The positive effect that site of care can have on finances was demonstrated in an initiative at the Medical University of South Carolina Transplant Center, in Charleston. By shifting the timing and location of antirejection drug infusions for kidney transplant patients, the university reduced its cost of care by tens of thousands of dollars, while maximizing Medicare reimbursements.
The key to the effort was the use of marginal kidneys (also called extended criteria kidneys)—organs that have suboptimal characteristics but still are suitable for transplantation under the right circumstances. The growing demand for kidney transplants, combined with a shortage of transplantable organs, has led to greater use of marginal kidneys, according to David Taber, PharmD, an assistant professor and the director of clinical research in the Division of Transplant Surgery. “A few years ago, these organs wouldn’t have been accepted for transplantation, but we don’t have enough donors for all the recipients on the list,” Dr. Taber said. “People are waiting longer and longer and we’ve had to push the margins of what we would accept.”
The cost benefits of switching from inpatient to outpatient ATG therapy
Per-patient cost savings per day
Per-patient revenue increase per day
Savings from shorter hospital length of stay
Total savings over study
ATG, antithymocyte globulin
Marginal kidneys usually function adequately and often are transplanted into older recipients. Frequently, however, the organs take time to resume full function and are more likely to be rejected by the recipient. That means that, in many cases, recipients require higher levels of induction agents, such as antithymocyte globulin (ATG) and basiliximab (Siumulect, Novartis) than those who receive nonmarginal kidneys.
“When you combine the high cost of these drugs with the longer hospital stays and closer follow-up care necessary for recipients of marginal kidneys—and the fact that most reimbursement for transplants comes from Medicare and is based on Diagnosis Related Group (DRG) calculations—it pushes transplant centers into a financial quandary and puts a lot of pressure on them to maintain their economic viability,” Dr. Taber said. “We’re going to get paid the same amount of money no matter how long a patient stays in the hospital.”
He and his colleagues evaluated the economic and clinical effects of shifting the administration of the first postoperative ATG infusion to the outpatient setting, where the cost of the drugs would be less expensive because of Public Health Service pricing rules, and the hospital can recover higher reimbursement because the charges are not constrained by the DRG restrictions that apply to inpatient treatment.
The researchers prospectively followed a control group of 146 transplant patients who received standard ATG dosing, and 85 patients whose day-of-discharge ATG infusion was delayed until several days after discharge and administered in the outpatient clinic. Dosing was adjusted accordingly, said Dr. Taber. Because all transplant patients stay close to the hospital for some period after discharge (in a hotel, if they don’t live in the area) and must return daily for outpatient clinic visits anyway, the new protocol did not create any additional burden.
The researchers found that shifting day-of-discharge dosing to the outpatient setting resulted in per-patient cost savings of $860 per day and a mean per-patient revenue increase of $1,856—a total gain of $2,716 per patient. The new protocol also resulted in shorter hospitalization (3.1 vs. 3.9 days; P<0.001), which translated to an estimated savings of $57,800. The total net margin increase over the 18-month study period was $230,867.
One-year patient graft survival rates were similar between the groups. The rates of infectious complications, including cytomegalovirus syndrome or disease, BK viremia and BK nephropathy, were comparable, as were readmission rates.
“We’ve demonstrated pretty convincingly that we can achieve reductions in the costs associated with these drugs,” Dr. Taber said. “We’ve also demonstrated that we’ve reduced the number of patients whose discharges are delayed.”
The program has been expanded to include additional high-cost antibody preparations, including basiliximab, rituximab (Rituxan, Genentech) and IV immunoglobulin, with a focus on giving all appropriate doses in the outpatient setting.
Cutting the Cost of COPD Therapy
Pharmacists at Nanticoke Memorial Hospital in Seaford, Del., reduced drug costs and waste by substituting ipratropium via common canister protocol in place of the more costly tiotropium (Spiriva HandiHaler, Boehringer Ingelheim/Pfizer) for patients with chronic obstructive pulmonary disease (COPD).
