New Medicare Drug Spending Dashboard Published
The Center for Medicare and Medicaid Services (CMS) released a new online dashboard that contains some interesting analyses of Medicare Part D drug utilization. The new dashboard presents drug data collected from Medicare Part B and Part D providers from 2010 to 2014. In an analysis of the top 15 drugs by total annual cost for Medicare Part D 2014, 10 out of the top 15 high cost medications are drugs that commonly show up on newly admitted hospice patients’ medication profiles. The remaining 5 medications are all specialty medications used for chemotherapy, immunotherapy or hepatitis C treatment. These 5 medications are curative in nature and are not typically encountered by hospice providers.
The 10 high cost drugs identified by the analysis are Nexium, Crestor, Abilify, Advair, Spiriva, Lantus, Januvia, Duloxetine, Lyrica, and Namenda.
Hospice Pharmacy Solutions also targets these medications for our hospice providers in patient medication reviews and monthly drug utilization reviews. Many of these can be switched to a more cost-effective alternative or safely discontinued at the end of life. Below are the common recommendations provided by HPS clinicians to manage hospice patients who are on the drugs listed above:
◾Nexium is a proton pump inhibitor (PPI) which has recently become generic in early 2015. The generic version, esomeprazole, is also available over-the-counter at a much lower cost than the branded version. Omeprazole is another cost-effective alternative in the same class of PPIs that has been generically available for a long time.
◾Crestor is a statin for hyperlipidemia. There was a study done that supports the discontinuation of statins at the end of life. It has also been shown that the discontinuation of statins can improve the quality of life for terminal patients. Click here to read an abstract of the study.
◾Abilify is a branded atypical antipsychotic. It is not recommended to switch an antipsychotic if the patient has been stable on this medication to treat certain existing mental/mooddisorders (such as schizophrenia or bipolar disorder)However, if the patient was newly prescribed Abilify for terminal agitation, haloperidol would be the most cost-effective alternative in the hospice setting.
◾Advair and Spiriva are both inhaled respiratory medications. If patients have a terminal lung conditions, they often fail to have enough positive force to inhale medication contents from these handheld devices. These medications are often switched to the nebulized formulation for better efficacy when patients have significant lung dysfunction.
◾Lantus and Januvia are used for diabetes management. Tight blood glucose control only provides long term survival benefit, so it is no longer recommended in terminal patients. The risks of hypoglycemia and the potential side effects from the diabetes medication at end of life often outweigh the benefit, thus they should be considered for discontinuation for terminal patients.
◾Duloxetine and Lyrica are both commonly used for treating neuropathic pain. The cost effective alternative for these is gabapentin. Methadone is also a very cost effective option to manage neuropathic pain and other types of pain, particularly in patients who also require routine narcotics for pain or dyspnea.
◾Namenda is used to improve memory, awareness, and the ability to perform daily functions in Alzheimer’s patients. It has NOT been demonstrated to provide any benefit in end stage dementia (FAST level 7 or greater). The potential adverse effects of Namenda, such as GI disturbance, are likely to outweigh any potential beneficial effects, so it is often recommended to discontinue these medications for patient with end stage Alzheimer’s disease.
Click here if you are interested in learning more about the Medicare Drug Spending Dashboard 2014.