The Secretary shall require PDP sponsors of prescription drug plans to utilize specific, uniform dispensing techniques, as determined by the Secretary, in consultation with relevant stakeholders (including representatives of nursing facilities, residents of nursing facilities, pharmacists, the pharmacy industry (including retail and long-term care pharmacy), prescription drug plans, MA–PD plans, and any other stakeholders the Secretary determines appropriate), such as weekly, daily, or automated dose dispensing, when dispensing covered part D drugs to enrollees who reside in a long-term care facility in order to reduce waste associated with 30-day fills.
Regardless of whether or not this HCR bill ever passes, many in the industry believe that Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) will eventually mandate the reduction of medication waste in LTC. So, while everyone agrees that eliminating medication waste in LTC is the "right thing to do," LTC pharmacies are extremely concerned with how this will impact their business operations (read more about the impacts in my last blog on the subject).
Therefore, in order to address the concerns and dispel some of the myths, I have attempted to describe the various options for reducing waste and outline the advantages and disadvantages of each:
Return and Reuse:
First of all, the Senate bill does not call for HHS to mandate shorter dispensing cycles, as many believe. It simply offers shorter cycles as an option for reducing waste. One very simple way to reduce waste is for pharmacies to accept returns and provide a credit to the payers. This method is already utilized extensively in Long-Term Care for patients covered under Medicare Part A, for which the LTC provider (i.e. nursing home) is responsible for the cost of the medications. It is a great way to reduce waste without a significant investment in infrastructure. However, there are clinical concerns about reusing medications that have left the controlled environment of the pharmacy. Therefore, regulations vary from state to state, and the DEA does not allow the return and reuse of controlled substances. As a result, CMS has indicated that they will not consider returning and reusing medications as an option because they feel it is not clinically safe.
Bingo-Cards
The most widely adopted mechanism for distributing medications to residents in Long-Term Care (LTC) facilities is the use of bingo cards. Bingo cards can hold up to a 30-day supply of oral solid medications (over 90% of the volume of doses in LTC are oral solids). Since most, if not all, LTC pharmacies currently use bingo cards for delivering medications, the pharmacy could simply reduce the supply from 30 to 7 days without investing in any additional technology or infrastructure. However, reducing the medication supply to 7 days does not completely eliminate waste, and it can significantly increase pharmacy labor and packaging costs, since it requires 3 additional dispensing cycles per month. However, pharmacies that have already invested in bingo-card filling automation will not experience as significant of an increase in labor.
- Advantages:
Moderately reduces medication waste
No investment in infrastructure/technology required - Disadvantages:
Significantly increases pharmacy labor and packaging costs
No mechanism (i.e. billing transaction) for shorter billing cycles with Part D plans
Multi-Dose Strip Packaging
Over the past decade many LTC pharmacies have adopted pharmacy automation technology that dispenses medications in multi-dose strip packaging (i.e. multiple medications for a patient and time in a single easy-to-open package). Because the packaging is easier to use when administering medications, many nursing facilities prefer it over traditional bingo cards. This fairly proven technology, which originated in the acute care / hospital market, also enables pharmacies to dispense medications in variable days supply. However, most LTC pharmacies have adopted 2-2-3, 3-4, and/or 7-day dispensing cycles. While shorter dispensing cycles significantly reduces medication waste, it does not completely eliminate it. Furthermore, since it provides very few benefits other than waste reduction, most pharmacies did not considered multi-dose strip packaging in the past.
- Advantages:
Significantly reduces medication waste
Reduces nursing time spent administering meds - Disadvantages:
Technology investment required
Does not reduce pharmacy fill or delivery costs
No mechanism (i.e. billing transaction) for shorter billing cycles with Part D plans
Remote / On-Demand Dispensing
Remote / On-Demand Dispensing is a relatively new concept that places the multi-dose strip packaging equipment at the Long-Term Care provider (i.e. nursing home). The equipment is operated by the nursing staff and remotely managed and monitored by the pharmacy. Because the medications are dispensed on-demand, unused medications are not dispensed and therefore never wasted. As a result, remote / on-demand dispensing is the only distribution model that virtually eliminates medication waste in LTC. Furthermore, having medications on-site presents many additional benefits to both the pharmacy and facility, such as reduced delivery and pharmacy labor costs, improved medication availability, and reduced diversion. Therefore, while remote / on-demand dispensing requires an investment in technology, the benefits far outweigh the costs. Unfortunately, because the concept is so new, only a handful of states currently allow remote dispensing. However, due to its numerous benefits, many Boards of Pharmacy are starting to embrace the concept and re-write their regulations to allow remote dispensing.
- Advantages:
Virtually eliminates medication waste
Reduces delivery costs
Reduces pharmacy dispensing labor
Reduces nursing time spent administering meds
Reduces diversion of controlled substances
Improves medication availability, increasing patient safety - Disadvantages:
Technology investment required
Not approved in all states
No mechanism (i.e. billing transaction) for shorter billing cycles with Part D plans
Conclusion:
It is very clear that the elimination of medication waste in LTC has become a priority for legislators and others in DC. In fact, reducing and/or eliminating medication waste will have a bigger impact on LTC pharmacy than anything else currently being considered in the Health Care Reform bill. As a result, LTC pharmacies are very concerned about the impacts it will have on their business operations. Many options for reducing waste are available, each of which has its advantages and disadvantages. Some require an investment in technology and infrastructure, while each varies in the amount of waste that is eliminated. Regardless, every scenario will require additional billing mechanisms with the Part D plans, which CMS is currently developing with the help of the National Council of Prescription Drug Programs (NCPDP), a not-for-profit ANSI-Accredited Standards Development Organization representing virtually every sector of the pharmacy services industry. And, just like most things in this world, no one solution is right for everyone. Therefore, it is absolutely critical that LTC pharmacies and the industry as a whole understand the different options for reducing medication waste and the impacts each has to the business.
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