The institutional-size tiotropium dry powder inhaler contains five doses—often more than required for the average COPD patient’s hospital stay.
Frequently, fewer than half of the doses of inhaled tiotropium are used before patients are discharged, and because the drug is a dry powder, it cannot be used with a common canister, said Merideth Moody, PharmD, BCPS, a clinical pharmacist at Nanticoke Memorial Hospital.
“We were dispensing individual tiotropium dry powder inhalers to every patient, many of whom were only here for one or two days,” Dr. Moody said. “There was a lot of wasted medication left in the inhalers.” Now, patients receive an individual spacer that can be used with the ipratroprium metered dose inhaler by multiple patients until its contents are exhausted. Respiratory therapists teach patients how to use the device and about the medication, and clinicians are instructed to take adequate steps to prevent cross-contamination.
“Our primary goal was to cut down on the waste of the tiotropium from doses that were lost or not used when a patient was discharged,” Dr. Moody said. “We hypothesized that if we could do a therapeutic substitution for all tiotropium patients and put them on a different anticholinergic bronchodilator that can be used with our common canister protocol, it would bring significant savings.”
Ipratropium, a short-acting bronchodilator, was selected as the substitute for tiotropium, a long-acting bronchodilator. Given that difference in length of action, the substitution is only suitable while the patient is hospitalized, after which they revert to the bronchodilator they used at home.
Their plan was implemented, and ipratropium delivered through common canisters has become standard. To determine the effect of the change, the researchers retrospectively identified the number of patients who received tiotropium and the number of wasted doses over a four-month period, then calculated the cost savings of substituting common canister ipratropium.
The total cost of wasted tiotropium doses exceeded $8,500. When the lower cost of common canister ipratropium was factored in, cost savings totaled $13,740. The authors added that the true economic implications should be assessed by the difference in cost per patient-day of drug expenditures to account for increased costs associated with providing individual inhalers to patients.
In 2009, the Institute for Safe Medication Practices commented on common canister protocol. Although it offered no definitive recommendations, the organization emphasized the risk for cross-contamination and the need for stringent adherence to infection control practices if common canisters are used (http://www.ismp.org/newsletters/acutecare/articles/20090409.asp).
Drs. Taber, Moody and Hong reported no relevant conflicts of interest.
Las Vegas—Implementing an automated anesthesia dispensing system enabled another hospital system to reduce costs—in that case, via improved inventory management, medication charge capture and patient safety in surgical suites.
“We wanted to make sure that the medications administered to the patients are documented accurately in the medical record for patient safety and the hospital captures appropriate reimbursement,” said Christine Hong, PharmD,
the pharmacy manager/medication safety officer at the Yale-New Haven Hospital, Saint Raphael’s Campus in New Haven, Conn.
Before employing the automated system, a manual billing process was used. An evaluation of manual charge capture for 324 surgical cases (inpatient and outpatient) over five days revealed a charge loss of $6,570 ($1,314 per day). Extrapolation to a full year equated to a loss of more than $427,000—nearly 40% of the pharmacy’s annual anesthesia medication purchases and about 8% of the total pharmacy budget.
“We found that approximately 20% of billing forms were completely lost, and the hospital wouldn’t get paid for those,” Dr. Hong said. “We also want to ensure that patients are being charged appropriately.”
Thirty-seven automated anesthesia-dispensing carts were installed, covering all operating rooms (ORs) and procedural areas. About 80 surgical procedures are performed daily in the main OR alone. During a four-month period after implementation, the new protocol led to an average daily increase in outpatient gross revenue of $8,700—the annual equivalent of about $696,000. There was also a one-time inventory savings of $11,500 from the reduction of duplicate anesthesia trays.
“We are continuing to monitor the utilization to determine the rate of stock-out and refill to optimize inventory control, work-flow efficiency and safe anesthesia medication management,” Dr. Hong said. Nurse anesthetists are now able to spend more time with the patients because the medications are readily available from the automated dispensing system in the OR, she added.