In Person: Denis Yost

Denis Yost could easily be called North Idaho's Renaissance Man of Pharmacy. Bringing with him almost four decades as a hospital director of pharmacy - six of them at Kootenai Health - a well-defined expertise in medical research, and his years as a faculty member at the University of Montana, Yost works today with Dirne Community Health Center and North Idaho Health Network.

During his tenure at KH, Yost installed robotic systems for dispensing medication; instituted bar coding for medications and placed additional clinical pharmacists throughout the hospital so they could be immediately available to work with physicians. During his tenure, the patient fee for a single aspirin decreased from $2 to 25 cents.

"Over the years," he said, "I've gained a lot of experience in many different situations and that all helps me with what I do now."

This interview was conducted at Dirne Community Health Center.

Here you are in your alleged retirement years, still working. Why?

I want to use my experience to help people. I can only play so much golf and I'm not the kind who can jump from cruise ship to cruise ship. I saw that if I stopped doing everything I'd been doing, I wouldn't have anything left.

What would you say is the most important work you're currently doing?

In Dirne's Medication Therapy Management program, I'm working with patients to make sure their drug therapy is correct and is the most advantageous for them. What I'm trying to do is improve patients' lives.

The patients here can be so complex - and medicine these days is complex as well. The patient may have four to five (prescribing) doctors and, even with computers, you haven't tied it all together.

In layperson's terms, how do you do what you do?

I'll take all the information I get, integrate it and then take the lab work and talk with the patient to find out what's happening with them. Then I'll write up a plan for the patient and consult with their physicians.

You know, I've sometimes got patients who're prescribed 15 different medications, but are only taking a few of them. Some doctors believe that if they write it, the patient will take it. From my end, I believe what the patient says.

It usually takes about one meeting with the patient and then we'll put together an action plan for them. We've had outcomes where we've made changes in their drug profiles.

What's the greatest number of medications you've seen prescribed for one patient?

I think I once saw a patient with 40.

What changes have you seen in medication dispensing practices over the years?

Well, when I first got out of school, legally a pharmacist couldn't put the name of the drug on the prescription bottle. You didn't want the patient to know what the side effects were because then he might not want to take the drug.

We have, of course, a lot more technology to work with today. But it's the people who make things work - technology is just a tool.

What's the insider secret for getting the most competent healthcare you can?

What you need to do is find a doctor who understands you - a true family physician. You need that primary care specialist to tie it all together and you want them to be someone who knows you - a patient-centered person.

I know you're currently working with Dirne on its continued implementation of the Patient Centered Medical Home treatment model. What makes this model a good thing for the patient?

People are doing this successfully all over the country - I think what's difficult is not the implementation of it but, rather, changing mindsets. PCMH is about putting the patient at the center of their own medical treatment plan. It's about using the primary physician as the core and bringing in other necessary supporting personnel such as dieticians, pharmacists, physical therapists and nurses as part of the patient's team.

I think the doctors are so busy today. Say they've got a patient on a lot of drugs and all they can do (during the appointment) is talk a little bit about the patient's current problems. A lot of their patients should be seen every week until they're stabilized and that's where the team concept comes in.

We've used PCMH in making medical rounds in the ICU. The physician would go and the pharmacist, the dietician, the respiratory therapist might be with them. Even the medical librarian was there to provide instant information.

Drugs are becoming increasingly expensive. Is there a way to make them more affordable?

I've found that what you go for first is quality. Quality refers to successful patient outcomes which come from accuracy (of prescribing). Those drugs are ultimately the most cost effective - the best drugs for the patient's condition.

Dirne has a patient-assistance drug program which probably provides patients about $2 million a year from the drug companies. This is based on specific patient qualification requirements and it recognizes that many of the newer therapies are extremely expensive.

But there is also this phenomenon I call "charge shifting," which translates to "One man's charge is another man's cost." Patients will tell you that they got free samples from their doctor. But if the drug company gives you samples here, you just end up paying somewhere else.

For instance, people who can pay, do pay for their drugs. They also pay indirectly for the people who can't afford to pay. Drug companies give 8 to 10 percent of their product away for free. But in the end it means they just raise their prices 8 to 10 percent.

People with extremely rare diseases often feel they're being pushed out of the clinical trials market because their "orphan drugs" don't bring in enough money. Is this changing?

Currently the drug companies' strategy for orphan drugs is they target a specific disease and get that drug on the market as fast as they can. Then, once it's on the market, they can develop off-label uses for it.

What about Obamacare?

The goal there was good, but they made it extremely complex. There are, however, a lot of good things in it, such as no preexisting conditions.

The way the concept of universal insurance is now, it's over-complicated. I think Medicare, on the other hand, is a good system because it pays for most of the things that are needed and it addresses most of the important problems. It's one-system-one-payer.

When it comes to making end-of-life decisions, how do we know the best medical choices?

You really have to explore end-of-life options and talk about it beforehand. So often we come to the end of life and a daughter or son might all of a sudden tell the doctor to "give them everything you've got." You know, so much of our cost of medicine happens in our last few months of life.

I'd done a lot of consulting on this, but until you've had it happen to you, you don't know. The decision we made with my wife changed my attitude.

How did that happen?

As I said, I'd done a lot of prior consulting on this type of thing and I'd helped start the first hospice in Montana. I'd approached all of it pretty clinically. And with my wife - who was a Type I diabetic - I'd always made sure she'd had an excellent primary care physician. But then she started having all these illnesses and getting breathing problems.

We got the whole family around her then in the hospital room - she couldn't talk because of the breathing device - and that was when our grandkids did something a million dollars couldn't have done. They painted her toenails her favorite color and the smile on her face was unbelievable - you couldn't buy that end-of-life with a million dollars worth of medicine.

Did something change for you at that point?

We had a really good, good afternoon together and I remember the grandkids were singing to her.

I could have elected to put her on a ventilator and just driven things all the way to the end, but I didn't and it was one of the best decisions I ever made.

That decision made the funeral and everything afterwards much easier - the way she passed away was peaceful.

What about future plans?

I don't have any desires to go after money. I could have gotten rich earlier in my career if I'd gone to Wall Street right out of school to sell drug and medical stocks. But, you know, that's just not my style. I would like to see this Medication Therapy Management program I'm working on take off - maybe get the university in here to help - because I can take it so far, but I can't take it forever.

I've always liked what Paul Newman said, "As long as you have a pulse, you have a purpose."