The cost of providing general inpatient care can be steep for hospices. Expenses run the gamut from staff wages and salaries to medications, as well as costs related to establishing and maintaining a physical facility. Medication management is a vital piece of both the clinical and financial puzzle when it comes to general inpatient care. 

Hospice providers have increasingly sought avenues to reduce medication costs amid financial and operational pressures from COVID-19 and changing payment models in a highly competitive market.

Managing medication and deprescribing are critical pieces of a hospice’s ability to financially sustain and support this type of care, according to Christine Simmers, PharmD, vice president of clinical logistics and resource utilization for Seasons Hospice & Palliative Care.

“Medication management is extremely important,” Simmers told Hospice News. “In the general inpatient care setting, we are often treating patients with uncontrolled symptoms, so it is important to identify any underlying reasons for a change in symptom exacerbation, what medications the patient has tried previously and is currently taking, and which medications are available at the inpatient center. This information helps the physician individualize each patient’s medications. Deprescribing is also an important aspect of medication management, which decreases costs and often improves a patient’s quality of life.”

Seasons merged with post-acute company AccentCare late last year. AccentCare is a portfolio company of the private equity firm Advent International. The combined organizations employ an automated dispensing system (or an ADS) to help control medication costs, according to Simmers. The systems are designed to reduce medication waste when a patient does not use the full amount, which is a challenge for many types of pain management medications that come in liquid form. Simmers reported that stocking cost-effective, unit-dose medications can be a more efficient process for the organizations.

One of the four core levels of hospice care, patients receive general inpatient care when their symptoms become too severe or complex to be managed in the home. General inpatient services represented roughly 1.2% of hospice care days in 2018, according to the National Hospice & Palliative Care Organization.

A number of hospice providers have opened new general inpatient centers this year. VITAS Healthcare, a subsidiary of Chemed Corp. (NYSE: CHEM), recently opened an inpatient unit in Florida, the company’s fourth so far in 2021. Ohio’s Hospice of Miami County expanded into the Florida market as well with a new facility set to open in August.

Seasons/AccentCare recently broke ground on an inpatient facility in Phoenix aimed at making serious illness and end-of-life care more accessible to patients and families in that region.

Medication costs are a growing concern at the inpatient level of hospice care in particular, according to Deanna Douglass, senior vice president of business development for the pharmacy benefit manager Enclara Pharmacia. Medication costs for hospice inpatients are typically much higher than in other settings, with providers often using more infusion-based medications that have higher costs of administration, preparation, dispensing and monitoring, along with sterility and stability, stated Douglass.

“Concerns around medications in hospice are that they tend to be changed frequently, and they have labor and dispensing costs associated with any supply worth of medication,” said Douglass. “In the inpatient setting, you may be dispensing a 15-day supply of medication that will only be used for the next 24 or 48 hours and then be changed to something else. There’s also a lot of change that can be created depending on the model for dispensing. That inpatient unit can create a lot of waste of medication.”

The single biggest opportunity to reduce costs is deprescribing the number of medications, according to Douglass. Deprescribing can simplify the medication regimen and bring down associated costs of managing multiple medications for patients needing pain and symptom management at the end of life. Getting a handle on medication management at the inpatient level also presents an opportunity for hospice to better comply and reduce the risk of diversion of medication, according to Douglass.

Tracking data trends around medication management and deprescribing can be instrumental for hospices to get a grip on inpatient costs, according to Seasons, who told Hospice News that partnering with a PBM could be helpful in navigating costs and regulatory paths.

“Being able to trend experiences across our inpatient centers is instrumental. Having systems and protocols is also helpful,” said Simmers. “General inpatient care stays are almost always measured in hours or days at most, because [the U.S. Centers for Medicare & Medicaid Services (CMS)] expects a discharge to a lower level of care as soon as symptoms are back under control. When you add in other levels of care such as respite, which have lower reimbursement, it’s important to have that proactive plan in place.”