A previous post (The Pendulum Swings Back) on the Advanced Medical Strategies blog contained the following line: “A report released by the Institute of Medicine in 2010 found that waste accounted for 30% of health-care spending: $750 billion dollars a year.”
Many factors contributed to this finding, which the authors described as Categories of Waste. They included:
- Failures of care delivery (inefficient preventive care or patient safety best practices)
- Failures of care coordination (inadequate medical records transfers; communication breakdown)
- Overtreatment/Overdiagnoses (unwarranted procedures; defensive medicine)
- Administrative complexity (red tape; standardized forms and procedures deficiencies)
- Pricing failures (drug profiteering; lack of transparency)
- Fraud and abuse (billing scams; inaccurate medication claims)
It was certainly an eye-opening article. While I was impressed by its depth & breadth, I couldn’t help but notice one conspicuous omission. Not included in their Categories of Waste was…well, waste.
Earlier this year researchers at Memorial Sloan Kettering Cancer Center published a study that found expensive cancer drugs are literally being thrown in the trash because of dosing inefficiencies. The report asserted that approximately 10% of the volume of cancer drugs purchased by doctors and hospitals is discarded. A prime example that co-authors Dr. Peter B. Bach and Dr. Leonard Saltz gave was the drug Keytruda. Currently, Keytruda is only available in one vial size of 100 mg. The proper dosing for the average 75 kg adult, however, is 150 mg. Because Keytruda is not a multi-dose drug (which do allow for storage and reuse of the drug contained within them), that means half of that second 100 mg vial is not used.
Keytruda manufacturer Merck is aware of drug leftovers, and in this case proposed packaging the drug in larger 200 mg fixed-dose vials that their reps said would solve the problem. There are a few flaws in this plan. One, there is no clinical benefit to receiving the extra medicine. Two, since there is no extra health advantage the leftover portion is simply excess, except that now the patient’s body is the waste receptacle. Three, like most cancer medicines Keytruda is a weight-based drug. Critics of the 200 mg vial argue that fixed dosing would be excessive (and even more wasteful) for anyone weighing under 75 kg—for example, the elderly.
Though it would seem that proper packaging of these expensive pharmaceuticals would prevent such waste, there are some who dispute that. While Sherry Glied, PhD, dean of New York University’s Robert F. Wagner Graduate School of Public Service, and Bhaven Sampat, PhD, associate professor of Health Policy and Management at Columbia University concur that problems of waste exist, they contend that making pharmaceutical companies provide drugs in smaller amounts would be “unlikely to reduce the costs that matter to patients and payers.” Part of that viewpoint was that the supplementary expenditures of R&D and marketing the new packaging would potentially be higher than the chemical costs. Further, they reasoned that whatever changes were made the added costs would ultimately be passed on to the consumer.
Their cynicism is probably warranted; however, in the latter case at least that extra revenue—which stems directly from avoidable waste—would be eliminated. As the study’s title succinctly puts it: Drug companies will make $1.8 billion this year by using package sizes that promote waste. In other words, while Merck is compensated in full for two vials of Keytruda, patients only receive benefit from 1 ½ vials; effectively, insurance companies pay for drugs that Big Pharma knows will never be used.
Keytruda is not an isolated case. Of the top 20 cancer medicines sold, 18 are only available in one or two vial sizes. The authors “believe it would be possible to reduce waste substantially if companies marketed additional vials that contained smaller amounts of drug…just one additional vial size for 18 of the 20 drugs in our analysis would reduce the amount of waste by approximately 75%.”
Many non-cancer medications also have limited vial sizes. So, the problem isn’t limited to just cancer drugs. Nor does it have to do with vials. Prescription pills are being squandered as well. MGUs, stop-loss carriers, TPAs and other clinical professionals can mitigate and eliminate dosing problems when processing claims by utilizing Advanced Medical Strategies’ PredictRx. This software solution is an invaluable touchstone in finding all the available dosages for a particular drug, and its Rx calculator simply and plainly lets claims specialists be sure they are not being billed for unnecessary waste.
Big Pharma is not the only guilty party. Physicians are at fault, too. Overmedication accounts for a great deal of drug waste. A recent study done by the University of Pennsylvania’s Perelman School of Medicine and School of Dental Medicine found that over 50% of opioids prescribed after wisdom teeth removal are not taken by the patient. Typically, 28 opioid pills were prescribed to patients (who had no post-surgical complications). After three weeks, patients had an average of 15 pills remaining. Says study author Dr. Brandon Maughan: “When translated to the broad U.S. population, our findings suggest that more than 100 million opioid pills prescribed to patients following surgical removal of impacted wisdom teeth are not used.” 100 million pills wasted from dental surgery alone!
Most of these pills will be needlessly thrown away, so the general public has to shoulder some of the blame as well. Worse, a portion will inevitably find their way into the opioid epidemic though patient abuse or misuse, or illegal redistribution on the black market. If there is a silver lining to this sad reality it is that the study also found educating the public about drug disposal programs is surprisingly effective. When patients were provided this information, it led to a 22 percent increase in proper medication disposal (or intentions to do the same).
An everyday occurrence at nursing homes is the dumping of unopened or otherwise unused unexpired medications. Perhaps a patient is now well and has gone home. Maybe a prescription was filled but for whatever reason the patient is unable to tolerate the medication. Or, as often is the case, the patient has passed away. In each instance the leftover pills are disposed of. On average, nursing home residents take 14 different medications. Researchers at the University of Chicago estimated that long-term care facilities discard roughly $2 billion a year in drugs.
Even if someone else in that facility has the exact same prescription, by law nursing home clinicians cannot “re-gift” those medications. However, they can utilize drug donation programs. Governmental social service providers can legally redistribute drugs to the uninsured or to those with low incomes. Non-profit groups have developed software to enable healthcare facilities, manufacturers and wholesalers to ship unused drugs to pharmacies that will dispense them to those most desperate for help, instead of having the potentially life-saving medications unnecessarily destroyed.
Drug waste continues to be a big problem. There are, however, relatively cheap, simple, and sensible solutions in which to combat it: Repackaging drugs into practical, economical sizes; dosing prudence; reuse and/or donations; and, if need be, proper disposal.