Drug Spend Trend Management Tools. Michael R McDaniel, R.Ph., MBA, FASHP Director of Pharmacy Services Huntsville Hospital Huntsville, Alabama

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1 Drug Spend Trend Management Tools Michael R McDaniel, R.Ph., MBA, FASHP Director of Pharmacy Services Huntsville Hospital Huntsville, Alabama

2 Huntsville Hospital 881 Beds 575 ADC 21% Critical care beds 154 pharmacy fte s 5.8 FTE s Employee Pharmacy 8 FTE s residency program Hospital pharmacy

3 Objectives Look at the money side of a pharmacy department Understand how the pharmacy can appear to facility senior leadership Examine some tools and tactics to analyze various spend trends within a pharmacy department How to put the information together to tell an effective story

4 Where Does the Money Go? Pharmacy Expenses 11% 19% Payroll Drugs Other 70%

5 % of Total How Does Pharmacy Compare? Total Pharmacy Expense as a % of Hospital Total Expense 12% 10% 8% 7.3% 8.0% 8.2% 8.2% 8.1% 8.7% 9.2% 9.4% 10.0% 6% 4% 2% 0% Fiscal Year This trend was predicted over 15 years ago Still, it would seem disconcerting to your average CFO Can you explain YOUR pharmacy spend trend

6 % of Total Payroll Impact Pharmacy Salary Expense as a % of Total Hospital Salary Expense 5.0% 4.5% 4.0% 3.9% 4.1% 4.2% 4.5% 3.5% 3.0% 3.2% 2.8% 3.1% 3.2% 3.2% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Fiscal Year Remember the years of routine mid-year pharmacist salary adjustments This is a trend senior leadership really looks at askance

7 Staffing Trends We ve been successful using our ROI data to grow the pharmacy department through the years.

8 Per FTE Per Adjusted Discharge Workload Trends Pharmacy Workload Trends 120, ,000 80,000 60,000 40,000 20, FY 07 FY 08 FY 09 FY 10 FY 11 - Annualized Fiscal Year - WLU's / FTE WLU's / Adjusted Discharge Our workload units (WLU) reports have corroborated the need for the additional staff and tracked the corresponding increase in work performed by the additional resources.

9 Drug Spend Trend But. This trend prompted some questions? Where did the ROI go!

10 So the CFO Wonders Pharmacy consumes a greater % of our spend each year We ve added a LOT of FTE s And yes, work for those FTE s to do But why does my drug spend trend appear to be skyrocketing Where is the ROI

11 Formulary Management We run a therapeutic interchange based formulary Almost every multi-drug family has a designated workhorse agent We have many, many workhorse drugs Broad powers to interchange w/o calling physicians Broad powers to change from IV to PO for many agents Broad powers to modify doses based on renal function Our pharmacy is very clinically focused

12 Total Hospital Drug Spend Net Drug Spend $45,000,000 $40,000,000 $35,000,000 $30,000,000 $25,000,000 $20,000,000 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Annualized This story we already knew We are spending more and more money on drugs Why

13 Cost per Discharge Hospital Drug Spend per Adjusted Discharge Drug Expense per Statistic $550 $500 $450 $400 $350 $300 $250 $200 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Annualized Period Calc'd Cost per Adj Disch Volume does make it look a little better But not as much as we would like it to look given our investments in pharmacy staffing

14 Ratio % Tracking a Major Change Drug Spend Trends 80% 70% 60% 50% 40% 30% 20% 10% 0% 73.2% 26.8% 71.1% 70.5% 28.9% 29.5% 65.6% 34.4% 59.7% 40.3% 53.5% 53.7% 46.5% 46.3% FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Annualized Period % Inpatient Spend % OP Spend Now we might be on to something Our formerly stable spending on the outpatient side had started to accelerate, greatly What impact is this having

15 Cost per Discharge Cost per OP Visit IP vs OP Spend Trend Drug Expense per Statistic $600 $140 $550 $120 $500 $100 $450 $400 $350 $80 $60 $300 $40 $250 $20 $200 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Annualized Period Calc'd Inpatient Cost Calc'd Outpatient Cost $- We split our drug spend trend analysis into OP and IP cohorts Now we see an another unexpected development Significant growth in the cost per outpatient

16 Cost per Episode Inside of the Outpatient Spend Trend Analysis of Outpatient Spend $80 $70 $60 $50 $40 $30 $20 $10 $- FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Annualized Period High OP Use Drugs All Other Drugs Our high cost high volume outpatient drugs are growing significantly But all other drugs are growing in utilization as well

17 Volume Analysis Our inpatient volumes, like many, have gone down compared to past years Our outpatient volumes, whether via the ED, or other outpatient environs, have grown very significantly

18 IVIG Spend Avg Monthly Patients The IVIG Story IVIG Trends $7,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000, $ Calendar Year 0 Annual IVIG Spend Avg Patients / Month Real growth industry for HH 90+% of our IVIG utilization is on outpatients Fortunately we have a positive revenue flow from this increase

19 Calendar Quarter The IVIG Story IVIG Expense - % of Total Drug Expense 25% 20% 15% 10% 5% 0% Q Q Q Q Q Q Q Q Q Q Q Q Q Q % of Total Its become a very significant portion of my total drug spend

20 Drug Expense Trends Shift from the inpatient side to the outpatient side Growth of a few high cost OP drugs IVIG Infliximab Lexiscan Consider the average inpatient, in house for 4.7 days at a total drug expense of $511 = $4.53 per hour Consider the average outpatient, in house for about 3 hours at a total drug expense of $115 = $38 per hour Outpatients add up! Fortunately, in general, we ve seen a healthy increase in net income as a result of this outpatient drug utilization

