Cost-containment Strategies Research Articles

Financial strategic impact on clinical laboratory managers - A review

The cost of operating a clinical lab where cost containment remains a major challenge is to be maintained in conjunction with smooth running of laboratory operations. This study aimed to account the results of service cost using workload-based costing in clinical laboratories. The review aimed at establishing cost containment strategies of all lab test services based on workload of the technical team in a clinical lab. Articles were searched in online databases, such as PUBMED, MEDLINE and Google scholar using keywords “financial, strategic, impact, clinical laboratory, managers.” Manual Search of Journals were also done. Articles were reviewed and analysed. The relevant articles were reviewed which showed the value analysis of lab services and its costs along with technical staff workload provides insights on the relationship between variables and the uncertainty of financial strategic effects.

Treatment Delays Associated With Prior Authorization for Infusible Medications: A Cohort Study.

Prior authorizations (PAs) are commonly used by health payers as cost-containment strategies for expensive medications, including infused biologics. There is scarce data about the effect of PA requirements on patient-oriented outcomes. We included patients for whom an infusible medication was prescribed for a rheumatologic condition. The exposures of interest were a PA requirement and whether or not the PA was denied. The primary outcome was the difference in days from medication request to infusion. Secondary outcomes included the proportion of denied PAs and differences in glucocorticoid exposure following a PA request. Of the 225 patients, the infusible medications of 160 (71%) required a PA. PAs were associated with a greater number of days to infusion compared to cases in which no authorization was required (median 31 days [interquartile range (IQR) 15-60 days] versus median 27 days [IQR 13-41 days]; P = 0.045), especially among the 33 patients (21%) whose PA was denied initially (median 50 days [IQR 31-76 days] versus median 27 days [IQR 13-41 days]; P < 0.001). PA denials were associated with greater prednisone-equivalent glucocorticoid exposure in the 3 months following the request than when a PA was not required (median 605 mg [IQR 0-1,575] versus median 160 mg [IQR 0-675]; P = 0.01). Twenty-seven of the 33 PA requests that were initially denied (82%) were eventually approved. Thus, 96% of all PAs were ultimately approved. PA requirements are associated with treatment delays and denials are associated with greater glucocorticoid exposure. Because the great majority of PA requests are ultimately approved, the value of PA requirements and their impact on patient safety should be reevaluated.

Postoperative complications and hospital costs following small bowel resection surgery.

Postoperative complications after major gastrointestinal surgery are a major contributor to hospital costs. Thus, reducing postoperative complications is a key target for cost-containment strategies. We aimed to evaluate the relationship between postoperative complications and hospital costs following small bowel resection. Postoperative complications were recorded for 284 adult patients undergoing major small bowel resection surgery between January 2013 and June 2018. Complications were defined and graded according to the Clavien-Dindo classification system. In-hospital cost of index admission was calculated using an activity-based costing methodology; it was reported in US dollars at 2019 rates. Regression modeling was used to investigate the relationships among a priori selected perioperative variables, complications, and costs. The overall complication prevalence was 81.6% (95% CI: 85.7-77.5). Most complications (69%) were minor, but 22.9% of patients developed a severe complication (Clavien-Dindo grades III or IV). The unadjusted median total hospital cost for patients with any complication was 70% higher than patients without complications (median [IQR] USD 19,659.64 [13,545.81-35,407.14] vs. 11,551.88 [8,849.46-15,329.87], P < 0.001). The development of 1, 2, 3, and ≥ 4 complications increased hospital costs by 11%, 41%, 50%, and 195%, respectively. Similarly, more severe complications incurred higher hospital costs (P < 0.001). After adjustments were made (for the Charlson Comorbidity Index, anemia, surgical urgency and technique, intraoperative fluid administration, blood transfusion, and hospital readmissions), a greater number and increased severity of complications were associated with a higher adjusted median hospital cost. Patients who experienced complications had an adjusted additional median cost of USD 4,187.10 (95% CI: 1,264.89-7,109.31, P = 0.005) compared to those without complications. Postoperative complications are a key target for cost-containment strategies. Our findings demonstrate a high prevalence of postoperative complications following small bowel resection surgery and quantify their associated increase in hospital costs. Australian Clinical Trials Registration number: 12620000322932.

