Montefiore Medical Center Maximizes Savings and Drives Efficient Medication Use with Analytics

Key takeaways:

• In searching for ways to reduce expenses while improving patient outcomes, Montefiore Medical Center Hospitals turned to PINC AI™ Service Line Analytics-Pharmacy (SLA-Pharmacy) to enhance their formulary management initiative.
• Combining purchasing, utilization and quality data, this technology helps give health systems a holistic view of medication usage in clinical practice and, as a result, helps organizations better understand where a drug is most beneficial.
• By changing practices related to medication utilization of one medication, Montefiore Medical Center Hospitals achieved annualized savings of over $300,000 with potential to expand to $1 million.

As prices for both new and existing drugs continue to climb in today’s inflationary environment, managing costs has become a top concern for healthcare leaders. With this in mind, Montefiore Health System, comprised of 10 hospitals and more than 200 outpatient ambulatory care sites in the Bronx, NY, began a thorough evaluation of its pharmacy operations, looking for ways to improve utilization and optimize payment.

With the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care. “Now more than ever, payment is tied to performance where excellent care leads to better reimbursement and not so good care offers less than optimal reimbursement,” said Dr. Mark Sinnett, Director of Clinical and Educational Pharmacy Services at Montefiore Medical Center. “There’s growing pressure to reduce costs overall and I believe we can achieve it by providing accurate evidence-based care,” said Sinnett.

Consequently, Montefiore created a systematic plan for continuous improvement in pharmaceutical cost containment. The plan calls for leveraging data to better understand drug spending and utilization trends, and then setting goals and outcome measures to track success. “Most of us now have access to large data sets, but the key is to harness that data to interpret how it affects patient outcomes,” said Sinnett. “So, we need to establish data analytics capabilities in our departments. It's crucial to teach people how to analyze that data and apply it to performance improvement science and outcomes research.”

The Formulary Decision Process

The pharmacy and therapeutics (P&T) committee at Montefiore serves as the focal point for cost management initiatives. The P&T committee makes evidence-based decisions that support the goal of providing high-quality care while reducing risks and costs to both the health system and the patient. “Now I like to say in every P&T committee meeting we are not necessarily interested in the unit costs of the drug, but rather the outcome that it provides,” said Sinnett.

The P&T committee is in charge of creating, managing and administering the formulary. A formulary is a continually updated list of medications that serve to ensure that drugs are rigorously evaluated for efficacy, safety and value. Montefiore approaches formulary management by establishing a standardized system formulary throughout their care facilities. By driving out variation in the manner of prescribing and administering drugs, healthcare organizations can get a handle on pharmacy costs while promoting high-quality patient care.

In order to figure out which drugs belong on the formulary and deliver the best value, Montefiore turned to PINC AI™ Service Line Analytics-Pharmacy (SLA-Pharmacy). PINC AI™ SLA-Pharmacy combines purchasing, utilization and quality data to analyze drug usage and outcomes. This technology played a hand when Montefiore was reevaluating its use of the drug intravenous (IV) acetaminophen.

Montefiore discovered that IV acetaminophen is significantly more expensive than its oral equivalent. “There has never been strong evidence to support improved outcomes over the oral equivalent. So, with that in mind, looking at the amount of money that we spent on acetaminophen every year, we decided to look into its use and reappraise its value using a rigorous data-driven process,” said Dr. Pavel Goriacko, Clinical Pharmacy Manager at Montefiore Medical Center.

Streamlining Cost Management with Technology

Using the PINC AI™ SLA-Pharmacy platform, Montefiore was able to extract the amount of money they would spend per month or per year on this medication across their entire health system. “At one point we were spending over $140,000 per month on the use of this single IV acetaminophen drug,” said Goriacko. “As a result, we took a deeper dive into specific use trends and noticed that it’s primarily utilized in general surgery, orthopedics and bariatrics. This insight was really important because we were able to speak with the responsible provider groups and understand how the use was primarily driven by protocols to reduce patient exposure to opioids. This provided us with sufficient background to begin a focused systematic review of literature on the role of IV acetaminophen in opioid-sparing protocols.”