21 Drug Spend Trend Component FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Annualized Net Delta Inpatient Discharges 39,631 40,839 42,929 45,671 44,805 41,850 39, % Outpatient Episodes 112, , , , , , , % Adjusted Discharges 66,943 66,286 69,924 72,975 75,124 78,377 79, % OP/IP Ratio 74.0% 73.9% 74.6% 73.9% 75.2% 78.2% 79.2% High Cost OP Drug Adjustments $ 2,246,385 $ 2,962,636 $ 3,918,170 $ 5,151,244 $ 6,393,679 $ 8,539,958 $ 8,713, % Net Spend IP 20,476,946 22,410,044 22,256,688 21,407,418 21,005,361 21,649,459 20,155, % IP % of Total 73.2% 71.1% 70.5% 65.6% 59.7% 53.5% 53.1% Net Spend OP 7,484,475 9,087,229 9,333,830 11,225,153 14,197,040 18,797,726 17,781, % OP % of Total 26.8% 28.9% 29.5% 34.4% 40.3% 46.5% 46.9% Total Calculated Cost 27,961,421 31,497,273 31,590,518 32,632,571 35,202,401 40,447,185 37,937, % Calculated Cost per IP Discharge $ $ $ $ $ $ $ % Calculated Cost Per OP Episode $ $ $ $ $ $ $ % High Cost Drugs per OP Episode $ $ $ $ $ $ $ % All other OP Drug Cost per OP Episode $ $ $ $ $ $ $ % Calculated Cost per Adjusted Discharge $ $ $ $ $ $ $ % Our staffing is focused on the inpatient side 21% of our beds are critical care Compare FY to FY our drug expense per discharge has declined 7.2% On the other hand, our OP expense has soared 74%. There appears to be an opportunity for a greater role of pharmacy in our outpatient environments

22 Utilization Management Start with the therapeutic interchange based formulary (6,000 interchanges per month) Steering via protocol Impact of focused clinical resources Impact of multi-disciplinary activities Impact of inter-departmental cooperation

23 $ per Adjusted Discharge Focused Clinical Resources Cardiology Costs per Adjusted Discharge $70 $60 $50 $40 $30 $20 $10 $- $62 $54 $45 $44 $43 $41 $36 $39 $31 $ Fiscal Year HH has invested in 3 cardiology clinical specialists pharmacy fte s Over the years this group has significantly gained the confidence of our large cardiology practice and influenced improved drug selection and utilization

24 $ per Adjusted Discharge Multi-Disciplinary Involvement Antibiotic Cost per Adjusted Discharge Trends $90 $80 $70 $60 $50 $40 $30 $20 $10 $- $83.37 $84.38 $76.24 $77.84 $78.35 $69.79 $64.21 $59.95 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Fiscal Year Shows the continuing impact of our Antibiotic Streamlining initiative launched in 2005 Shows the immediate (and dramatic) impact of our Antimicrobial Management Team pilot launched this year

25 $ per Case Inter-Departmental Cooperation Thrombin Cost / Surgical Case $30 $25 $20 $19.80 $25.05 $25.43 $21.58 $15 $11.44 $13.53 $14.67 $10 $8.31 $7.20 $5 $ Fiscal Year Worked with the OR on vendor selection and vial size. Eliminated a LOT of waste 2011 shows the impact of beginning participation in 340B

26 Cost per Case Delta from Prior Year Interdepartmental Cooperation Anesthesia Gas Cost Trends $30 $25 $20 $15 $10 $5 $- $27.00 $26.49 $24.51 $25.72 $ % $19.68 $ % $ % $20.41 $ % 5.8% 8.1% 10% 2.7% -2.9% 0% -9.2% -9.1% -10% -15.0% -14.1% -20% Calendar Year Cost per Case Delta Working with Anesthesia to utilize more sevoflurane and less desflurane

27 Net Impact Over our four key initiatives Antibiotics - $1.45 million Cardiology agents - $2.7 million Thrombin - $700,000 Inhaled anesthetics - $350,000 Our net savings over baseline exceed $5 million for FY 2011

28 Cost Avoidance Active Initiatives Formulary Initiatives Formulary Initiative Trends $14,000,000 $12,000,000 $10,000,000 $8,000,000 $6,000,000 $4,000,000 $2,000, $ Fiscal Year - Annual Avoidance Active Initiatives All formulary activities are tracked Estimated or actual cost impact is charted As our opportunities have expanded over the years and our resources grew as needed, our capture rates increased Significant growth in effectiveness

29 Pharmacy ROI Apparent ROI on Expansion of Pharmacy Services Year Pharmacists Initiatives Salary Expense Savings ROI $ 1,274,000 $ 1,102,563 87% $ 1,731,600 $ 2,556, % $ 3,003,000 $ 5,223, % $ 3,978,000 $ 6,861, % $ 5,002,400 $ 8,022, % $ 5,002,400 $ 9,556, % $ 5,380,960 $ 11,117, % $ 5,380,960 $ 13,072, % Cumulative $ 30,753,320 $ 57,511, % Tracks over time the impact that adequate resources can have on drug expense management Always a part of our continuing story

30 In Summation Drug expense has risen year by year The primary driver of drug expense has proven to be significant growth of outpatient volumes Outpatient margins are good The impact on hospital margins has been very good We know what is going on We can document significant involvement in driving down unnecessary drug expense

31 Summary Tell your story Have your data ready Know what s going on in your facility Respond to issues positively Don t forget to look at the revenue side of things every now and then As we are doing Re-examine your deployment of resources What worked in the past may not be optimal for the present, or advisable in the future