Principal-agent theory-based cost and reimbursement structures of isavuconazole treatment in German hospitals.

Isavuconazole (ISA) is a frequently used antifungal agent for the treatment of invasive fungal diseases (IFDs). However, hospital reimbursement data for ISA is limited. The primary objective of this study was to analyse the different perspectives of relevant stakeholders and the (dis)incentives for the administration of ISA in Germany. To that aim, the health economic effects of using ISA from a hospital management perspective were analysed. Based on principal-agent theory (PAT), the perspectives of (a) the patient (principal) as well as (b) physicians, (c) pharmacists and iv. hospital managers (all agents) were analysed. For the evaluation of the cost-containment and reimbursement strategies of ISA, the German diagnosis-related group (G-DRG) system was used. Hospitals individually negotiating additional payments for innovative treatment procedures (zusatzentgelte [ZE]) within the G-DRG system is a key element of hospital management for the reduction of total healthcare expenditure. Our analysis demonstrated the beneficial role of ISA in healthcare resource utilisation, primarily due to a shortened overall length of hospital stay. Depending on underlying disease, coded G-DRG and ISA formulation, large differences in total reimbursement and the amount of ZE was shown. The PAT demonstrated disincentives for hospital managers to use innovative drugs. Based on the PAT, beneficial, detrimental and indifferent perspectives of different stakeholders regarding the usage of ISA were shown. A reduction of bureaucratic hurdles is needed in Germany for the extension of effective and innovative antifungal treatment strategies with ISA.

Public health and multiple sclerosis in Italy

Abstract Background Multiple Sclerosis (MS) is a complex and progressive disease of the central nervous system. In Italy, prevalence of MS ranges from 198 (continental Regions) to 370 (Sardinia) per 100,000. Despite a National Health System, differences among Regions cause inequalities in access to and quality of care, also involving chronic diseases and disabilities, including MS. Methods Interviews and focus groups involving persons with MS, caregivers, institutions, patients association and other stakeholders were conducted in 2019, to evaluate MS policy landscape, existing services, guidelines and care pathways regarding diagnosis, therapy, follow up, strenghts and weaknesses. Results 600 MS specialized neurologists and 350 MS nurses operate in 240 MS Centers located in hospital neurology departments providing clinical care, disease modifying drugs (DMDs), interdisciplinary care. 13 Regions on 20 approved a PDTA (Diagnosis, Therapy, Care Pathway), other are due by 2020. A reference national PDTA has been already discussed by Regional Health Authorities Conference and Ministry of Health. Regional multistakeholder observatories will be organized. A national MS registry started in 2017, at present involving over 140 Centers and including data of 50% (60.000 patients) of estimated prevalence. Discussion MS specialized centers are recognized as the key component of MS care in Italy and the main refererral for 80% of patients, also taking in account that over 60% of patients receive a DMD. Access to rehabilitation is lacking and hospital, community and primary care linkage is needed, also considering transition from early stages to severe disability. Access to psycological support is variable and cost containment strategies restrict drug access and symptomatic care in some areas along with lacking of interdisciplinary management. It is mandatory to integrate health and social care pathways accordingly with the National Plan for Chronicity in which MS has to be included. Key messages MS specialized centers are the backbone care network in Italy. Integrated care pathways (PDTA) stated as National Health System rules define the right for the patients to receive the proper care.

Improving Quality as a Solution to the Health Care Cost Problem? Health Policy Experts and the Promotion of a Controversial Idea.

