Medication Shortages Imperil Hospice Access, Quality

Hospice providers and patients are having difficulty procuring medications due to nationwide drug shortages, threatening quality of care and patients’ access to hospice. These include essential drugs for pain and symptom management.

The scope of the shortages seems to be widening. Slightly more than 240 medications were in short supply at the close of Q1 2022, compared to 195 during the same period in 2016, according to data from the American Society of Health-System Pharmacists (ASHP). Injectable medications represented 66% of the new shortages identified thus far this year, the ASHP reported.

This scarcity complicates care delivery and could mean that some patients in need may not receive hospice, according to John Paglino, vice president of pharmacy services at VITAS Healthcare, subsidiary of Chemed Corp. (NYSE: CHEM).

“Medication shortages can serve as a barrier to transitioning to hospice,” Paglino told Hospice News in an email. “Shortages can also impede our ability to honor some patient and family wishes. Access to medication is always relevant for patients nearing the end of life, as it supports pain and symptom management.”

The shortages have existed for some time, including cardiac medications and intravenous (IV) artificial nutrition, hydration and opioids, such as morphine and fentanyl, among others.

Injectable medications are a particular concern because they have shorter shelf lives, making it harder for hospice to maintain sufficient back-up supplies.

These factors can make the always-difficult decision about end-of-life care even harder for patients and families.

Pain and symptom management is the highest priority for patients and families, according to a 2014 study. Patients may be more wary of entering hospice if they have greater access to those medications in another setting, according to Paglino.

Medication shortages can also impact patient satisfaction scores, according to Paglino. Oftentimes, using an alternative pain medication may not be “quite as effective” and can impact a patient’s quality of life, he indicated.

This in turn can adversely affect hospices’ performance on publicly reported quality measures, which are key considerations for referral partners and payers.

“Hospice providers face challenges that other providers do not,” said Paglino. “Hospice providers can be extremely vulnerable to disruption in access to medication and supplies and are not always the first to receive additional stock. In a hospice setting, we often require new medications extremely quickly — sometimes within hours — to best care for highly complex and acutely ill patients.”

Not only is the number of medications in short supply going up, the duration of shortages for specific medications is getting longer, according to a report by the U.S. Food & Drug Administration (FDA).

For some drugs, the shortages have lasted as long as eight years, the FDA indicated. The agency attributes this largely to logistical and regulatory challenges that slow the market’s recovery after a disruption.

The high demand and low supply is also driving up drug prices for providers, even as rising fuel and labor costs make shipping and delivery more expensive.

“Multiple manufacturers are competing solely on cost, so prices actually tend to trail inflation,” Marisa Todd, PharmD, clinical pharmacy lead at Enclara Pharmacia, told Hospice News. “Even when there are multiple manufacturers of a particular drug, they may all be relying on a handful of suppliers for key ingredients.”

Other factors contributing to the shortage include trends in the pharmaceutical industry itself.

The pharmaceutical space has become more complex and fragmented in the last two decades, in part due to more production overseas and increasingly using contracted drug manufacturers.

This has complicated the ability to both find new sources of active pharmaceutical ingredients in short supply, as well as obtain approvals from varying national regulatory bodies, reported the FDA.

Moreover, this scarcity is creating fierce competition among health care providers seeking to purchase medications for their patients, especially when it comes to generic drugs. These represent roughly 90% of the medications are in shortage, according to Todd.

Generic manufacturer consolidation and subsequent lack of redundancy among product options is the biggest driver of shortages in the hospice space, according to Joseph Solien, PharmD, vice president of clinical services for OnePoint Patient Care, which is the pharmacy brand of BrightSpring Health Services.

“Hospices may have had to temporarily order a more expensive competing product,” said Solien. “The best thing hospices can do to offset any drug cost increases is typically to focus on utilization, ideally in conjunction with a hospice clinical pharmacist.”

Staying afloat through these shortages will take a collaborative effort to manage costs between hospices and their pharmaceutical suppliers, according to Todd. She recommended that hospices work with a pharmacy benefits manager that can track utilization trends.

Pharmacists can also assist with the conversion to alternative medications and administration routes to maintain pain and symptom management, Todd added.

Medication shortages don’t appear to be abating any time soon, and the pandemic has only exacerbated the issue as demand for IV medications and others in the hospice space has climbed.

However, the strain of the pandemic has called attention to these problems, leading regulators and manufacturers to seek solutions.

“One positive outcome of the COVID-19 pandemic has been increased awareness of supply chain issues as well as concerted efforts on the part of the FDA, drugmakers and other key players to secure our drug supply. If that continues, we could see an improvement,” said Todd. “If people get complacent and we see more geopolitical instability, we might face greater risk. As hospice professionals, our role is to advocate for the former while preparing for the latter.”