Dollars & Death

Everyone knows you pay a steep price for death. At least figuratively. For all of us, on some level, the idea of dying comes at great cost. Life is our known everything and in losing it we lose our value. But death has a literal cost, too, one I am coming to know increasingly as a physician in a smaller-but-growing hospice on a budget. I'm seeing the discrepant cost between pharmacies of basic medications and it is surprising.

I've got some recent examples of medication costs between three pharmacies - of note, I'm not here to name names or blame anyone; I just think the discrepancies are fascinating and problematic. Morphine 100 mg/5 ml, 30 milliliters, varies between $12 and $35 dollars; Ativan 1 milligram, 40 pills, costs between $3 and $35; Keppra 500 milligrams, 30 pills, costs $30 with one pharmacy and $115 with another; Levaquin 750 milligrams daily, 14 days, costs $41.20 at one pharmacy and $750 dollars for 10 days at another. But to cap the discrepant costs off, let's look at a 5-pack of 25, 50, and 75 microgram Fentanyl patches. Our first pharmacy states the 25 microgram patches cost $117, the 50 microgram patches cost $205, and the 75 microgram patches cost $306; the second pharmacy says the 25 microgram patches cost $11, the 50 microgram patches cost $25, and the 75 microgram patches cost $25; the third pharmacy says the 25 microgram patches cost $25, the 50 microgram patches cost $50, and the 75 microgram patches cost $75.

And for higher level care, it gets trickier. A comparison between two pharmacies is befuddling. At the first pharmacy, for a Dilaudid, Fentanyl, or Morphine drip (continuous infusion for pain or sedation), you have to pay a $132.50 pump charge; a $37.50 cassette fee per cassette of medication; $10.50 for a 6-set of 45 inch extension tubing; and $19.50 for 2 subcutaneous infusion sets. These costs are not including the medication, which for 100 milliliters (1 cassette) of Dilaudid 10 mg/ml costs $357.58 and for 2 mg/ml costs $242.50; for Fentanyl 50 mcg/ml, 100 milliliters costs $187.50, and for Morphine 10 mg/ml, 100 milliliters costs $164. This is in comparison to another pharmacy where you're charged $8.50/day for the pump, anywhere for $150-$200 for the cassette and medication, and $50 for the tubing.

With all of this in mind, that the cost from pharmacy to pharmacy for one basic medication can range from a twofold to a-greater-than-tenfold markup, consider also that hospice is reimbursed by Medicare (our main insurance payer) with set per diems for the level of care, which is generally routine home care (RHC) at approximately $154/day for the patient. This per diem payment to hospice serves to cover all costs of care, including medications related to the terminal diagnosis and for palliation. So, when everything is factored in, a widely variable medication cost, variable patient acuity not always captured by the level of care, and basic operational cost, you can imagine that the hospice margins can be tight. It is up to each hospice to carve out its own ethical niche of profitability in order to pay for aspects of care with more variability.

I've written this piece to say that there should be more standardization between pharmacies and PBMs and pharmaceutical companies for affordable medication pricing. I don't think that health care can be free entirely - it always comes at some cost - but I don't think that excessive pricing is good, especially at the end of life. Patients really do have different needs, and to make someone's final passage into the afterlife go smoothly and peacefully, diligent and careful management needs to be done. Medications are a large part of keeping patients comfortable and when one basic hospice medication can run the gamut from affordable to exorbitant, when one medication can negate the ability to pay for much else, it begs the question why? Truly, we get one shot at the end to medicate well; it isn't then that we should be limited.

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