In the late 2000s, the contention that quality improvements achieved by reforms in the delivery of care would slow the growth of costs throughout the US health care system became the predominant strategy for cost containment in the discourses and programs of all the 2008 presidential candidates. The question that this paper addresses is why, despite all of the critiques of this idea (especially those of the Congressional Budget Office), what the author terms the quality solution has remained credible enough to be a possible argument in policy makers' discourses and programs. To answer this question, the article explores the role of health policy experts-who are expected to provide credibility and legitimacy to proposals defended by policy makers-in supporting and diffusing this quality solution. The empirical research combines written sources with evidence from 78 interviews. This article highlights the political factors that explain the rise and growing prominence of the quality solution in the community of policy analysts: the political support for delivery reform-oriented research since the 1980s and also the importance of political calculations for prominent health policy experts. This policy history contributes to works that underscore the political dimension of policy analysis.

Benefits of an International Volunteer Experience in Residency Training

In this article, we review the literature describing the benefit of international surgical volunteerism on resident training. Review of recent data demonstrates a resident benefit by decreasing burnout and improving clinical skill, cost-containment strategies, and personal and professional development. There is also a demonstrable benefit to institutions by way of improved resident recruitment and additional philanthropic funding sources. Finally, benefits to healthcare systems have been documented by way of “reverse innovation” and increased healthcare worker productivity. We provide data to support that international volunteerism reaches beyond the patients and providers at the individual level to also provide domestic benefit to practices, institutions, and the healthcare system as well.

Successful transition from bortezomib subcutaneous to generic intravenous bortezomib: Cost savings initiative with global economic impact.

e19375 Background: It is estimated that the U.S. will spend $370 billion in 2019 on pharmaceuticals and by 2020 the cost of cancer care will be approximately 158 billion. Cost containment strategies for high cost drugs are needed. There exists an opportunity to decrease overall cost related to bortezomib by switching patients to generic bortezomib. Generic bortezomib was first approved by the FDA in January 2018 but it can only be administered intravenously. Based on previous studies on occurrence of peripheral neuropathy we hypothesized that patients who have not developed bortezomib induced peripheral neuropathy (BIPN) after or during 4 cycles of subcutaneous (subQ) bortezomib could be switched to IV bortezomib without greatly increasing neuropathy. Methods: A protocol was implemented to switch patients from SubQ to IV bortezomib at our hematology outpatient clinic. Patients had to complete 4 cycles of SubQ bortezomib and have either Grade 1 or no BIPN to qualify to switch to IV bortezomib generic formulation. After approval from the hematology/oncology providers and nursing department, this protocol was implemented to start accrual in November 2018. After provider approval for eligible patients, pharmacists would update the treatment plan orders and also notify nursing and patients of the change. Results: Fifteen patients have received at least 1 cycle of IV generic bortezomib for various indications from Nov 2018 to Nov 2019, ranging from 1 cycle to 12 cycles. The diseases for which bortezomib was being used included multiple myeloma (n = 8) and AL amyloidosis (n = 2), renal transplant rejection and thrombotic thrombocytopenic purpura (TTP). Two of the 15 patients had Grade 1 BIPN prior to switching, while all others reported no neuropathy prior to the switch. None of the patients have developed new neuropathy after making the switch from subQ to IV bortezomib. Nursing and patient satisfaction surveys showed that majority of both groups did not have a preference for IV versus subQ administration. Conclusions: We describe a method to switch from subcutaneous bortezomib to generic IV bortezomib instituted at a large academic medical center as a cost containment strategy. This has resulted in no new cases of neuropathy in our growing data set.

Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey

Physicians play a key role in mitigating and managing costs in healthcare which are rising. Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs. Random sample of 1200 US physicians from the AMA Masterfile. Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.

