Cost saving ideas in hospital pharmacy

[3ztiwnt]

Hey guys!

Long time lurker on these forums who finally decided to make a profile, LOL! I was wondering if some of you could weigh in on cost saving ideas/activities you guys do at your hospital as we have been asked to kick around some ideas at the place I work at (around 400 beds non teaching). Maybe confettiflyer, BMBiology, Xiphoid, etc (and anyone in retail don't hesitate to post too if you have any ideas, not trying to discriminate!). Like everywhere they are looking for ways to save $ in the new economy.

We currently have
1. as stewardship program for ABX (but it only limits use of a few like Dapto, Zyvox, and Azactam) so maybe we could expand this
2. like most places we try to have decent formulary management by having one preferred PPI, H2A, etc.
3. I don't cover the Onc floor, but I'm sure there is some definite $ on the table there (though I do know that we limit CSF to Leukine (Neupogen if MD provides reasoning/NF request), and try to limit use of some of the adjunctive/supportive medications to more cost effective ones)
4. We try to limit use of things like combivent (use albuterol and ipratropium HFA if duoNebs can't be used) and use autosubs for ACE I's, ARB's, nasal steroids, LABA's (also combos changed to advair diskus), HMG-coa's, etc. Maybe you guys know of a real $ saving category for autosubs we haven't thought of?

Anyways, I just wanted to throw out a few things we were already doing to get the ball rolling. Again, there are not any wrong or foolish suggestions, I would greatly accept any input any of you have to offer.

Thanks so much!

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[confettiflyer]

Your focus seems to be on drug acquisition...how's your workflow? Are your techs and/or pharmacists duplicating work or spending 2mins on a task that should take 1? Streamlining ancillary duties can curtail some largess on hours worked, if your staff is burning into OT, that should be addressed first.

Is your CPOE system tuned up? IT fixes that can save 15 seconds each order are huge when multiplied over the course oft he say.

And how is your acquisition process? How many turns are you achieving with your inventory? Sometimes it's not what you buy and restrict, it's how your process is so you don't just have stale inventory which can lead to waste.

Oh and don't forget restricting IV PPI to lower GIB and aggressively pushing a change to PO...remember even incubated pt's often have a Dobhoff at least so you can put some liquid formulation down that for SUP.

I've found that IV to PO doesn't save much money/isn't cost effective....maybe if you have a free student you can repackage that as "clinical work" and they'll be happy to do it.

So leverage your students with respect to clinical work or dispensing tasks as appropriate.

 

[confettiflyer]

Is your onc an outpt infusion facility separate from inpt? Are you leveraging 340b?

 

[3ztiwnt]

Your focus seems to be on drug acquisition...how's your workflow? Are your techs and/or pharmacists duplicating work or spending 2mins on a task that should take 1? Streamlining ancillary duties can curtail some largess on hours worked, if your staff is burning into OT, that should be addressed first.

Is your CPOE system tuned up? IT fixes that can save 15 seconds each order are huge when multiplied over the course oft he say.

And how is your acquisition process? How many turns are you achieving with your inventory? Sometimes it's not what you buy and restrict, it's how your process is so you don't just have stale inventory which can lead to waste.

Oh and don't forget restricting IV PPI to lower GIB and aggressively pushing a change to PO...remember even incubated pt's often have a Dobhoff at least so you can put some liquid formulation down that for SUP.

I've found that IV to PO doesn't save much money/isn't cost effective....maybe if you have a free student you can repackage that as "clinical work" and they'll be happy to do it.

So leverage your students with respect to clinical work or dispensing tasks as appropriate.

Wow, thanks for the quick and thoughtful reply! I'll try to address each one:
1. CPOE is fairly efficient, especially for those who are relatively quick on a CPU (I can input a 30-40 med AMR in about 2-3 minutes if no complicated NF items are there), so I don't know that we will save much on that front, but I will look into it.
2. I'm not sure about inventory turns and I also am not sure about returns/outdate audits so I will definitely ask our purchaser the 411 on the processes there (great point)
3. I guess that IV PPI limitations could be advantageous esp given the volume. Just looked and IV PPI costs $3/dose vs 0.3/dose, though I'm sure the susp is higher.
4. Yeah we don't do too aggressive IV/PO d/t this as well, it's more of if time permits from bigger items.

Thanks, and I'll try to get back/ follow up with the inventory details later

 

[3ztiwnt]

Is your onc an outpt infusion facility separate from inpt? Are you leveraging 340b?

I honestly don't know this for sure, I know we have both inpatients and outpatients at the floor, but the two are not physically separated (though they may be for billing/grouping purposes ie some rooms for outpt, etc). I know they had been working on getting 340b for disproportionate share and were close to it last year, and I thought that they did get 340b on ONC this year, but will have to ask. Any chance you could elaborate more on this so that I could ask more informed questions? Thanks again!

