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    When Price Dictates Treatment

    When drug prices spike, health-care providers are forced to make tough choices.

    Recent data suggest that hospitals—a setting where patients and physicians are usually shielded from the effects of drug cost increases—are seeing the effects of massive price hikes in vital drugs.

    In a research letter in published on the New England Journal of Medicine’s website, three staff members at the Cleveland Clinic, including one pharmacist, detailed the plight of hospitals facing large price hikes on nitroprusside and isoproterenol.

    Umesh Khot, MD, Vice Chairmen of Cardiovascular Medicine at Cleveland Clinic and lead author of the letter, told Drug Topics that he and his colleagues knew about the high price increases, but weren’t sure what the results of their research would be. He said that nitroprusside and isoproterenol grabbed their attention because of the “greater than typical” price increases, noting that they were having an impact on pharmacy planning and budgets. He wanted to see if the data actually showed any noticeable effects, and found what he called a “significant impact.”

    Related article: Why Specialty Drug Prices Will Continue to Soar

    According to the authors, the price of nitroprusside has increased drastically from $27.46 per 50 mg in 2012 to $880.88 in 2015 and the price of isoproterenol has increased from $26.20 per milligram to $1,790.11 in 2015. As they note, those prices are the wholesale acquisition cost and thus may not represent the actual cost to the hospital or patient.

    The authors looked at 47 hospitals in the Vizient database and found that usage of nitroprusside and isoproterenol had decreased. They compared the two drugs with two cardiovascular drugs with relatively stable prices during the same time period, nitroglycerin and dobutamine. The number of patients receiving nitroprusside decreased by 53% during the testing period, while the number of patients receiving nitroglycerine increased by 118%. The number of patients receiving isoproterenol use decreased by 35%, while the number of patients receiving dobutamine increased by 7%.

    “Clearly,” the letter concludes, “physicians have decreased their rate of prescribing the drugs even though in the hospital setting both they and patients are typically insulated from the cost increases.”

    Khot said that these data discredit the claim that rising costs do not impact utilization. He said that he has heard from other hospitals of the need to substitute the drugs. “From an operational standpoint,” he said, “these situations force pharmacists and physicians to come together to figure out the best way to deliver these drugs to patients, find other options, and find inefficient uses of the drug.”

    He added that, because this is “an increasingly common scenario, hospital pharmacists should use this as an opportunity to collaborate with their physician group,” saying that the “best thing is open conversation between all parties.” He said that these conversations need to be about how to solve this problem and how to balance patients’ problems with cost problems.

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