PCN206 BIOMARKER DRIVEN PRESCRIBING IN ONCOLOGY: BALANCING COST AND PATIENT ACCESS

Biomarker-driven prescribing is paramount in oncology indications. Although preferred for targeted treatment, these therapies are premium-priced and often subject to payer restrictions and cost-containment strategies constraining their uptake. Focusing on key oncology indications, this research explored the drivers and barriers to use these agents and how reimbursement impacts drug selection and prescribing. In August 2019, 100 medical oncologists across the United States were surveyed regarding the role cost and reimbursement play in their decisions for prescribing of biomarker-driven therapies and 30 payers who influence pricing and reimbursement in their commercial plans were surveyed. Additionally, data was analyzed from DRG’s Fingertip Analytics, a nationwide database of formulary coverage. Although most payers (67%) believe that premium pricing for biomarker-driven therapies is justified, these therapies present a significant financial burden for U.S. payers; leading to various contracting agreements and management strategies to control the costs of biomarker-driven therapies. Most surveyed payers indicated their MCOs are using indication-based formulary approaches for oncology therapies that treat multiple indications (83%) and have received health economic outcomes data to support their value assessment (70%). Furthermore, payers indicated that companion diagnostics tests (67% of payers) and the company pharmacoeconomic submissions with compelling data (63%) have positive influence for tier placement on coverage decisions. For many surveyed oncologists, changes in payer policies would not change their prescribing. However, clinical pathway programs including biomarker tests (64-77%) and utilization management controls are increasingly popular measures for curbing treatment costs. Evaluating drugs for overall benefit versus overall cost to the system is the new norm and providing robust pharmacoeconomic data is crucial to demonstrate a biomarker-driven therapy’s value and achieve optimal market access. Compelling efficacy and cost-effectiveness data in a real-world setting over standard therapies support more favourable value assessment, pricing and reimbursement negotiations, and prescribing overall.

PRO52 EXPENDITURE, UTILIZATION, AND PRICE OF SPECIALTY DRUGS FOR MULTIPLE SCLEROSIS IN THE U.S MEDICAID POPULATION 2008 - 2018

Multiple sclerosis (MS) is a rare, long-standing, and disabling disease that affects the central nervous system and causes several clinical manifestations. As a result, this disease is associated with a high societal economic burden. To analyze the trends in drug expenditure, utilization, and cost of specialty drugs for the treatment of patients with MS in the US Medicaid program. In this retrospective drug utilization research analysis, we obtained prescription data and reimbursement of disease-modifying therapies for MS from the Centers for Medicare & Medicaid Services Medicaid State Drug Utilization Data between January 2008 and December 2018. The specialty drugs considered in our analysis included dimethyl fumarate, fingolimod, teriflunomide, cladribine, siponimod, alemtuzumab, natalizumab, ocrelizumab, daclizumab, glatiramer acetate, peginterferon beta-1a, interferon beta-1a, and interferon beta-1b. The annual trends of the number of prescriptions, reimbursement expenditures, and costs were calculated. The average reimbursement per prescription was calculated as an estimate of the drug cost. The annual MS drug utilization increased from 85,209 prescriptions in 2008 to 223,604 in 2016, and then decreased to 194,877 in 2018. The annual reimbursement surged by 633% in the 10-year study period between 2008 and 2018, from almost $172 million in 2008 to more than $1.4 billion in 2017, and then to approximately $1.26 billion in 2018. The cost per prescription increased over time for most MS brand-name drugs (eg, from $2033 in 2008 to $5114 in 2018 for natalizumab, and from $19,138 in 2016 to $23,588 in 2018 for alemtuzumab). In 2008, self-injectable drugs dominated the market. In recent years, a shift has occurred in the utilization and reimbursement of MS drugs, with oral medications becoming predominant. The study findings indicate intermarket and interbrand competition among the MS specialty drugs. The growing utilization and spending trends for specialty MS medications are significant and sizable in the US Medicaid programs. Medicaid cost-containment strategy is warranted to control the economic burden of state budgets across the country.

The hospital costs of complications following colonic resection surgery: A retrospective cohort study.

