A retrospective analysis of inpatient utilization of paliperidone palmitate and readmission rates

BACKGROUND

Only 1% of the US population is affected by schizophrenia, or an estimated 2.4 million people, but the National Institute of Mental Health estimates the yearly economic burden to be nearly $20 billion in direct and more than $50 billion in indirect costs.¹ Data from the 2008 Healthcare Cost and Utilization Project show that patients admitted for schizophrenia have the second-longest average length of stay (11.1 days), highest average total cost per stay ($7,500), and highest aggregate cost of hospitalization ($2.7 billion) compared with other mental health and substance abuse disorders.²

It is reported that 20–60% of patients with schizophrenia are nonadherent with their prescribed treatment regimen of antipsychotics.¹ The chronic and relapsing nature of the illness leads to the use of more healthcare resources than other psychiatric disorders. It is estimated that relapse rates for patients with schizophrenia could possibly be halved if adherence rates were increased, as relapse is one of the most costly aspects of schizophrenia. The vast majority of clinically stable individuals with recent-onset schizophrenia will experience an exacerbation or relapse after the discontinuation of antipsychotic medications, even after more than a year of maintenance therapy.³

Reimbursement rates for inpatient psychiatric stays are unpredictable and readmission for schizophrenia [diagnosis related group (DRG) psychosis] is a growing concern for hospital systems as they may not be reimbursed for readmissions for the same DRG within 30 days of a previous discharge.⁴ Antipsychotic regimens that promote adherence could therefore lead to cost savings, depending on the acquisition cost of these regimens. Long-acting injectable antipsychotics (LAIs) have previously been shown to improve adherence and decrease hospitalizations.1⁵ They provide consistent drug levels that are sustained over weeks, and missed injections are immediately known, permitting the opportunity for intervention.⁵

Costs and reimbursement rates for LAIs such as paliperidone palmitate can vary dramatically between inpatient and outpatient entities. Given variable reimbursement rates for inpatient psychiatric care and high cost of paliperidone palmitate, the drug cost could be justified if patients who received the LAI demonstrated a subsequent reduction in readmission, especially within 30 days. Paliperidone palmitate received FDA approval in July 2009 for maintenance treatment of schizophrenia,⁶ and by January 2010, Alegent Creighton Health facilities were utilizing it for inpatients. Given the high cost of this non-formulary medication, pharmacy administration was interested in the therapeutic utility of this treatment.

METHODS

This is a not-for-profit community hospital with 29 adult behavioral inpatient beds. In 2012 and 2013 we averaged 225 admissions per month or 2,700 admissions per year for all DRGs. The payer types for these patients for fiscal year 2013 included Medicare 27%, Medicaid 35%, Managed Care 15%, Commercial 1% and Self-pay 22%.

Using the electronic medical record, patients were identified who received at least one injection of paliperidone palmitate within the Alegent Creighton Health system from January 2010 to April 2012 during their inpatient stay. Any initiation of paliperidone palmitate and any maintenance doses administered during the inpatient stay were included. Data were retrospectively collected to determine indication, dose, administration date, concurrent psychotropic medications, previously failed antipsychotics, length of stay (LOS), and time to next admission at any Alegent Creighton facility. Time to readmission was examined at 30, 60, and 90 days. Finance reports determined hospital cost and reimbursement for each inpatient stay and pharmacy cost of each paliperidone palmitate injection.

For the comparison group, we extracted LOS data and readmission rates at 30, 60, and 90 days for all patients who met the DRG criteria for psychosis on admission during the defined study period (roughly 500 patients met such criteria). The report was generated at Alegent Creighton Health using data from Crimson (The Advisory Board Company^®).⁷

RESULTS

A total of 32 patients were identified that received an inpatient injection of paliperidone palmitate during the time period examined (Table 1). The majority (72%) were taking at least one other psychotropic medication in addition to paliperidone palmitate. The most common concurrent psychotropic medications were other atypical antipsychotics, benzodiazepines, valproic acid, and lithium. Time to readmission data are presented in Table 2. There were no statistically significant differences in time to readmission between the paliperidone palmitate group and the control group.

