One of the unique aspects of hospice is the active role of pharmacists in patient care. Most hospice specialty pharmacies employ pharmacists to consult on the needs of individual patients. Enclara Pharmacia goes a step further by providing consultant pharmacists to address the needs of the larger hospice organization. Each Enclara client is assigned a clinical manager to provide education, analysis and support. It’s a role Enclara has developed over time to help hospices succeed and grow.
For Director of Clinical Management Ryan Krout, PharmD, it’s about being a resource to support patient care and hospice success. “Hospices benefit from access to a pharmacist who keeps track of what’s going on with treatment regimens and best practices. There are always new drugs coming on the market, and it can be hard to know the benefits,” Krout said. “As a clinical manager, you’re trying to do two things. You want to help the hospice provide the highest standard of care. You also want to minimize the cost of that care.”
A Delicate Balance
Minimizing drug costs is crucial for hospices. Unlike other medical providers, they pay directly for most medications used by their patients. On average, medication accounts for about eight percent of a hospice’s costs. However, that number can vary widely.
It’s a delicate balance. Hospices want to provide the best possible care to their patients. However, it can be hard to find information comparing one drug to another. Similar drugs can also carry very different price tags. For example, the atypical antipsychotics Pimavanserin and Quetiapine have similar clinical indications, but the former can cost $142 a day, while the latter is less than two dollars.
Clinical managers help fill the gap. They stay up on the latest clinical data and prescribing trends for the hospice community as a whole, as well as the recommendations of the Enclara formulary management committee. Their goal is to identify opportunities to reduce spending while providing the best possible care.
“Patient needs come first. We want our patients to have the best quality of life and pass away comfortably. That’s the basis for everything we do,” Clinical Manager Rosemary Geier, PharmD, said. “I would never suggest something that wasn’t in the best interest of the patient, no matter how much money it saved. If I did, I would lose the respect of the clinicians I’m working with.”
Two Ways to Reduce Drug Costs
Hospices can reduce spending in two ways. One is to shift from high cost drugs to lower-cost, clinically appropriate alternatives. The other is deprescribing – reducing the overall number of medications for each patient. When it comes to identifying drugs that cost more without providing greater benefit, inhalers are a frequent target. Patients in hospice often lack the lung capacity and dexterity to use them properly. Nebulizing the active ingredients allows for more consistent absorption at a much lower cost.
Deprescribing has been a hot topic in the larger medical community for some time but continues to be a challenge due to the shear scope of overprescribing among older Americans. According to the Lown Institute, the number of older adults taking five or more medications a day has tripled over the last two decades, now accounting for four of every 10 seniors. Nearly 20 percent take 10 drugs or more. Often, the risks and side effects outweigh the benefits. That’s especially true in hospice. For instance, many patients enter hospice with maintenance medications that reduce long term health risks or slow the progress of a chronic condition. For a patient with months or weeks to live, long-term benefits may be irrelevant, while side effects like nausea and pain negatively impact quality of life in the short term. Many patients also have trouble swallowing as they near the end of life, making it harder to deal with a lot of pills. Changes in weight and food intake may also necessitate reducing or discontinuing some medications.
Strategic deprescribing has taken on renewed importance due to new requirements from CMS. The “addendum rule” requires hospices to provide patients with a list of any items, drugs or services the hospice will not provide based on a determination that they are unrelated to the terminal illness and related conditions for which the patient is electing hospice. While hospices are solely responsible for determining medication coverage for individual patients based on their terminal prognosis, Enclara clinical managers can review overall utilization and assist nurses and physicians with deprescribing strategies.
Information is the Key
Clinical managers develop recommendations that are clinically backed, aligned with the hospice’s own priorities and based on positive experiences of other hospice partners. Once a hospice commits to an initiative, education is central to augmenting prescribing behavior. Clinical managers use Enclara’s extensive library of clinical resources and their own research to develop custom training programs. For example, when it comes to deprescribing, they may combine real-world case studies and detailed data to demonstrate how to determine when risks of a medication outweigh the benefits for a specific patient. They can also share tips for bringing up the topic of deprescribing with patients and caregivers.
“A lot of times, it’s using our existing training programs as a starting point for a presentation tailored to the client’s specific needs. For example, a lot of our clinical content is for nurses, but sometimes we’ll need to develop content for doctors or administrators,” Senior Clinical Manager Dan Morrow, PharmD, said. “Other times, we will develop entirely new content, which may then be shared more widely. We regularly keep up with industry-leading clinical journals to ensure that we’re always sharing the most up-to-date guidance.”
Evidence-based recommendations require actionable data. Enclara’s reporting platform, Enclarity, makes it easier for both staff and clients to identify trends at every level of the organization. Enclara’s clinical analytics team can take an even deeper dive when required. By aggregating data across hundreds of hospices, they develop benchmarks to help each hospice put its own outcomes in context.
“We can run analyses comparing a hospice to their peer group at the national level,” Geier said. “Because we have such a large variety of clients, we can narrow that down to a group that is similar. Then we see how they compare and determine what we can do in areas where the hospice is underperforming.”
More Than Just Drug Costs
Thanks to detailed data and concrete goals, the clinical management program has a proven track record. It’s common for clients to cut their drug costs in half after successfully implementing a major initiative. The impact also extends to improving overall efficiency and patient outcomes. One common example is discontinuing Percocet, which combines oxycodone and acetaminophen in a single pill. While the single pill combination is convenient for ambulatory patients and reduces the risk of abuse, it can be a problem for hospice patients. They often need higher doses of oxycodone for periods of intense pain, but a higher corresponding dose of acetaminophen can lead to liver failure. That creates risk for patients and additional work for nurses calculating maximum dosages. Prescribing the two drugs separately is cheaper, easier and less risky.
The value to the client is more than just numbers. It’s also about having a partner to turn to for advice and perspective. Whether it’s concern about a new medication that’s showing up more often or an emerging utilization trend, the hospice’s clinical manager is a phone call away.
“One of the things that I really enjoy is the trust that clients have in you,” Krout said. “They rely on you for advice and come to you with any question that they have. That’s really the most satisfying part: knowing people count on you. It makes this job very gratifying.”