BackgroundColonic resection is a common surgical procedure associated with a high rate of postoperative complications. The aim of this observational study is to estimate the in-hospital costs of complications and to identify perioperative variables associated with complication development following colon resection surgery.Materials and methodsWe conducted a single-centre cohort study with retrospective data collection of 487 patients undergoing colonic resection surgery between 2013 and 2018. Postoperative complications were graded according to the Clavien-Dindo classification system. In-hospital cost of index admission is reported in 2019 United States Dollars. Regression modelling was used to investigate the relationship of a priori selected perioperative variables and presence of complications and costs.ResultsOverall complication prevalence was 69.6% (95%CI:65.5%–73.7%). Median [interquartile range] cost of patients with postoperative complications was significantly increased as compared to patients without complications ($17,963 [13,533:25,178] vs $12,578 [10,196:16,140]; p < 0.0001). Clavien-Dindo Grade I, II, III and IV complications increased costs by 15.8%, 36.8%, 169.4% and 240.1% respectively (p < 0.0001). Presence of complications was significantly associated with Charlson Comorbidity Index (Odds ratio (OR) per 1-unit increase: 1.09; 95%CI:1.02 to 1.17), preoperative albumin levels (OR per 1-unit increase: 0.94; 95%CI:0.90 to 0.98) and open as compared to laparoscopic resection (OR: 2.41; 95%CI:1.32 to 4.42).ConclusionsThere is a high prevalence of complications following colonic resection surgery. Postoperative complications, including minor complications (Clavien-Dindo Grade I-II), were associated with a significant increase in hospital costs and are a key target for cost containment strategies.

Geographic Variation in Costs of Transsphenoidal Pituitary Surgery in the United States

Geographic variations in health care costs have been reported for many surgical specialties. In this study, we sought to describe national and regional costs associated with transsphenoidal pituitary surgery (TPS). Data from the Truven-MarketScan 2010-2014 were analyzed. We examined overall total, hospital/facility, physician, and out-of-pocket payments in patients undergoing TPS including technique-specific costs. Mean payments were obtained after risk adjustment for patient-level and system-level confounders and estimated differences across regions. The estimated overall annual burden was $43 million/year in our cohort. The average overall total payment associated with TPS was $35,602.30, hospital/facility payment was $26,980.45, physician payment was $4685.95, and out-of-pocket payment was $2330.78. Overall total and hospital/facility costs were highest in the West and lowest in the South (both P < 0.001), whereas physician reimbursements were highest in the North-east and lowest in the South (P < 0.001). There were no differences in out-of-pocket expenses across regions. On a national level, there were significantly higher overall total and hospital/facility payments associated with endoscopic compared with microscopic procedures (both P<0.001); there were no significant differences in physician payments or out-of-pocket expenses between techniques. There were also significant within-region cost differences in overall total, hospital/facility, and physician payments in both techniques as well as in out-of-pocket expenses associated with microsurgery. There were no significant regional differences in out-of-pocket expenses associated with endoscopic surgery. Our results show significant geographic cost disparities associated with TPS. Understanding factors behind disparate costs is important for developing cost containment strategies.

Priority setting and resource allocation in the US health system: is there a place for hard caps?

PurposeThe United States devotes a larger share of its GDP to health care and spends more on health care per capita than any other country. The sheer size of the total spending on health care, at approximately $3.5 trillion in 2017, puts significant pressure on all payers and crowds out other forms of public and private spending.Design/methodology/approachIn this brief commentary the authors suggest that, as part of the effort to deal with this pressure, the United States should look at borrowing a cost containment strategy from other countries: the use of hard caps on spending growth. The authors draw on our their experience of working with decision-makers over the last 20 years on the topic of priority setting to put forward some ideas on whether there is potential for application of trade-offs in the United States.FindingsAs hard caps force choices to be made, a necessary condition for successful implementation of this policy is the presence of an effective priority-setting framework to ensure that the right choices are made in operationalizing spending limitations. Work on this topic elsewhere can provide some insight into the use of a criteria-based framework for priority setting that purports transparency in decision-making to achieve value-based decisions.Originality/valueOther countries still have much work to do, but there is a substantial track record of using formal priority-setting approaches that could potentially inform practice in the United States. We suggest that there are key segments of the US healthcare system where the adoption of formal priority-setting frameworks to guide trade-off decisions is feasible. Piloting such activity in these contexts is the next natural step in this line of inquiry.

