Whack-a-mole: Reducing impact of rising drug prices on hospital costs
A previously inexpensive workhorse drug suddenly increases in price. This scenario, highlighted in recent public controversies over the prices of the antiparasite drug Daraprim and EpiPen autoinjectors, has been playing out with increasing frequency over the past few years.
At a November 2 Emory Center for Ethics conference on drug development and pricing, pharmacist Collin Lee, assistant director of clinical and educational services for Emory Healthcare, explained how she and her team manage the impact of increasing drug prices on hospital costs.
While other speakers explored nationwide economic trends and regulatory or ethical issues, Lee's concerns were more immediate and close at hand. When it comes to drug price increases, she says, hospital leaders want to know: "What are we going to do about this?"
Lee is part of the Pharmacy and Therapeutics ("P and T") committees for Emory University Hospital and Emory University Hospital Midtown. She described work in this area as being somewhat like a game of "whack-a-mole," responding to drug increases with creative tactics to keep the hospitals' costs at bay.
She and her colleagues have used a variety of tactics, such as repackaging to reduce waste and managing provider demand.
Take, for example, the synthetic hormone vasopressin, which is used for many indications, such as increasing blood pressure when a patient is in shock. Available as a generic product for years, vasopressin's price increased dramatically in 2014 after Par Pharmaceuticals conducted efficacy studies on a reformulated version and obtained approval for this version from the FDA.
To reduce waste, vasopressin is being removed from hospital emergency "crash carts," where it would remain unrefrigerated and need to be discarded sooner. In addition, pharmacists now administer the drug in much smaller IV doses. This requires that nurses change IV bags more frequently and that they understand revised dosage concentrations (a patient safety risk), says Lee. "Because vasopressin was so inexpensive before the price increase, it wasn't even on our radar to assess how much we might be wasting," she adds. Other major medical centers have taken similar measures with the drug, according to Bloomberg News.
Managing demand was used as a tactic for intravenous acetaminophen, which has become more popular of late as part of a nationwide push to de-emphasize opioids in pain management.
After the price of IV acetaminophen tripled in 2014, Emory's hospitals established a patient scoring system, coupled to electronic ordering. Only patients who met certain criteria, such as obstructive sleep apnea or contraindications for non-steroid anti-inflammatory drugs, would be approved. This helped put a ceiling on rising costs.
To nudge doctors and other providers toward fiscally conservative choices, managers have also experimented with subtle hints, like dollar signs ($$$) next to expensive antibiotics in the electronic ordering system. In addition, Emory critical care specialists established temporary financial incentives for teams to limit the use of expensive supplies such as fluids containing albumin.
Lee and her team have been resourceful in dealing with other types of medications as well. There are 11 different types of antivirals for hepatitis C, says Lee, each customized to individual patient needs and viral genotypes. And they're available in bottles of 30 tablets that cost as much as a new car. That's why it's cost-effective for Emory to send a courier to a patient's home to pick up their own such medications. "I can't have all 11 sitting on my shelf at $30,000 per bottle," Lee says.
The economic forces that drive increasing costs, such as FDA re-approvals of old generic drugs and mergers that reduce competition, will likely continue to perpetuate the need for similar management efforts, but Lee and her team are ready. "I could come up with 50 more examples," she says.—Quinn Eastman
Calming stress in the call center
One patient calls the Emory Clinic to request an appointment for a routine colonoscopy. Another contacts Winship to find a doctor after receiving a cancer diagnosis. Yet another rings a primary care office in North Georgia because they are not feeling well.
Those patients may not realize that their calls—and those for all Emory Healthcare outpatient services—are actually routed to the Emory Healthcare Call Center. More than 220 employees field some 15,000 calls a day, most of them from an expansive space on the fifth floor in Decatur Plaza.
|Alan Kramer, Pollie Thomas
The team members who answer these phones are often a patient's first contact with Emory. "They are our voice," says Alan Kramer, director of patient access at Emory. "They are representing our institution, our brand, and our doctors."
As such, call center employees are expected to deliver compassionate and professional care. "They have to hear us smiling through the phone," says Pollie Lateece Thomas, a patient access specialist.
