05/01/11

Long-term care facilities are under significant pressure to control phar­macy costs and with good reason. They are the second highest costs for fa­cilities, behind only wages.

The LTC-pharmacy consulting firm I am part of, Senior PharmaStrategies, es­timates that drug-price inflation will be 4%-9% over the coming year. But don’t expect reimbursement to match that rise. 

Many facilities already have begun to work with their pharmacy providers to develop “in-house formularies” to damp­en the upward spiral of drug costs for Medicare Part A and managed care resi­dents. These formularies for the most part attempt to replace brand-name products with therapeutically equivalent generic drugs. Medicare Part D plans are also trying to reduce coverage of brand­ed products while expanding coverage of generic equivalents.

There is reason for optimism in this scenario, as an impressive number of branded drug products have expiring patents and should see generic equiva­lents become available over the next year. 

Here are the brand-name drug prod­ucts, their generic equivalents, and when their patents expire:

• Xalatan (latanoprost) 3/22/11
• Tricor (fenofibrate) 3/28/11
• Concerta (methylphenidate) 5/1/11
• Femara (letrozole) 6/3/11
• Nasacort AQ (triamcinolone ace­tonide) 6/15/11
• Levaquin (levofloxacin) 6/20/11
• Uroxatral (alfuzosin HCl) 7/18/11
• Zyprexa (olanzapine) 10/23/11
• Zyprexa Zydis (olanzapine) 10/23/11
• Zyprexa Vial (olanzapine) 10/23/11
• Combivir (lamivudine-zidovudine) 11/15/11
• Lipitor (atorvastatin calcium) 11/30/11
• Lexapro (escitalopram oxalate) 3/14/12
• Boniva (ibandronate sodium) 3/17/12

Encouraging? Yes, but maybe not as an answer to the squeeze on budgets this year. Remember that, typically, there is a small drop in the price of a product the first 6 months of generic availability, when usually only one generic manufacturer has been granted a Food and Drug Ad­ministration license to produce the drug. After that, more manufacturers will join in and drive down the cost significantly.

Pharmacy Tip

Recently, I was discussing the impor­tance of vitamin B₁₂ with Chris Patter­son, MD, CMD, of Spartanburg, S.C. He enlightened me as to how he keeps costs under control for this product. He also stressed that residents who fall, show ear­ly signs of depression or memory loss, or who have been on proton-pump in­hibitors and H2 antagonists for a long time might need this supplement. He said that B₁₂ levels should be drawn and evaluated for many residents. 

But B₁₂ therapy through cyanocobal­amin injections can be wasteful. That’s because state regulations typically re­quire that a cyanocobalamin multidose vial be discarded 28 days after its first puncture. In most cases, a resident gets one injection before the vial – costing at least $9 – is discarded, thus wasting 90% of the available medication. 

Some facilities have switched to one-dose, 1-cc ampoules. However, the usual cost for each ampoule is only slightly less than that of the multidose vial. 

Dr. Patterson instead finds a way to use the oral form of B₁₂ as much as pos­sible. He has looked closely at B₁₂ blood levels in his facility’s residents and found that those testing over 500 pg/mL can be switched from injections to an oral dosage form, as long as their B₁₂ levels are monitored for 3-6 months. If B₁₂ remains in the therapeutic range, above 500 pg/mL, then Dr. Pat­terson continues the oral form. If blood B₁₂ drops, the resident can return to the injections.

Dr. Patterson has helped my consulting firm develop a detailed dosing algorithm for effective and effi­cient B₁₂ therapy. If you would like a copy of the algorithm, e-mail me at fred.wendt@sps4ltc.com.

Mr. Wendt is vice president of pharmacy services and clinical operations for Fundamental Clinical and Operational Services/Senior PharmaStrategies, which is the parent company of more than 100 skilled nursing facilities in 10 states.