Demographics, Cost, and Sustainability of Haemodialysis among End-Stage Kidney Disease Patients in Southern Nigeria: A Single-Center Study.

Context:Access to chronic hemodialysis for patients with end-stage kidney disease has improved over the years. However, it is unclear if this has resulted in lower cost and improved dialysis vintage.Aim:We aimed to assess the demographics, cost implication, and sustainability of maintenance hemodialysis in our cohort of end-stage kidney disease (ESKD) patients.Methods:Retrospective descriptive study of ESKD patients on maintenance HD from 2014 to 2018 using hemodialysis records. Time-to-HD discontinuation and reasons for discontinuation were recorded. Using Kaplan–Meier graphs, the time-to-dialysis discontinuation experience of the cohort was shown. Log-rank test was used to compare the experience between both genders. Univariable and multivariable Cox proportional hazard models were built to identify independent associations with time-to-dialysis discontinuation.Results:Over the 5-year period, 702 individuals initiated HD, males were older than females, the complete cohort contributed 65,714 person-days to the study and the median time-to-HD discontinuation was 10 days (interquartile range, 2–42). Females had a shorter time to HD discontinuation (8 days [1–32 days]) compared to males (11 days [2–48 days]). Only 28.5%, 15.3% and 8.3% of the patients had HD beyond 30, 90, and 180 days, respectively. About 128 (18.2%) had thrice-weekly HD. Most sustained the treatment for the 1st week. Majority (98.4%) of the patients were presumed dead, while 4 (0.65%) were still alive and 6 (0.98%) had renal transplantation. All patients who discontinued dialysis did so for financial reasons. Multivariable Cox proportional hazards model showed that individuals who could afford dialysis more than once a week had reduced hazard of dialysis discontinuation.Conclusion:Most patients cannot sustain HD beyond a few weeks for financial reasons. Several cost containment strategies need to be deployed to bring down the cost of care.

Implementation of a standardised pharmacist check of medical orders prior to preparation of anticancer drugs to reduce drug wastage.

The increasing cost of anticancer drugs is now being recognised as a global problem, and measures against drug wastage are among the most important cost containment strategies for anticancer drugs. When blood examination results or changes to a patient's condition necessitate dose reduction or discontinuation of anticancer drugs after their preparation, the compounded anticancer drugs are discarded. To reduce anticancer drug wastage after preparation, we developed a protocol that set the eligibility, start of treatment, dose reduction and discontinuation criteria for injectable anticancer drugs and assessed the effect of pharmacists' checks of these criteria based on the present protocol prior to preparation of injectable anticancer drugs. Observations before and after introduction of the protocol were conducted at Gifu University Hospital. We recorded the number, type and cost of anticancer drugs discarded after preparation and the reason for discarding these drugs in our dedicated database. Checking the criteria for anticancer drug administration before preparation significantly reduced the rate at which anticancer drugs within a chemotherapy cycle were discarded after preparation compared with that prior to the protocol's introduction (0.367% [18/4909] vs 0.032% [2/6248], P<.001). Additionally, the total cost of anticancer drugs discarded after preparation was reduced from JPY 2041786 (USD 18562) to JPY 398414 (USD 3622). Pharmacists' checks of the eligibility, start of treatment, dose reduction and discontinuation criteria for anticancer drugs based on the present protocol prior to preparation of injectable anticancer drugs was useful for reducing drug wastage after preparation.

Parenteral cytotoxic drug wastage at a tertiary hospital in Kuala Lumpur: How much and why?

