for the hospital and pharmacy for increasing the gross profit, but also for the central department, because

the rebate pay in the form of % . However, increasing in the selling price, must be under the maximum mark up

percentage allowed of the government hospital regulation. In addition, per capita budget under the UC is limited for

the UC patients. Increasing in must not come from dispensing more than necessary, but it is acceptable if the cost

per head decrease or equal former while the hospital care the patient more than previous.

4. A CASE STUDY

The studies will be divided in 3 parts as follows:

Part I: Study the OUT-PATIENTS pharmacy cost and benefit and interview the hospital executive for finding the

hospital condition

The historical data were collected; the number of patient, the number of medicine items, the usage of the

medicine, administration cost, inventory cost and selling price in the pharmacy department of a state own teaching

hospital in Thailand. One of out-patients pharmacy that is the EENT (Eye, Ear, Nose and Throat) out-patients

pharmacy was selected to study because completeness of the information at that time. The expense for one patient visit,

gross profit, and then operation profit for EENT out-patients pharmacy department were calculated.

The data was collected from electronic database (pharmacy department), document research (policy and

planning department) and interview the chief of pharmacy department and the director of the hospital. SPSS FOR

WINDOWS version 12.0, Microsoft excel 2009 were used to analyze the data and descriptive statistics to summarise

the list and calculated cost and benefit of the out-patient’s pharmacy services in the pharmacy department.

Part II: Study the related factor to the service of pharmacy when becoming the pharmacy in

the network

The ten qualified local pharmacies in Bangkok, Thailand were selected by random. The collected data was about

the financial system, medical supplies management system including the data collection of expense and revenue of the

pharmacy or the group of disease. The data then was studied by separating the data as following topics:

• Analyse the missing medicine: by comparing the drug list of the EENT out-patients pharmacy department

to the drug list of out-patient’s pharmacy services in the pharmacy department.

• Average revenue, average expense and operation profit : Collect data to analyze the capital (The number of

staff and payment for all pharmacies and warehouses, the public utility expense for all pharmacies and warehouses,

all expenses of all wasteful material cost and related durable articles, the revenue from selling and others revenue per

month)

• Opinion on the investment: The previous area of the pharmacy and medical supplies warehouse and the

increased area when becoming the pharmacy in the network. The area for the out-patient while waiting for the

pharmacy service.

17

• Calculate the payback period

SPSS FOR WINDOWS version 12.0, Microsoft excel 2009 was used to analyze the data and

descriptive statistics to calculate percentage and arithmetic means.

Part III: Applying the model of hospital-pharmacy network.

The data from Part I and Part II for model by hold on to the benefit of all related

departments were used for analyzing the strength of each party and applied the VMI concept

with rebate contract to the model. The patient under the UC for model was selected.

Results of the study are presented as follows.

Part I, Study the OUT-PATIENTS pharmacy cost and benefit and interview the hospital executive for finding the

hospital condition

Finding cost of the OUT-PATIENTS pharmacy department

The structure of capital analysis as whole pharmacy department is as follows:

Total cost = direct cost (labour cost + material cost + capital cost) + indirect capital (from the

other department)

Data collected from database is shown in Table 1-3. Please note that exchange rate was

around 1USD: 30.92 Thai baht.

Table 1

The detail of direct cost of the pharmacy department

Details Total

Total labour cost 39,108,782.79

Total material cost 71,651,798.23

Total capital cost 1,849,149.38

Total direct cost 112,609,730.40

18

Total direct cost = direct labor cost + direct material cost + direct capital cost

= 39,108,782.79 + 71,651,798.23 + 1,849,149.38

= 112,609,730.40 Baht

Table 2

The detail of indirect cost of the pharmacy department

Details Total

The cost from the departments that

does not generate revenue. 13,735,925.12

The cost from the departments that

generate revenue. 449,464.62

Total 14,185,389.74

Total cost of the pharmacy department:

Total cost = Total direct cost + Total indirect cost

= 112,609,730.40 + 14,185,389.74 Baht

= 126,795,120.14 Baht

Because the hospital is also a school of medicine which the whole pharmacy department cost is separated by 3

types of activity, that are the cost of service 83.73 percent, the cost of learning 11.47 percent, and the cost of research

4.81 percent. In this case, costs associated with this study are only the service related costs, so the cost of pharmacy

department for the service of the big hospital is equal to 106,165,554.10 Baht. In addition, the budget of the pharmacy

department for the Inpatient and Outpatient’s service is 30:70. Then the cost of the pharmacy department for the

Outpatient’s service is equal to 74,315,887.87 Baht The number of visits of the outpatient is 1,266,947 visits. So the

cost of the pharmacy department per visit is 58.66 Baht. The number of visits of the outpatient from the EENT

department at the time of study was 210,600 visits. So the outpatient’s EENT department spent 12,353,796.00 Baht for

the pharmacy department In conclusion, it is found that the cost of pharmacy department for the service to the

outpatient is 74,315,887.87 Baht. The pharmacy department of EENT department uses budget

12,353,796.00 baht or the cost of the pharmacy department per patient visit is 58.66 Baht.

