The Cost of Unused Medications

High-Dollar Medications

Although the cost of a number of generic medications may be negligible, a number of medications continue to have a significant associated cost. Of the prescriptions returned, 170 cost > $100. Of these, 16 prescriptions cost > $500, and the total was > $13,000.

The U.S. Air Force had a high dollar program, in which patients were limited to a 30-day supply if the 30-day supply cost > $500 for treatment of a chronic condition. The staff burden and difficulty of maintaining such a program is unknown; however, the program is thought-provoking. Specifically, instead of dispensing 90-day supplies, the facility might consider limiting expensive prescriptions to ≤ 30 days for medications with additional refills if needed. Quantity limitations are already implemented for medications such as sildenafil, migraine medications, and opioids.

There is clearly a financial burden that needs to be addressed, and as this study evaluated the waste involved in patient returns, additional sources of waste were illuminated. Lean Six Sigma highlights several forms of waste: transportation, inventory, motion, waiting, overprocessing, overproduction, and defects/errors.^8,9 This study found that there were several forms of waste in the prescribing and dispensing processes. Specifically, the authors found inventory mismanagement, overprocessing (overprescribing), overproduction (dispensing more than prescribed), possible misuse of costly resources, and defects/errors.

Limitations

The results of this QI project were limited to unused medications that patients returned to the facility. Returning unused medications is neither requested nor mandatory. Therefore, it is estimated that the true amount of unused medications that could be returned for destruction is vastly greater than the brief collection obtained in this data set. Furthermore, this collection is only a snapshot at one military treatment facility. With multiple facilities within the DoD, the total amount and value of unused medications is likely to be immensely greater than the $63,000 collected in this study.

Additionally, the cost to discard hazardous waste medications was not quantified. Evans Army Community Hospital pays $1.95 per lb for disposal of hazardous waste medications (eg, fluticasone/salmeterol, albuterol, warfarin, insulins), but this financial burden was not addressed in this QI project.

Recommendations

There are a number of behaviors that could be addressed to reduce the waste observed in this study:

• Prescribers should reevaluate prescribing habits to assess whether they are overprescribing medications. They may consider asking the patient whether they plan to take the medication prior to writing the prescription. If the patient is not agreeable to the treatment plan, then the treatment plan may need to be reevaluated.
• Facilities may consider a policy that allows no more than a 30-day supply for new medication prescriptions. Patients should have a follow-up to determine whether the treatment is effective or whether there are AEs, and a new maintenance prescription may be written at that time.
• Pharmacies should ensure that pharmacists fill the quantity prescribed. Prescriptions that have overfills in quantities are considered misbranded.
• Pharmacies should enforce policies for returning to stock the prescriptions that were prepared but never dispensed to patients.
• For medications that are on back order or in short supply, prescribers should consider changing the quantity dispensed to a 30-day supply (or less as appropriate) with refills.
• Pharmacies should consider limiting quantities of high-dollar medications and adding refills for any additional therapy needed.
• Hospitals should evaluate patient use of emergency resources. Other local health treatment facilities outline clearly for patients what constitutes an emergency and what does not. A similar policy change should be considered at EACH.

Summary

Polypharmacy is an increasing problem in today’s medical field. Consequently, unwanted and unused medications accumulate in patients’ homes. In an attempt to keep patients and the environment safe, EACH takes back unused medications every day for destruction. During the collection period of patient returns from December 16, 2012, through April 5, 2013, > $63,000 of unused medications were returned for destruction, which did not include the cost of labor or additional supplies. These data illuminated possible prescribing and dispensing patterns contributing to this waste and inspired further exploration of additional sources of waste, such as overprocessing, overproduction, inventory mismanagement, misuse of resources, and defects/ errors. This study highlighted a number of strategies that, if implemented, may significantly reduce the deficit burden and reduce costs associated with polypharmacy.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.