Corey Diamond, PharmD
Drug waste costs U.S. insurers billions of dollars annually, with Medicare Part B spending increasing year by year as a result. But a new process improvement project could provide insight into how institutions can optimize injectable drug waste production and significantly reduce costs.
The improvement process was detailed in the February 2023 issue of the American Journal of Health-System Pharmacy. Trovato and colleagues found that the implementation of a “grouper” with intelligent medication selection logic and custom dose rounding in the electronic health record (EHR) for three high-cost drugs—bevacizumab-bvzr, carfilzomib, and ipilimumab—resulted in drug waste savings of over $800,000 within a 3-month period.
Since the introduction of the JW modifier in 2007, CMS has been rigorously tracking injectable drug waste to ensure appropriate use of single-dose vials—a particular challenge for health institutions. There are no thorough processes in place to ensure Medicare Part B billing requirements are met each time staff prepare a dose of an injectable drug, resulting in excess drug waste.
Process improvement
Trovato and colleagues conducted a pre–post study design over a 6-month period. The authors identified 2 key process gaps at their institution. Firstly, the EHR failed to list available vial sizes or combination of vials to use when preparing an injectable dose, with the staff having to rely on their own knowledge to make decisions on which vial sizes to use to minimize drug waste. Secondly, their institution did not have a dose-rounding policy to allow staff to automatically round patient-specific doses to the nearest vial size.
To remedy these problems, the hospital’s informatics team implemented a grouper functionality within their EHR that used an intelligent algorithm to automatically select the optimum combination of vial sizes for an ordered dose. The optimal vial size or vial size combination would display on the “Dispense Preparation” screen in the clean room. A dose-rounding policy was also approved in the postimplementation phase to automatically round injectable doses to the nearest vial size if the ordered patient-specific dose was within 10% of the vial size.
To obtain the best snapshot of the potential cost savings of these process improvements, the authors initially limited their process improvement implementation to three drugs—bevacizumab-bvzr, carfilzomib, and ipilimumab—that would reasonably produce waste at an amount greater than necessary.
Overall, the authors evaluated a total of 826 claims to Medicare Part B for the three drugs prior to the process improvement implementation versus 1,075 claims afterward. The authors found that there was a reduction in waste of approximately 34% for all three drugs (55.1% prior to implantation vs. 20.8% after 3 months postimplantation).
The total estimated cost savings—calculated using the wholesale acquisition cost—was approximately $828,396 ($1,397,437 in 3 months prior to project implementation vs. $569,041 after 3 months postimplementation).
Limitations
The authors could not, unfortunately, assess the efficacy of the implementation of the grouper alone. The study could only assess its efficacy within the context of being used in combination with a dose-rounding policy. “Around the same time as grouper implementation, staff received notice that certain commercial payors might begin requiring dose rounding. Pharmacy staff sought approval from organizational leadership to implement dose rounding based on this information,” the authors explained. “Even though the department knew that dose rounding would confound assessment of the efficacy of the grouper alone, they wanted to implement it as soon as possible, rather than wait another two and a half months until the grouper implementation phase was over.”
The authors went on to explain that although having both features helped reduce drug waste and improve billing compliance, this was a major limitation in understanding the true effect of the grouper alone on reducing waste.
Despite only containing 3 months’ worth of efficacy data, Travato and colleagues’ study may help inspire similar programs for other health systems in the future. ■