Montefiore now had to define whether using IV acetaminophen actually improved outcomes compared to its oral equivalent. According to Goriacko, the health system implemented the process of reappraisal using three important components:

1. Systematically Review the Latest Evidence. “First, we performed a systematic review of the latest evidence focused specifically on the use cases reflected in our institution.”
2. Invite Stakeholder Input. “We invited the Vice Chair of Anesthesia to present evidence to the P&T committee that can justify the continued use of this agent. In conversations about low value use of therapeutics, it’s important to give stakeholders the opportunity to meet the burden of proof required to continue utilizing the drug.”
3. Conduct Risk/Benefit Assessment. “To ensure that decision makers have a holistic view of the evidence, we trialed what we called a “devil's advocate” approach, suggested by our chief medical officer. When a presenter makes a case in favor of adding a specific drug to the formulary, we identify a subject matter expert to present a structured argument against the request. This ensures a balanced presentation of risks and benefits needed for effective decision making.”

Evidence-Based Decision Making

Following the reappraisal process, the P&T committee found insufficient evidence of value to keep IV acetaminophen on the formulary for adult patients and, as a result, removed it. Montefiore then used the PINC AI™ SLA-Pharmacy platform to conduct a follow up to assess the impact of removing IV acetaminophen.

“This formulary change happened only at the Montefiore Medical Center hospitals, which is just one part of the larger Montefiore Health System. So, when we're comparing the utilization of IV acetaminophen at Montefiore Medical Center versus the rest of the health system, a very clear picture emerges,” said Goriacko. “When surgical cases resumed after the COVID-19 surge in early 2020, the use of IV acetaminophen quickly reached pre-pandemic levels at most Health System hospitals, yet Montefiore Medical Center continued to see decreases in inappropriate utilization. This resulted in a net savings of over $300,000 per year at the Medical Center.”

Montefiore Medical Center is where most of the high-risk bariatric and orthopedic surgeries take place. The pharmacy team was heavily involved in building opiate reduction protocols and were successfully able to incorporate oral acetaminophen formulations into those protocols and they significantly reduced their patients’ exposure to morphine equivalents of opioids. “As a result, this type of process ended up saving us over $300,000 per year and helped redirect our efforts into much more effective multimodal perioperative opioid reduction strategies. If we can successfully expand this process to other institutions within our health system, it can result in savings of up to $1,000,000 per year” said Goriacko. In the year following the implementation of this process, the Montefiore Joint Replacement Center has received its 2nd consecutive Joint Commission Certification for Advanced Total Hip and Knee Replacement – the only instruction in both the Bronx and Westchester to receive this national certification which demonstrates extraordinary commitment to patient safety and surgical excellence.

Moving from Cost to Value

Formulary decisions impact all aspects of care delivery. With the right tools, procedures and people, the process of identifying, prioritizing and implementing these changes can be refined. “There are important lessons learned here and the first one is that it's really important to routinize this type of reevaluation of formulary decisions and value. This shouldn't be a process that's reactive. It shouldn't happen only when the evidence of a problem is already so obvious,” said Goriacko. “We should routinely look at those lists of highest impact therapeutics and kick in this performance improvement process as early as possible. This way, if we implement this rigorous systemic process, we can avoid a lot of unnecessary costs due to low value use of medications.”

It’s vital for healthcare organizations to use the right data analytic tools and clinical resource databases to make informed care decisions. Using the PINC AI™ SLA-Pharmacy platform helped Montefiore in its determination of drugs’ appropriate use and its making of evidence-based care decisions that Montefiore believes best serve patients.

“Data analytic tools can be really effective to starting the right conversations and taking the right actions to reduce the low value use of medications. This is how we can find a common language between clinical departments, pharmacists, administrators and analysts, and it's really important to involve all of these stakeholders when it comes to these conversations with evidence and data being the central tenet that unites us all,” said Goriacko. “No longer are we talking about the cost of medications. Instead, we're talking about the value of medications, and it’s much easier to agree on a course of action when we shift that kind of discussion from cost to value.”

These are challenging times for healthcare organizations. It’s not wise to continue to use outdated cost-containment techniques. Healthcare organizations can reduce costs and enhance patient care by fusing pharmacy expertise with the right strategy and technology.

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