To identify the cost and reasons of returned parenteral chemotherapy regimens at a tertiary hospital in Kuala Lumpur, Malaysia. Data were retrospectively extracted from all the Chemotherapy Return Forms in 2016, which is a compulsory documentation accompanying each return of parenteral chemotherapy regimen. The following data were extracted: patient's diagnosis, gender, location of treatment (i.e. ward/daycare clinic), start date of chemotherapy regimen, type of cytotoxic drug returned, dose of cytotoxic drug returned, number of cytotoxic drug preparations returned and reason for return as well as whether the returned cytotoxic drug preparations could be re-dispensed. The cost of wastage was calculated based on the cost per mg (or per unit) of the particular returned cytotoxic drug. One hundred and fifty-nine cases of returned chemotherapy regimen comprising of 231 parenteral cytotoxic drug preparations were analysed. The total cost of returned chemotherapy regimen for 2016 was €3632, with €756 (20.8%) worth of chemotherapy regimens returned due to preventable reasons and €2876 (79.2%) worth of chemotherapy regimens returned due to non-preventable reasons. Approximately 50% of cases returned chemotherapy regimen were due to deterioration of patient's clinical condition and another 24.5% of cases of returned chemotherapy regimen were attributed to adverse drug reactions. Wastage associated to non-preventable reasons such as adverse drug reactions and preventable causes like refusal of patients can be further reduced by using newer healthcare innovations and establishment of written institutional protocols or standard operating procedures as references for in-charge healthcare personnel when cytotoxic drug-related issues occur. Adoption of cost-saving strategies that have been proven by studies could further improve current cost containment strategies.

General practitioner as a gatekeeper and medical scheme benefit design in South Africa.

General Practitioners (GPs) serve as a gatekeeper function in many healthcare systems. Cost containment strategies in the health care ecosystem usually focus on the role of GPs as the point of entry. The healthcare expenditure as the proportion of total healthcare spent on medical schemes in South Africa has been declining over time. This could be attributed to a shift in benefit design and product development employed by schemes. The aim of this study was to investigate GP health spending by medical schemes, the average spent per GP visit, the level of co-payment that members are subjected to and the GP to member ratio in South Africa. The study design was a cross-sectional study which was performed by linking annual statutory returns data, claims data and provider distribution data collected on an annual basis by the Council for Medical Schemes. The data was further mirrored to the Practice code numbering data received from the Board of Healthcare Funders (BHF). A total of 79 medical schemes claims data was included in the analysis, this accounted for nearly 82% of beneficiaries (81.6%). The average number of visits per beneficiaries was 3. The distribution of GPs claiming from medical schemes follow the distribution of beneficiary by province. The ratio of claim GPs per 1000 beneficiaries is 2. These results further revealed a shift in benefit design and that medical scheme members bypass GPs directly to specialist services which is a secondary level of care, thus undermining the role of GPs as gatekeepers. It is concerning that GPs consultation is attracting a co-payment of as high 39%. Reprioritisation and emphasis on the role of a GP as gatekeepers as a function of the benefit design process is key to improving quality of care.

Successful Transition from Bortezomib Subcutaneous (SubQ) to Generic Intravenous (IV) Bortezomib: Cost Savings Initiative with Global Economic Impact

