My partner at work was complaining about the bill his spouse got from going to the Emergency Department a month ago. We have a great health insurance plan, as long as you don't use it. Which is weird considering that we are "Ambulance Drivers" (EMT's and Paramedics) and are the extension of the ED.
The fact that his spouse went to the ED bothered him ("I could have treated her for free, it was just a twisted ankle!" - EMS is like that, if you're not dying wait till I get home and take care of it is the attitude.). The multi-bill format bothered him, but one charge really ticked him off, "Tylenol, 325 mg, x1 ---$45".
Later that shift we ended up in the ED she had gone to, and he asked the Charge Nurse about that charge.
Ok, that should be a good teaser, more after the squiggle.
The Charge Nurse had no answer but directed my partner over to the "Pyxis" machine and the Pharmacy gal who was restocking it.
We did not get specific answers, but what we saw and what we were told, make some of the higher cost understandable.
Here is what we found out.
First most ED's use the Pyxis MedStation System (TM, C, PDQ) for dispensing of drugs. This is a super-duper vending machine. The one at this ED had a fingerprint scanner, PIN code, and badge requirement to dispense drugs. Which makes it very expensive.
How it works is the Doctor/PA/NP tells the RN or LPN to give X drug and amount. The RN/LPN goes to the machine, taps their badge, places a finger on the scanner, then types in their PIN. The machine then asks what drug/amount is wanted. The RN types in the name of the drug and picks the amount, hits enter and one drawer pops open, the drawer is full of smaller compartments and the one with the drug requested opens up. In that second drawer is the requested drugs in single dose packing (in most cases, some times not.)
The Nurse counts how many are in the second drawer and enters that number, pulls out the amount needed, counts the remaining, then enters that number in, then closes the drawer.
When the machine notes it is getting low on supplies it tell the hospital pharmacy what is needed and they send a person up to restock it.
For the really strong drugs, a second Nurse has to also log in and validate the counts. Some drugs LPN's can't give so an RN has to do it just to make things more confusing.
So why the higher cost?
First off the Pyxis is not cheep. That cost is going to be passed on.
Next, the individual packaging is more expensive than a single bottle full. (why don't they use a bottle? accountability to make sure not too much was given, prevent cross contamination of dirty fingers pawing through pills over and over, and shear meanness making Nurses have to struggle with the super sealed pill wrapper.) That means the cost is going to be higher anyways.
And there is the need for Nurses to get the medication instead of a CNA, ED Tech, or housekeeper. Nurses cost more per hour than the others, if you have to staff for Nurses to be going to the Pyxis twice for each patient, and it takes just 3 min per visit, and they run 4 patients an hour, you "lose" 24 min an hour to getting meds, which means they can't take on a fifth patient.
There is the cost of stocking the machine, instead of putting things on a shelf (easy) it has to be put in to each drawer one at a time. (The Pharmacy gal said she can open up to five sub-drawers of the non-narcotics at a time but it still takes time and you have to rotate the stock) That cost is added in.
Then there are the internal audits that happen every week to a month to validate that drugs were actually being used by comparing the use log with the patients charts. Another cost.
Ok, that is a lot of extra steps, but is it really $45 per pill?
Not likely. Oh, i'm sure we are looking in the $3 to $6 range when I do my combat math on it. I think the rest is anticipation of insurance companies "negotiating" a lower price...maybe down to $3 a pill?, or/and the people who don't have insurance or don't have good insurance who don't pay the bill.
I saw that when I worked in the lab at a hospital and the charge per test was much higher just to cover the no-pay and the difference between what Medicaid paid and what it cost.
I am convinced that getting your Tylenol from the ED is the most expensive way to get it.