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What Do You Need to Know About State Opt-out Provisions, Access and Costs?

mortar 321795 1920A January 2017 article in the New York Times suggests concerns for pharmacists in the hospice care sector concerned with “aid in dying” impacts on practice and care

Last month, the New York Times ran an article, “Physician Aid in Dying Gains Acceptance in the U.S.” It outlines the current “Aid in Dying” debate among hospice and palliative care physicians and providers. Questions raised through this debate create ethical, legal, and professional issues for pharmacists and pharmaceutical companies.

The goal here is not to discuss the moral or ethical dilemmas each of us necessarily considers deeply and personally. For those who would like to do so, a 2011 article in “American Journal of Health System Pharmacy” may prove useful. Also, “Aid-In-Dying Practice in the United States Legal and Ethical Perspectives for Pharmacy,” was published in Research in Social and Administration Pharmacy (Summer 2016). The JAMA Journal from January 2016 focused on diverse issues clinicians face in death, dying, and end of life.

Additionally, clinicians may also wish to refer to position statements on the issues issued by American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA).

Here, we’ll focus on implications of mainstream coverage in the January 2017 New York Times article. Specifically, this piece will address two issues with relevance to pharmaceuticals: state opt-out provisions, access and costs.

Issue 1: State Opt-Out Provisions
The New York Times article states that in the U.S. states that have opt out provisions for hospice physicians: “State opt-out provisions allow any individual or institution to decline to provide prescriptions.” It follows logically that pharmaceutical industry professionals would have a similar ability to decline to provide prescriptions.
Opt out provisions are determined at the state level. State laws impact pharmaceutical professionals, informing practices and procedures. State legislatures determine laws regarding professional pharmaceutical practice and govern access to particular types of medical procedures. Statutes differ from state to state, and may or may not resemble industry policy. We have a responsibility to remain current in our area of expertise.

Issue 2: Access and Costs
The article also delineates cost and access concerns of patients who would choose to end their pain and suffering by ending their lives. Less than one percent of hospice and palliative care patients in the four U.S. states with “Aid in Dying” provisions ever choose to exercise those rights. Those few hospice patients require access to a pharmacist willing to fill their prescriptions. Then, cost becomes a factor.

The New York Times notes the increase in cost for barbiturates from a couple of hundred dollars in years past, to $3-4,000 after insurance. The article reveals that Valeant Pharmaceuticals acquired Seconal, a commonly prescribed barbiturate, in advance of California’s 2015 legislation. Then, the company deliberately “spiked the price.”

Apart from ethics concerns, we are left with more questions than answers.
• Should pharmaceutical companies inflate costs for formerly affordable prescription drugs?
• How should price be determined?
• What mark-up can consumers realistically expect to pay for a prescription?

These types of questions have both broad and situational implications within pharmaceutical professions. We might also ask if intended usage of the drug should determine market price, or if substitutions are appropriate in terminal cases.

Without doubt, informed hospice pharmacists remain critical to pain and symptom management teams for those with serious illness or at end of life.


Drew Mihalyo is founder and president of Delta Care Rx.

About Delta Care Rx:
Delta Care Rx – http://www.deltacarerx.com/ – transforms and improves the hospice pharmacy industry through business transparency, innovation, extreme customer service, and the maintenance of vital community-pharmacy relationships. As a pharmacist owned, privately held provider, Delta Care Rx sets the industry benchmark for pharmacy benefit management, on-demand pharmacist services, and hospice tailored electronic prescribing.

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