Background: It is estimated that the U.S. will spend $370 billion in 2019 on pharmaceuticals and by 2020 the cost of cancer care will be approximately 158 billion. Cost containment strategies for high cost drugs are needed. In 2019 global sales from subcutaneous (SubQ) bortezomib manufactured by Takeda® will exceed $1 billion. There exists an opportunity to decrease overall cost related to bortezomib by $300-400 million across the globe by switching patients to bortezomib intravenous (IV) (manufactured by Fresenius Kabi®). Generic bortezomib was first approved by the FDA in January 2018 but it can only be administered intravenously. A phase 3 randomized controlled trial of twice weekly SubQ vs IV bortezomib showed no difference in time to progression or 1 year overall survival, however rate of Grade 3 peripheral neuropathy doubled in the IV arm compared to SubQ (Moreau et al, 2011). Although twice weekly bortezomib has fallen out of favor and there are retrospective data suggesting that neuropathy from weekly subQ and weekly IV bortezomib may be similar, there exist no prospective data to date to confirm this. Bortezomib induced peripheral neuropathy (BIPN) typically occurs by cycle 4 of twice weekly therapy, and the majority of cases are partially reversible (Dimopolous et al, 2011). We hypothesized that patients who have not developed neuropathy after or during 4 cycles of subcutaneous bortezomib could be switched to IV bortezomib without greatly increasing neuropathy. Methods: Boston Medical Center Health System is a 500 plus bed integrated delivery network which not only functions as payer but also as a provider. A protocol was implemented to switch patients from SubQ to IV bortezomib. Patients had to complete 4 cycles of SubQ bortezomib and have either Grade 1 or no BIPN to qualify to switch to IV bortezomib generic formulation. Patients were eligible to be switched regardless of indication or dose, if other criteria were met. After approval from the hematology/oncology providers and nursing department, this protocol was implemented to start accrual in November 2018. Patients eligible for the switch were identified primarily by pharmacists. After provider approval, pharmacists would update the treatment plan orders and also notify nursing and patients of the change. Nursing and patient satisfaction surveys were also administered to obtain input from all stakeholders. Results: Eleven patients have received at least 1 cycle of IV generic bortezomib for various indications from Nov 2018 to June 2019, with minimum of 2 doses and maximum of 16 doses. The diseases for which bortezomib was being used included multiple myeloma (n= 6) and AL amyloidosis (n= 2), renal transplant rejection and thrombotic thrombocytopenic purpura (TTP). One of the 11 patients had Grade 1 BIPN prior to switching, while all others reported no neuropathy prior to the switch. None of the patients have developed new neuropathy after making the switch from subQ to IV bortezomib. Results of the nursing and patient satisfaction surveys are being collected and will be presented. Conclusion: We describe a method to switch from subcutaneous bortezomib to generic IV bortezomib instituted at a large academic medical center as a cost containment strategy. This has resulted in no new cases of neuropathy in our growing data set. Global adoption of this protocol has the potential to substantially reduce drug costs related to multiple myeloma. Disclosures Sanchorawala: Celgene: Research Funding; Takeda: Research Funding; Proclara: Consultancy, Honoraria; Caelum: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding; Prothena: Research Funding. Sloan:Merck: Other: endpoint review commitee; Abbvie: Other: Endpoint Review Committee; Stemline: Consultancy. Sarosiek:Acrotech: Research Funding. Shah:Rigel Pharmaceutical: Consultancy, Speakers Bureau.

Medicaid Use among Older Low-Income Medicare Enrollees in California and Texas: A Tale of Two States.

States face increasing Medicaid expenditures largely as a result of growing dual-eligible populations. In this article we examine self-reported community-based Medicaid participation among Medicare recipients 65 and older in California and Texas, with a particular focus on the older Mexican-origin population. We use six waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) covering the period from 1993-94 to 2010-11. The data reveal relatively high Medicaid participation rates by older individuals of Mexican origin, but significant differences between the two states. At baseline, 30% of older Mexican-origin Medicare beneficiaries in California reported receiving Medicaid compared to 41% in Texas. Despite California's more liberal eligibility criteria, community-dwelling Texans were more likely than Californians to report coverage at some point during the 17-year follow-up. Our data, as well as administrative data, reveal that California classifies nearly all of its community-dwelling Medicaid recipients as "full duals," meaning that they receive full benefits, whereas Texas is more likely to classify similarly poor and disabled individuals as "partial duals," meaning that they receive less coverage, thereby lowering overall program expenditures. Cost containment strategies that restrict access may be especially consequential for vulnerable Hispanic populations.