That's not always easy. Thomas and her colleagues each handle 80 to 100 calls a day—auto-delivered nine seconds after the previous call ends—from 8 am to 5 pm, with two 15-minute breaks and a short lunch. They talk to patients and loved ones who are often sick, frightened, or angry. "I think it's one of the most stressful jobs at Emory Healthcare," says Kramer.
Since taking over call center operations 2-1/2 years ago, Kramer has made several changes to reduce that stress. This includes a facelift for the main office in Decatur Plaza that did away with offices in favor of an open floor plan with lots of glass and bright colors. White noise machines help mitigate the din of hundreds of simultaneous conversations. And after a successful work-at-home pilot with 15 top performing team members, there are now more than 70 and soon to be 100 staff members working from home.
Kramer has instituted regular promotions and training focused on career development. Topics such as conflict resolution, public speaking, and presentation skills prepare employees for a career beyond the call center. "Each month we have four to five employees who get promoted into other roles at Emory," he says. "The majority of the nonclinical positions in the clinic are filled with former call center employees. It's a big motivator for the staff."
The call center is also the pilot site for a mindfulness study. The 60 who signed up were divided into two groups, one that uses an app called Headspace to guide them through a 10-minute mindfulness exercise and the other who just take a regular break for the same amount of time. Researchers are collecting saliva samples to measure biomarkers related to inflammation as well as asking participants a variety of questions about how they are feeling and functioning. If the app is able to help users reduce stress and restore focus, it may be rolled out to other Emory populations.
"We're serious about using the most effective means to reduce stress," says Kramer. Such efforts may not only help employees, but help them in turn calm the stress of their callers. —Martha McKenzie
New perspectives on Ebola and other viruses
In some respects, Anita McElroy is indebted to one of the viruses she has encountered. Several years ago, during a postdoctoral fellowship at a U.S. Army research facility in Maryland, she was accidentally exposed to hantavirus and was sent to the hospital for observation.
"Fortunately, I didn't get sick," says McElroy, a pediatric virologist. "But being in the hospital made me want to know more about the clinical aspects of the diseases I was studying so I could be a better scientist. So I went back to school and got an MD."
She studied medicine at George Washington University, where she made another discovery. She preferred working with pediatric patients.
"Parents want the best for their kids all the time," McElroy says. "When you tell them they need to do something for their child's health, they do it. So I fell in love with pediatrics. And that's what brought me to Emory."
It's been a good fit. McElroy is an attending physician in the infectious disease service at Children's at Scottish Rite. She spends most of her time in a lab at Emory and at the Viral Special Pathogens Branch at the CDC.
In 2014, when four patients were treated here for Ebola virus disease, McElroy was the only Emory clinician qualified to handle the patients' samples in the CDC's Biosafety Level 4 (BSL4) lab. Thus McElroy became the liaison between Emory University Hospital's Serious Communicable Diseases Unit and the CDC.
"This was a phenomenal opportunity for all of us because no one had collected serial samples from Ebola patients before," McElroy says. "That wasn't doable in West Africa, where they could take blood samples from patients only for diagnostic testing. There was no sampling over time to evaluate electrolytes and cell populations to help understand how to support patients clinically."
McElroy continues to collaborate on Ebola research involving the SCDU, the Emory Vaccine Center, the CDC, and other partners across the country and is the lead author on two published studies.
In the first study (published in 2015), the four Emory patients' immune systems showed strong signs of T and B cell activation, a finding that ran counter to previous assumptions and that provided new insight into vaccine design.
"We found that patients' immune systems were activated in response to Ebola," McElroy says. "Until then, everyone thought that Ebola shut down the immune system and that's why people got so sick."
Results from the second study (published in 2016) yielded clues as to how some people survive the disease. Using samples from the seven patients treated at Emory and University of Nebraska Medical Center, scientists tracked 54 immune system biomarkers to determine which ones correlated with less severe disease. The study was the first to use samples taken from patients during the course of their entire illness and into their recovery.