Table 1: Patient demographics (N=32)

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Table 2: Admission data

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The Alegent Creighton Health facilities experienced a net loss of roughly $5,610 per stay for the paliperidone palmitate patients studied. This figure represents an average of the net revenue/loss for patients included in the paliperidone palmitate group. Net revenue/loss for each individual patient was determined by subtracting the total hospital cost for the visit from the reimbursement received for that visit. There were three patient visits included in these figures for which we received $0 reimbursement. The maximum gain was $7,400 and maximum loss was $61,500. Paliperidone palmitate constituted, on average, 16% of the total hospital cost per stay, with a minimum of 4% and maximum of 50% (Table 2). This figure represents an average only for patients included in this study. It was determined for each individual patient by totaling the drug cost for all paliperidone palmitate doses received during the visit and dividing it by the total hospital cost for that visit.

DISCUSSION

Inpatient administration of paliperidone palmitate did not seem to reduce readmission at 30 or 90 days but may have contributed to a slight decrease in readmission at 60 days at Alegent Creighton Health facilities. Paliperidone palmitate accounts for a notable portion of hospital cost for those patients who receive it while inpatient. Without seeing a decrease in readmission rates, the hospital is unlikely to recoup the high cost of this injection. A major factor is the reimbursement structure developed by the Centers for Medicare & Medicaid Services (CMS) for LAIs. Inpatient visits are reimbursed by DRG with all services, supplies, and medications provided during that admission included. LAIs are not reimbursed separately in the inpatient setting. Specialty psychiatric hospitals may be able to bill for LAIs separately but we are not such a facility. Private insurance companies reimburse hospitals based on individually arranged contracts between the facility and the payer. In the outpatient setting, LAIs are reimbursed a specific dollar amount per mg as well as a flat rate administration fee. For 2011, paliperidone palmitate was reimbursed $6.50/mg with a $23 administration fee in the outpatient setting.⁸ Despite cost and reimbursement challenges, it may not always be appropriate to delay administration of LAIs for patients who are suspected of being nonadherent with follow up after discharge. It should also be mentioned that the manufacturer of paliperidone palmitate does have a replacement program through 2014 for initiation injections administered to inpatients, which could help offset hospital pharmacy cost.⁹

We acknowledge certain limitations in this study. Previously tried antipsychotics data relied solely upon dictated history and physicals available in the electronic health record and, therefore, any errors or missing data in the history and physical were carried through in this study. As with all patient reported medication histories, especially amongst this population, some ambiguity may exist among the medication history data. Some readmissions may have been due to the patients seeking refuge from adverse social situations and not due to any effect of paliperidone palmitate, exacerbations of psychosis, or an episode of schizophrenia. Readmission data were not available for institutions outside Alegent Creighton Health. However, the Alegent Creighton Health system is by far the largest provider of institutionalized psychiatric services for our metro and surrounding areas. The acquisition cost of paliperidone palmitate decreased from January 2010 to April 2012. The hospital cost of paliperidone palmitate as of April 2012 was used for all calculations in this study. Therefore, percentage of total drug cost represented in this study may be underestimated. Another potential limitation of this study includes the ultimate disposition plan for each patient. These data were not collected on the initial review. In general, patients discharged from this facility remain primarily within the metropolitan area. These patients are discharged to a variety of places including alcohol and/or substance rehabilitation facilities, assisted living facilities, group homes, nursing homes, homeless shelters and home.

The package labeling for paliperidone palmitate states that maintenance injections may be given within seven days of their “due” date. Ten of the 13 patients who received a maintenance injection had received it within seven days prior to discharge. Theoretically, these 10 patients could have received their maintenance injection after they were discharged from the facility, as an outpatient, where reimbursement rates for the injection are more favorable.

This study alerted pharmacy administrators to potentially injudicious and costly use of paliperidone palmitate on an inpatient basis at Alegent Creighton Health facilities. Prescribers should cautiously consider indication, cost, and potential effect on readmission rates of inpatient versus outpatient administration of paliperidone palmitate. Careful thought of the timing of administration in regard to planned discharge should be considered and maintenance doses delayed for outpatient therapy if possible and clinically appropriate.