 

[DrWrong]

Put restrictions on some of the other high cost medications

IV Tylenol, factor products, etc.

 

[DrWrong]

Put evidence based restrictions on total parenteral nutrition. Just a few ideas I can think of.

 

[Protongenic]

<snip>
3. I don't cover the Onc floor, but I'm sure there is some definite $ on the table there (though I do know that we limit CSF to Leukine (Neupogen if MD provides <snip>

340B is huge. Also consider taking advantage of generics/biosimilars; e.g. the final U.S. results of tbo-filgrastim should be coming out in the next few months.

 

[3ztiwnt]

340B is huge. Also consider taking advantage of generics/biosimilars; e.g. the final U.S. results of tbo-filgrastim should be coming out in the next few months.

Thanks Proto and DR W! We def try to restrict TPN (and due to stock solution shortages have been using premix for several months (a unplanned cost saver haha). I agree that restrictions should be imposed where possible. I also will check into whether we will be testing the waters with biosimilars upon launch.

 

[xiphoid2010]

You can do an itemized breakdown of drug purchases from your wholesaler, so you can focus in on drug/formulary changes that are cost-effective. We don't have onc, but abx stewardship, renal adjustment by pharmacy, automatic stop dates, IV to PO, all can save you money. Get connects with other hospital pharmacies, take a look at their auto-subs and protocols for ideas. Review drug wastage. Review the main purchaser's performance. At higher levels, negotiate/play off different wholesalers on the % rebate, I've seen as high as 4.25%.

 

[confettiflyer]

What GPO are you with?

I know I'm asking a bunch of questions....I really don't know anything about your hospital, I think what you'll find is this thread may give you little hints as to where you should look to find some money.

My point about your CPOE being tuned up is just a point about efficiency...if you can trim the fat off your workflow and operations, you can flex/breathe as census rises and falls without having it break the bank and/or your core metrics (basics like delivery times, productivity, etc...)

You won't save a dollar per se, but efficient operations reduce frustration, waste, and over the long term...employee turnover.

 

[confettiflyer]

Oh! and leverage shortages to your benefit...whenever we had something go short, we'd obviously restrict it (example: IV PPI)...once the shortage goes away, don't be so quick in lifting the restrictions (unless it's clinically inappropriate to do so...like with propofol or something).

 

[spacecowgirl]

Dose/vial rounding for chemo. IV to PO. Discouraging ordering of bulk items, autosubs to institutional sized products - esp inhalers. People don't need a lot of bulk items inpatient - nasal steroids, creams, inhalers when nebs can be used. What is your insulin use/waste? Walk your shelves and think about what each item is doing there. We have a small inventory and restrictive formulary and I'm still surprised at what makes it onto our shelves. Make sure ESAs are being used appropriately and that you're not missing reimbursement because of inappropriate use.

 

[spacecowgirl]

Holy crap, I've been on this board for almost 10 years.

 

[confettiflyer]

Holy crap, I've been on this board for almost 10 years.

me too. i remember coming here looking for info on MHA vs. MBA coming out of undergrad....then i drank the kool-aid, went into pharmacy, now i'm a unicorn w/ six sigma aspirations. my my.

 

[rxlea]

What do y'all think of the zosyn q8 extended infusion dosing? Is it saving you money?

 

[xiphoid2010]

What do y'all think of the zosyn q8 extended infusion dosing? Is it saving you money?

It does, so does meropenem 500mg q6 instread of 1 gram q8. But those savings were bigger when the said drugs used to cost $20 a dose.

 

[3ztiwnt]

Wow, didn't realize there were more responses, guess the email alert on a thread doesn't work all the time LOL. Confetti, we are now with a large GPO with about 11-12 other hospitals so we likely are getting good pricing at least for the most part. I'll def suggest we take a close look at $ for things like chemo, IVIG, etc. great point on the workflow too, it may not show hard dollars, but more can be done with less staff burdens. Space cowgirl, those are great points, I know we round things like IVIG, etc as we did at my old hospital, I really like the idea of limiting non essentials like PRN nasal steroids (I don't send a bottle of fluticasone if it's PRN as it may never get used, I wait for the floor RN/patient to request it) Great points and I'm looking into the 340b so I can ask some follow ups to you confetti. Thanks!

 

[xiphoid2010]

I'm pushing to adding ferrlecit to formulary and make it preferred, maybe even autosub for venofer. Pretty good cost saving there.

 

[3ztiwnt]

It does, so does meropenem 500mg q6 instread of 1 gram q8. But those savings were bigger when the said drugs used to cost $20 a dose.

I concur with Xiphoid on this. We were saving a bunch of $ before by batching Zosyn too, but it's not as significant now. You also have to think of personnel cost impacts (tech/pharm compounding/checking) or with EXT int the added costs of nursing personnel time and infusion pump usage.

 

[rxlea]

It does, so does meropenem 500mg q6 instread of 1 gram q8. But those savings were bigger when the said drugs used to cost $20 a dose.

