Successful Strategies for Drug Cost-Containment in Oncology Practice
Salt Lake City, UT—Before establishing measures your oncology practice can implement to lower costs, review your physicians’ prescribing habits, identify causes of drug waste, and look for outlays that are not captured in reimbursement channels, said Bhavesh Shah, RPh, BCOP, a clinical pharmacy specialist with Boston Medical Center (BMC) at the 2011 Hematology/Oncology Pharmacist Association meeting. He outlined successful examples of cost-saving strategies that BMC has adopted.
The Benefit of Dose-Rounding
Rounding the dose of certain oncology biologics to within 10% of the amount ordered is one successful measure. The purpose is:
- Ensure the drug is measured accurately
- Minimize drug waste
- Maximize cost avoidance.
- The 10 drugs that are the most amenable to dose-rounding are listed in the Table.
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“For any order that comes through the pharmacy, the pharmacist can round the dose to the nearest vile size for the concentration,” said Mr Shah. The exceptions include when the difference between the ordered dose and the nearest vile size exceeds 10%. “That’s when we try to round it to the nearest concentration size available.”
Dose-rounding is only as effective as the level of adherence by pharmacy clinicians. A retrospective study (J Oncol Pharm Pract. 2010 Mar 23 [Epub ahead of print]) showed that a 3- month pilot program to round doses for orders of 7 anticancer biologics would have produced a 42% reduction in drug wastage and $24,434 in savings (in 2005 dollars) had there been 100% compliance with the program. Instead, because the dose-rounding protocol was not used in 29 of the 126 orders, savings amounted to only $15,922. It is important to include measures for monitoring adherence.
The following strategies implemented at BMC for chemotherapy infusion have led to hundreds of thousands of dollars in annual savings.
Shift Inpatient to Outpatient Administration
Encourage your physicians to shift from inpatient to outpatient chemo – therapy administration. “We developed this because a lot of chemotherapy was being administered in the hospital, primarily due to convenience, where we got reimbursed by DRGs [diagnostic-related groups] but not based on what the patient was actually receiving,” Mr Shah said.
Under Medicare, inpatient claims can list only 1 DRG, whereas outpatient claims permit multiple ambulatory payment classifications (APCs). Chemotherapy drugs are also not bundled under APCs, allowing for greater reimbursement.
“Now, we always push our physicians to do it on the day of, or the day after, hospital release, so we can capture that cost,” he said, adding that orders for inhospital chemotherapy administration declined by 50%.
Test Rituximab before Infusion
Another new policy at BMC is to test the dose of rituximab (Rituxan) before starting infusion. Mr Shah said that 80% of patients receiving rituximab will have a reaction to their first infusion, which leads to discontinuation and drug waste. In 2009, infusion reactions resulted in $50,000 in wasted rituximab.
“We implemented a test dose for each patient, and we saw a drastic decline in waste of rituximab,” he said. The test dose is 100 mg and is administered to all patients at BMC who are scheduled for rituximab infusion and have not received the drug for at least 6 months. In 2010, BMC saved approximately $2000 per patient using rituximab.
Follow Guidelines for Pegfilgrastim
When Mr Shah and his colleagues were seeking ways to reduce costs, they observed that orders for pegfilgrastim (Neulasta) had increased. Based on published data, they thought it might be safe to delay administration of white blood cell growth factor support for patients treated with paclitaxel (Taxol).
They tested this on 10 patients prescribed 4 cycles of paclitaxel (175 mg/m2 every 2 weeks), and administered a single dose of pegfilgrastim with the first dose of the second cycle of paclitaxel. All patients completed therapy without delay, with no neutropenic events or hospitalizations. Mr Shah speculated that delaying pefilgrastim led to less bone pain from paclitaxel-induced arthralgia. It also cut costs by $60,000.
He noted that pegfilgrastim was sometimes administered as primary prophylaxis in situations inconsistent with established practice guidelines. “There was a lot of inappropriate utilization, in metastatic prostate cancer, stage IV non–small-cell lung cancer [NSCLC], and metastatic colon cancer,” said Mr Shah. They requested that physicians stop using growth factor support when the intent was not curative and use dose reductions or delays instead. Physicians were also told to stop giving it to patients receiving chemotherapy with curative intent and an associated incidence of febrile neutropenia <20%.
To adhere to evidence-based guidelines for pegfilgrastim, BMC required physicians to administer it in the adjuvant setting for patients with colorectal cancer (CRC) and NSCLC, the neoadjuvant setting for patients with solid tumors whose operative procedure had curative intent, and for patients with a malignancy related to AIDS.
Even with these measures, BMC decreased expenditures by $250,000 annually, which does not factor in potential cost-savings from ensuring that all appropriate patients received the drug.
Rapid Infusion for Improved Utilization
Mr Shah noted that no formal economic analysis has ever been done on the cost-effectiveness of rapid infusion. Agents to consider for rapid infusion include rituximab, bevacizumab (Avastin), trastuzumab (Herceptin), cetuximab (Erbitux), as well as lowmolecular- weight (LMW) iron dextran (INFeD). “This can increase your resource utilization,” he said.
One 2007 study tested a 90-minute rituximab infusion in more than 1200 patients, a 0% rate of grade 3/4 toxicity related to the faster infusion was observed. Other studies found 30- minute infusions of trastuzumab and bevacizumab and 60-minute infusions of cetuximab and LMW iron dextran to be relatively safe.
A higher rate of adverse events was seen in patients allergic to >2 drugs who received LMW iron dextran. Mr Shah cautioned that Dexderm—another form of iron dextran—should not be used in a rapid fashion.
“I think rapid infusions are great. It totally increases the volume for your clinic and decreases the absentees, and you can get your patients out faster,” Mr Shah said; it also increases satisfaction among patients and nurses.
Cetuximab versus Panitumumab
BMC switched from cetuximab to the lower-cost panitumumab (Vectibix) for CRC based on studies showing little difference in overall response rate or survival. Although the cost per 100 mg is higher for panitumumab than for cetuximab ($618.81 vs $367.83, respectively), cetuximab requires an 8- vial loading dose.
A BMC 4-week cost analysis of panitumumab averaged $5953.70 compared with $8460.09 for cetuximab. In addition, reimbursement from the Centers for Medicare & Medicaid Services (CMS) was higher for panitumumab than for cetuximab ($49.737/10 mg vs $87.326/10 mg). Other cost-savings with panitumumab included reduced chair time, because it can be administered every 2 weeks, and the reduction in febrile neutropenia treatment.
BMC takes advantage of bio-oncology spoilage programs offered by pharmaceutical companies. “They’re not well known, and you have to actually call, but…it’s pretty easy,” he said. “We had about $20,000 in waste that we saved last year using these programs. Fill out a form and they send you a check for the drug that’s been wasted.”
Adopting such programs allows you to request reimbursement from CMS for “discarded drug/biological remaining in a single-use product after administering what is reasonable and necessary for the patient’s condition” (per Pub. 100-04, Chapter 17, Section 40 in the Medicare Claims Processing Manual).
Mr Shah said, “There’s a JW code that mirrors the J code you’re billing for.” CMS requires documenting the cause of waste in the patient’s medical record, which BMC has implemented to recover those costs.
When looking for ways to save costs, patient safety is the most important consideration, he said