Finding gross profit and operation profit of the out-patients pharmacy department

19

Table 3

Revenue, cost and difference of revenue and cost of medicine from EENT out-patients’ pharmacy

No of the medicine items 137.00

Revenue from selling medicine 70,756,748.00

Medicine costs 49,863,428.97

The difference of revenue and costs 20,893,319.03

The total drug sale amount of the OUT-PATIENTS pharmacy is 70,756,748.00 baht with the cost

of drug is 49,863,428.97 Baht so the gross profit is 20,893,319.03 Baht or 29.5 percent of the total sale

amount. Profit was calculated from drug sale deducted by the cost of the OUT-PATIENTS

pharmacy, operation profit, and the operation profit is 8,539,523.03 Baht or 12.07 percent. So to

remain the benefit of the hospital, the operation profit of the OUT-PATIENTS pharmacy department

should be not less than 12.07 percent of revenue. For the condition of the hospital for this model,

because the hospital would not want to reduce their finance benefit, the model must provide at

least the same benefit as before.

Part II, Study the related factor to the service of pharmacist community when becoming the

pharmacy in the network

The revenue, cost, and important opinion from 10 community pharmacists when the

pharmacies become a hospital-pharmacy network were collected. All of the pharmacy are the

owner of pharmacist and already are part of the local pharmacy.

Finding additional medicine needed in order to service EENT patients

The list of drugs available in pharmacies compared to the hospital’s drug list was explored in

order to find the incremental cost of adding an entry of the inventory items.

Table 4 shows the items needed by comparing the OUT-PATIENTS pharmacy drug list with

pharmacy drug list. The average cost that will increase when a pharmacy must have all items at

least one unit or one treatment course was explored. Table 4 shows that the average value is

10,871.91 Baht that means the local pharmacy has to invest more about 10,871.91 Baht for

covering the EENT drug list.

20

Table 4

The average costs that need to increase when there has one treatment course

Type of Drug The cost when all list

completes (Baht)

% of the missing

items (%)

The cost according to

the percent of the

missing items (Baht)

Pills, capsules 1,050.01 38.89 408.35

Ear drop 149.74 70.00 104.82

Inhaler 5,370.73 45.33 2,434.55

Eye drop 10,516.34 61.82 6,501.20

Syrup, powder,

solution 361.45 30.48 110.17

Other drugs 2,500.61 52.50 1,312.82

9,948.88 10,871.91

Average revenue, average expense and operation profit of 10 local pharmacies were

investigated in order to find cost-effective of the model. Data are shown in Table 5.

Table 5

Summarize the average revenue and average expense per month of 10 local pharmacies in Baht.

Revenue and Expense details Value (Baht)

Average revenue 102,500

Medicine cost (70%) 71,150

Average Expense

Labor cost (not including pharmacist) 18,250

Public utility expense 2,130

Others expense 2,020

21

From table 5, the difference from the average revenue and the whole cost of the local

pharmacy is 8,350 Baht or the average operation profit of the local pharmacy is 8.15 percent from

average revenue.

Opinion on the investment of 10 local pharmacies when becoming the network

The opinion of all pharmacies is that it is not necessary to invest in expanding the area of the

pharmacy and medical supplies warehouse. In addition, when becoming the pharmacy in the

network it will result in the increased revenue by 10 percent because of the increased reliability of

the pharmacy in the eye of customers. Moreover, the pharmacies estimate the investment to

increase when becoming the pharmacy in the network and result in the increase revenue 10

percent in table 6.

Table 6

Estimated cost increase

Subject of concern Average increasing in total investment

(Baht)

Building / area 0.00

Equipment 4,700

Medicine cost 10,871.91

Labor cost 0.00

Total 15,571.91

Table 6 shows the average increasing in total investment is 15,571.91 Baht while the revenue

increase 10 percent or the revenue increasing 10,250 Bath and average revenue will be 112,750

Baht. The calculation of payback period is 2.21 months. This cost of additional inventory apparently

is not high and is acceptable by the pharmacies.

Part III: Apply the model of hospital-pharmacy network by using the data from Part I and Part II

22

From three majors’ perspective concern of becoming the healthcare network as

Ratanavichitsilp (1998) suggested are service, financial, and management arrangement. In this

study only the financial arrangement was focused on. The developed model is related to the

benefit of 2 parties which are the pharmacy department of the big hospital and the local

pharmacy. The idea of model is to keep hold of the benefit of all related parties by bring out the

strength points of all related parties and then allocate the benefit accordingly on the basis of

feasibility.

Strength points

The strength of the hospital is the power of purchasing negotiation, the intensity of

technical knowledge, the reputation and reliability. The local network pharmacies’ strong point is

the presence of pharmacist at all time in the open hour. The atmosphere is comfortable so the

people who get the medicine could receive the pharmacist suggestion without a rush. In addition,

the pharmacy is the primary health service unit for the people that there are lot outlets closer to

home. So it will be more convenient for patients.

