Pharmacoeconomic considerations regarding hospice and palliative care according to pharmacists and hospice managers

Abstract

This study focused on pharmacoeconomic issues affecting pharmacists in residential hospices in Poland. We conducted a questionnaire survey among hospice pharmacists and their managers. The results revealed that the amount of money received from the National Health Fund is insufficient for drug purchasing and therefore hospices often raise additional funds from external sources. Because of the limited financing, pharmacists and hospice directors undertake various activities to reduce costs. Generic drug reimbursement, pharmacoeconomic analysis and participating in tenders to purchase drugs are the most common measures undertaken to decrease expenditure.

Introduction

Palliative care is the active, total care of patients whose disease is not responsive to curative treatment.¹ It aims to control pain and other symptoms, and to support patients and their families socially, psychologically and spiritually.² Since the emphasis is on palliative rather than curative care, a multidisciplinary and holistic approach is required to maintain or improve the patient's quality of life.³ Inpatient hospice and palliative care is a unique component of hospital pharmacy activity. End-of-life care, especially pain control using drugs, requires pharmaceutical services comparable to those provided in hospitals. The pharmacist employed in the hospital pharmacy is responsible for the safe, effective and optimal use of medicines.⁴ Pharmacoeconomics is an essential part of hospital drug policy and can benefit from pharmacist involvement.⁵ Palliative and hospice care generates costs which depend on patient diagnosis, disease status, and the age of the patient as well as the offered packages of services.⁶

In Poland, most hospices have a contract with the National Health Fund (in Polish Narodowy Fundusz Zdrowia, NFZ) which finances them. Annual NFZ expenditure on hospice and palliative care in 2012 was about 74 million Euros, or 1.93 Euro per capita for reimbursed services.⁷ Moreover, charity organisations, foundations, churches, other institutions and private donors support hospices.

The aim of this study was to determine the opinions of pharmacists and hospice directors concerning pharmacoeconomic issues affecting hospice and palliative care.

Methods

This survey is a part of a nationwide study on the role of the pharmacist in hospice and palliative care which was conducted in all residential hospices (n=93) in Poland. The section of the study presented here concerns the pharmacoeconomic activities of staff in the residential hospices. Pharmacists and hospice directors were requested to complete an anonymous questionnaire and answer multiple choice questions on the following topics: pharmacist activities leading to a decrease in therapy costs (pharmacists and directors), funding sources for pharmaceutical services (directors) and financing of hospice drug procurement (directors).

Results

A total of 32 hospices took part in this survey (response rate 34%). We received 31 questionnaires filled in by hospice directors and 16 by pharmacists.

Regarding drug financing, none of the examined units received sufficient money from the NFZ to procure all essential drugs. At 10 hospices (32%), NFZ funding covered 75% of the cost of drug purchasing, and 50% at 9 palliative care units (29%). Four examined hospices did not benefit from the NFZ at all. On the other hand, 10 hospices received 25% of their funds for drug purchasing from grants and donations, 3 received 50% and 3 received 75%. Three hospices only received funds from non-NFZ sources of drug financing. Most of the surveyed pharmacists were able to reduce the costs of pharmacotherapy by purchasing generic instead of brand name drugs. Table 1 lists actions pharmacist take to cut costs as described by pharmacists and directors of hospices, which cooperated with a pharmacist (19 out of 31 settings). Fourteen (45%) directors reported that hospices carried out pharmacoeconomic analysis in order to decrease the cost of therapy, with 11 out of 31 units participating in tenders to purchase drugs and medicinal products. Eight units did not undertake such activities.

Table 1.

Pharmacists’ actions to decrease the costs of therapy

Pharmacists may decrease the costs of the therapy by:	According to pharmacists (n=16)		According to hospice directors (n=19)
	n	%	n	%
Negotiating drug prices	10	63	7	37
Searching for and purchasing generic drugs	12	75	11	58
Applying to pharmaceutical companies or suppliers for drug donations	5	31	5	26
Finding sponsors/grants outside the pharmaceutical market	1	6	2	11
Negotiating with a pharmaceutical representative	5	31	2	11
The pharmacist is not involved in decreasing the costs of therapy	1	6	2	11

Most of the hospice directors (n=26, 84%) believed that pharmaceutical services should be solely financed by the NFZ. None of them would like to finance the employment of the pharmacist from hospice resources.

Discussion

Money for medicines has always been an important part of hospice budgets. The high costs of modern palliative care are usually due to the use of expensive drugs and medicinal products recommended in formularies and other guidelines,^{8 9} for example, low molecular weight heparins, newer intravenous antibiotics, special drug formulations such as transdermal therapeutic systems containing opioids, slow release tablets, and expensive advanced wound management dressings.

The study presents pharmacists’ and hospice managers’ perspectives on pharmacoeconomic issues in hospice and palliative care settings. Pharmacists employed in hospice pharmacies and procuring drugs for inpatients, have an impact on the cost of therapy. Most of the surveyed pharmacists and hospice directors claimed that purchasing generic drugs can decrease the total costs of therapy. Moreover, there is an observed tendency to encourage cost-efficient generics prescribing since these drugs are much cheaper than the original products and have very similar pharmacokinetic properties and almost equal efficacy.¹⁰ Also, pharmacists may negotiate prices with drug suppliers or pharmaceutical companies, and so reduce costs. This activity is probably more common in larger units which buy a lot of drugs. According to several managers, pharmacoeconomic analysis and tendering for the purchase of drugs and medicinal products also helped to decrease drug costs.

For most hospices, the money received from the NFZ covers between 50% and 75% of all drug purchases and so the hospices must find additional funds to ensure access to all essential medicines. Only five pharmacists sought to reduce costs by applying to pharmaceutical companies for donations, while one attempted to find sponsors outside the pharmaceutical market. However, the managers had different views. According to them, the hospices, as formal institutions, were active in applying for donations and sponsorships since 19 of 31 were supported by additional grants. It is interesting that three hospices benefited only from this type of financing.

Finally, directors believe that the hospice pharmacist should be paid from the same funding sources as other palliative care staff. Financing the pharmacist's services from the NFZ may promote development of these services in residential hospices.

Conclusions

The financing of hospice and palliative care in Poland is unsatisfactory so hospice staff seek to reduce costs. Pharmacists may limit expenses by exploring the pharmaceutical market for low-cost drugs, while hospice managers may appeal for charitable funds and donations.

The present study shows that both directors and pharmacists are aware that pharmacists can help to decrease therapy costs in residential hospices.