"The biomarker study showed higher levels of several proteins in patients who had moderate disease," says McElroy. "We were able to say, 'Look, this response is much better in these patients. This might be an area we can target for future studies.' "
McElroy will soon complete a study on a patient treated for Lassa fever at EUH last year and is partnering on studies of Zika virus. In an earlier study, she explored why children and adults have different immune responses to Ebola virus. Working in the BSL4 lab at the CDC, she examined blood serum samples (45 children and 50 adults) collected by the agency during the 2000–2001 outbreak in Uganda. The children's samples had higher levels of RANTES, a protein that stimulates T cell responses.
"In the Uganda and West Africa outbreaks, school-age children (ages 5 to 14) did best in terms of survival," McElroy says. "This phenomenon is not unique to Ebola. We've seen it with TB and other diseases. The kids in Uganda who did well had higher levels of RANTES, which we didn't see in the adult patients. That led us to hypothesize that those kids did well because they had better T cell responses to the virus. What we need now are better animal models to tease out the role of these different biomarkers."—Pam Auchmutey
Turning to students for health app needs
|MPH student Kyndall White helped develop an app to study transmission of Buruli ulcers.
At the Rollins School of Public Health, a student-run organization is out in front in the emerging field of mHealth, which uses mobile phones and tablets to support public health education and interventions. Through the Rollins mHealth Collaboration (RmC), mHealth-savvy students are teaching other students how to build and use a wide variety of applications, how to connect to a local SMS gateway provider, and how to devise a user interface. The sessions, which meet every other week for two hours, end with hands-on practice.
A key facet of the mHealth collaboration—and the reason it was dubbed "collaboration" instead of "club"—is that its members consult professionally with professors, alumni, and organizations. This means students get to practice and perfect the highly marketable skills they have gained in RmC and researchers get help with projects that require mobile technologies.
Oswaldo Henriquez, a physician at Grady Hospital, found RmC when he Googled mHealth, looking for a mobile app to help low-resource cancer patients access the care they need. RmC students are creating a text message system that Henriquez will be able to use to remind patients of the various appointments they have. Patients will have to respond to each reminder with a "yes" or "no," which Henriquez hopes will reduce the number of no-shows. It also means he will be able to stay in touch with his patients, even if they move without telling his office.
"A lot of our patients at Grady are marginalized, and it's easy for them to miss appointments and fall off our radar," says Henriquez. "They may show up again months later and the cancer has progressed. This message system will help keep them in the system so they get the care they need."
Lance Waller turned to RmC for help in preparing a grant application to study the transmission of Buruli ulcers in West Africa. The ulcer is a rare skin and soft tissue infection that tends to strike in poor rural communities. If untreated, it can leave victims permanently disfigured and disabled.
Exactly how the ulcer-causing bacteria are transmitted remains a mystery. "You can have a village with very high prevalence right next to a village with no cases," says Waller, chair of biostatistics and bioinformatics in RSPH. "We wanted to find out how people interact with the water systems in their communities to try to discover the route of transmission."
So RmC students helped organize a scavenger hunt around campus. Volunteer students were randomly assigned as "infected" or "healthy." They were given a list of five buildings that they needed to visit—in no particular order and along no particular route—and an app called Map My Run to track their movements. Then they were sent on their way to wander the campus. One building—which appeared on all the infected students' lists and on none of the healthy students' lists—represented the infected water source.
The RmC team was then able to create a color-coded map (healthy runners in blue, infected in red) overlaying participants' routes and the buildings they visited. Even an untrained eye could discern easily that every infected student visited the same building.
"I wouldn't have been able to do this without their help," says Waller. "The students were able to pull multiple sources of information—routes from the running app on the phone, an open source mapping system that had the streets and buildings on campus, and the designation of infected or healthy. When you combine those three bits of information that previously had nothing to do with each other, it tells a story."
Waller will use the results as proof of concept in his grant application and hopes to roll out a similar approach in field studies in Ghana or Benin.
James Michiel, a senior mHealth analyst at the Center for Global Safe Water, Sanitation, and Hygiene, uses RmC students on several projects and finds their input invaluable. "It's almost like having an mHealth innovation lab right here at Rollins," says Michiel. Read more. —Martha McKenzie