Previously, the hospital makes the gross profit is 29.53 percent of the sale amount or made the operation profit

is around 12.07 percent of the sale amount. Therefore, at the beginning, it has to keep the operation profit 12.07

percent for the hospital when the local pharmacy become in the network. The hospital’s operation cost was 17.46

percent at the beginning of the model. The budget is covered for the pharmacy and the central department.

.

Table 7

Summary of costs and revenue expectations

Hospital Pharmacy Central department

Sales price 100 100 100

Cost 70.47 60

Gross profit 29.53 40

Operation cost 17.46 31.85 5.78

Operation profit 12.07 8.15

Expected profit when

become network At least 12.07 At least 8.15 At least 5.78

Table 7 demonstrates an initial allocation of benefits for each party, now it has 29.53 percent that is the

average gross profit of hospital for starting this model. The hospital accepts the benefit at 12.07 percent while

pharmacies 8.15 percent and the central department at least 5.78 percent. Hence, the required benefit that 3 parties is

26.00 percent. In addition, with more efficiency management administration and operation costs could be reduced.

Using model proposed in Section 3, the central department sets the same wholesale price, , to both hospital

and pharmacies and set the standard price to sell to the patients at . Where, is the base-stock level of item j

23

determined by the central department for pharmacy i. The central department give the local pharmacy a % rebate or

8.15 percent from the value of . when is a value of medicine from prescription. Given = �50,000,

, the transfer payment with the rebate contract of the pharmacy to the central department allow equation

(1) is �28,370. Whereas hospital transfer payment to the central department allows the equation (2), given = �

5,000,000 and = 12.07 percent, is �4,396,500. While the cost of the central department to pay allows equation (3) is

the actual cost of purchasing goods from the suppliers and the central department’s gross profit is 9,396,500- 6,833,123

= �2,563,377 when the value is about 70.47 percent or �6,833,123. When the operation cost is about 5.78 percent of

the revenue or �543,118, the central department still has the operation profit equal to �2,563,377- �543,118 = �

2,020,260 which therefore is attractive for investment.

5. CONCLUSION AND RECOMMENDATION

This model is very useful for changing the responsibility of dispensing medicine from out-patients pharmacy

to local pharmacy by improving the quality of life of patients without a major change in reimbursement rules and the

involved parties’ incomes are not reduced. With better operation synchronization, the profit could be increased. The

model based on the balancing the returns of two parties that are hospital and pharmacy in order to better service

patients. In our model, the gross profit need to be spilt to satisfy two parties and left just enough for the third party, the

central department. However, more benefits could come from the supplier in form of management fee. When applied

the VMI concept with rebate contract to the business process, the cost could also reduce. Moreover, from the

mathematical model, three parties must conduct meetings to conclusion the suitable retail price, the wholesale price,

the rebate for adjust the reasonably price in advance.

From the model of the pharmacy service providing to the outpatient of the hospital

through the pharmacy, it is found that the model could satisfy the requirements of both the

hospital and the pharmacy in the network. In addition to monetary benefit, hospital network has

also been a powerful warehouse management system that easy to manage and response faster

while hospital do not have to intense in the medicine warehouse and worry about dispensing

quality. The most important prospect is the improved overall quality of treatment for patients.

The contribution of the proposed model is for the development of national health system without a major

change in reimbursement rules and do not affect their income of the parties involved. The limitation of our model is

demonstrated only one hospital in the hospital-pharmacy network. In addition, the benefit from supplier’s credit term

has not been included in our model yet. For the future research the model will be extended to other hospitals that have

own clients pharmacy which one pharmacy can be more than one hospital host, financial of regulations, and try to

uncovered the most effective contract for the model.

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27

��0�1��(��"�($��'�"#%+�]��"��)*+�$."�""�*"�� 2��,��

Developing guideline for screening and referral Dengue Hemorrhagic Fever (DHF) suspected cases by

community pharmacist in Surin Province

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29

Abstract

This descriptive study aims to develop guideline from Taiwan prototype for screening and referring

Dengue Hemorrhagic Fever (DHF) suspected cases by community pharmacists to reduce morbidity and

mortality. The study was divided into 2 phases as (1) training program of DHF screening tools for community

pharmacists and outcome monitoring compared with statistic report from Surin province (2) evaluation the

efficiency of DHF screening tool. There were 16 community pharmacists participated in the training program

and running the screening and referring patients during February-April, 2010. Totally 162 patients were

screened. Two patients were suspected cases and referred to the community hospital but diagnoses were not

DHF. Only one patient was excluded from suspected case but he was later diagnosed DHF in community

hospital. The specificity of diagnosis tool was 99.36 percent and negative predictive value (NVP) was 98.76

percent. However, constrained service time of community pharmacists and limited waiting time of patients were

barriers in this study. This study suggested sensitive screening tool for DHF suspected cases for community

pharmacist. This tool need more patients to investigated the reliability.

Keywords: Dengue Hemorrhagic Fever, drugstore, pharmacist

30

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