We recently started it.

The outcomes seem to be better so win/win.

 

[xiphoid2010]

We recently started it.

The outcomes seem to be better so win/win.

A little late to the party. We have it here, 3.375 q8 or q12 based on cr > or < 20. This was a significant cost saver 3-4 years ago. Outcomes wise, my knowledge is a couple of years old now, but the data back then was there for ICU population, but not really showing difference in medsurg. Tying up lines and incompatibility with vanco can cause headaches.

Mean while, keep an eye on the zyvox and cubicin. For renal and dialysis patient, try to use cubin if appropriate, since when dosed q48 it will be significiantly cheaper vs zyvox.

 

[type b pharmD]

I'm pushing to adding ferrlecit to formulary and make it preferred, maybe even autosub for venofer. Pretty good cost saving there.

I did a cost analysis on iv iron last summer... feraheme actually came out significantly cheaper than venofer if you can believe it! Venofer is such a ripoff after you account for infusion costs

 

[rxlea]

I did a cost analysis on iv iron last summer... feraheme actually came out significantly cheaper than venofer if you can believe it! Venofer is such a ripoff after you account for infusion costs

What did you use in your analysis?

 

[rxlea]

A little late to the party. We have it here, 3.375 q8 or q12 based on cr > or < 20. This was a significant cost saver 3-4 years ago. Outcomes wise, my knowledge is a couple of years old now, but the data back then was there for ICU population, but not really showing difference in medsurg. Tying up lines and incompatibility with vanco can cause headaches.

Mean while, keep an eye on the zyvox and cubicin. For renal and dialysis patient, try to use cubin if appropriate, since when dosed q48 it will be significiantly cheaper vs zyvox.

I first saw the q8 extended on my IPPE last year.

We're a bit late, yes. We're using it in ICU.

At my old institution, zyvox was heavily restricted for ICU. I haven't seen much use at this institution either.

I've been contemplating fighting the ertapenem battle.

 

[Its Z]

We recently started it.

The outcomes seem to be better so win/win.

David Nicolau at Hartford was big on Carbapenem Extended infusion with lower dose...published that crap every year early 2000's....then in 2007 british CID he published how bad their Ps.A resistance has become.. something about in critical care areas it requires Meropenem 2 grams q8h..

Before evaluating cost savings, evaluate if a drug is used in outpatient setting with "revenue." And if your institution is making a profit, why fight it.

 

[confettiflyer]

David Nicolau at Hartford was big on Carbapenem Extended infusion with lower dose...published that crap every year early 2000's....then in 2007 british CID he published how bad their Ps.A resistance has become.. something about in critical care areas it requires Meropenem 2 grams q8h..

Before evaluating cost savings, evaluate if a drug is used in outpatient setting with "revenue." And if your institution is making a profit, why fight it.

OMG IT'S YOU. We were just talking about you in the Unicorn thread.

 

[RXSavingsPartner]

I just happened to come across your request and just signed up for this forum myself. I do hospital pharmacy cost savings as an independent business and would be happy to see if I could find any savings value for your hospital. My model is risk-free and completely transparent for hospitals which is something that is greatly appreciated by Pharmacy System Directors, Directors, and Clinical Managers. Also, I become a complete resource partner for my clients to give that extra boost to get things approved and implemented. You get me in touch with the right people at your hospital...I would do my best to make you look like a superstar Feel free to email me, [email protected]

Hey guys!

Long time lurker on these forums who finally decided to make a profile, LOL! I was wondering if some of you could weigh in on cost saving ideas/activities you guys do at your hospital as we have been asked to kick around some ideas at the place I work at (around 400 beds non teaching). Maybe confettiflyer, BMBiology, Xiphoid, etc (and anyone in retail don't hesitate to post too if you have any ideas, not trying to discriminate!). Like everywhere they are looking for ways to save $ in the new economy.

We currently have
1. as stewardship program for ABX (but it only limits use of a few like Dapto, Zyvox, and Azactam) so maybe we could expand this
2. like most places we try to have decent formulary management by having one preferred PPI, H2A, etc.
3. I don't cover the Onc floor, but I'm sure there is some definite $ on the table there (though I do know that we limit CSF to Leukine (Neupogen if MD provides reasoning/NF request), and try to limit use of some of the adjunctive/supportive medications to more cost effective ones)
4. We try to limit use of things like combivent (use albuterol and ipratropium HFA if duoNebs can't be used) and use autosubs for ACE I's, ARB's, nasal steroids, LABA's (also combos changed to advair diskus), HMG-coa's, etc. Maybe you guys know of a real $ saving category for autosubs we haven't thought of?

Anyways, I just wanted to throw out a few things we were already doing to get the ball rolling. Again, there are not any wrong or foolish suggestions, I would greatly accept any input any of you have to offer.

Thanks so much!