2017 marks the sixth year of medication shortages as well as unprecedented drug price increases in the United States. The result is the exploding need to plan for medication availability for emergency patients by both EMS leaders and hospitals.

There’s still no explanation for the shortages, which encompass everything from medications to intravenous fluids. The list of intravenous fluids that are not available now exceeds the list of emergency medications that are not available.

There are ongoing price increases that far exceed rates of general inflation and health care inflation. Some medications have now become prohibitively expensive. This is a major challenge to the budgets of EMS leaders. 

Epinephrine and Naloxone

The two medications with lifesaving utilization in emergency care that have gotten the most headlines are epinephrine and naloxone. Each of these medications have been produced in forms that are now designed for use by almost all levels of first responders, and the lay public.

Both have been marketed to the public and packaged in kits that are designed to be consumer-friendly, but extraordinarily expensive. Naloxone is also now marketed heavily to law enforcement personnel.

The prices of most of the medications and fluids needed by EMS providers have risen dramatically. This now requires the leaders of EMS organizations to plan for the expense of the medication, in addition to the availability.

Most agencies are developing processes for active inventory management so that they’re as efficient as possible in the use of emergency medications. Some agencies are now also responsible for the coordination of naloxone purchases for the law enforcement agencies they work with.

The unprecedented increase in opioid overdoses has resulted in major increases in the supply of naloxone for public safety responders, while at the same time unit prices for that medication have skyrocketed.

Developing an Accounting System for Drug Availability and Price

The current strategies for managing drug shortages have been outlined previously.1 The budget for medications is now requiring timely management. Until there’s some indication that both supplies and prices have stabilized, it will be a “best practice” to develop an accounting system for both the availability and prices of medications and fluid supplies used in emergency care.

The list of medications used in EMS care have been relatively stable over the past 10 years. A list of the medications used across those years, the comparative purchase prices, and the times when the medications are not available, would be the elements of the accounting database.

Before you destroy all of your old invoices, record the acquisition prices for medicines and supplies. Advisory notes on when orders could not be fulfilled due to supplier shortage should also be documented.

Also note when the type of medication purchased had to change because of shortages. The price accounting, multiplied by the number of units utilized, can provide an estimate of the annual drug cost.

Some drugs are not utilized by their expiration date and, subsequently, must be wasted. This is another element that is useful to document, as it allows you to  to identify medicines that need to be rotated more rapidly, or exchanged (in a method that satisfies regulatory requirements).

The financial impact and the escalation in total costs will be useful for budget planning, accountability to the funding agencies for EMS and for any reporting to the community that is necessary.

What Are Representative Price Increases?

Lee County EMS in Fort Myers, Fla., has been tracking medication prices increases to prepare annual budgets. The EMS Division of Lee County’s Department of Public Safety responds to 83,000 EMS calls per year, with a workforce of 320 members, including EMTs and paramedics.

For years, the agency has used an innovative regional acquisition process for medications and some other disposables and equipment used in providing their emergency medical services. That purchasing entity includes the county’s hospitals and public health providers.

This purchasing process results in much better acquisition prices for medications, and serves as a model for other EMS agencies looking to improve their purchasing effectiveness. Even with this purchasing power, the prices of medications have been rising rapidly.

The agency compared the prices of 41 medications purchased in 2015 to those purchased in 2016. This list includes all medications used in their EMS medical protocols, which mirror the drugs used by most EMS agencies in the country. For comparison purposes, the medications had to be in the same form and content between the two years.

The 41 medications on the list had a pricing total of $483.71 for 2015. The pricing for 2016 was $622.49. That reflects a one-year increase of 29%.

On the list of 41 medications, 35 had a price increase, which ranged from 419% to 2%.

There were six medications that had price decreases, which ranged from 2% to 31% lower than the previous year. These medications all happened to be those which have relatively little use under the EMS protocols.

Representative Price Increases Include

  • Epinephrine 1:1000, increased in price 419%. The epinephrine infusion kit increased in price by 405%, and the multi-dose vial increased by 93%.
  • Calcium Chloride 1gm vial, increase of 99%
  • Nitroglycerine infusion kit increased 68%
  • Ringer’s Lactate solution, increase of 42%
  • Magnesium Sulfate single dose vial, increase of 30%
  • A 1 milligram single dose of glucagon increased by only 4%, to a unit cost of $185.21

What Should EMS Leaders Plan For?

It’s unlikely that the shortage will resolve itself in the next three years. That timeline should prepare all EMS leaders to adjust their budgets, improve medication inventory management systems, expand training, update medical protocols and cooperatively develop innovative electronic solutions to assure that emergency patient care is not compromised.

As the health care industry, the health insurance payors, and the state and federal governments wrestle with drug costs, it will be necessary for EMS and emergency leaders to report on the financial and operational challenges.

Best practices will need to be shared regarding the efficient use, storage and planning for medication use, with greater flexibility, accountability and regulatory compliance. Budgets for medications clearly need to be increased.

Emergency leaders may also be concerned that other supplies and equipment used in the field may look at the pricing strategies of the United States drug manufacturers, and decide that similar approaches may benefit their bottom lines.

Reference:

Augustine J. “Severe Saline Shortage. Managing another emergency medication challenge.” JEMS. 2014;39(6):20-21.