As rising costs and falling reimbursements cause many physicians to move out of the business of giving specialty-drug infusions, hospitals are taking over the task.
When St. Jude Children's Research Hospital in Memphis, Tenn., made the decision to open an outpatient specialty-drug infusion center, it did so for a number of practical and financial reasons. Underlying them all, according to Steve Pate, DPh, manager of outpatient pharmaceutical services, was a desire to improve patient care.
"We feel no one can take as good care of our patients as we can because we see them for all of their healthcare needs," Pate said.
Changes in where and by whom the drugs are delivered as well as how they're paid for were also factors in the decision made by St. Jude and other hospitals that have opened infusion centers.
Having prescribing physicians and pharmacists under the same roof or at least in the same hospital system can lead to better communication, which is key when patients are given specialty drugs. "The more they can interact, the better patient care, the better decisions pharmacists and physicians make, and the fewer opportunities for errors," says Teri Guidi, president and CEO of Oncology Management Consulting Group in Pipersville, Pa.
Rising costs and falling reimbursements are causing many physicians to move out of the specialty-drug infusion business and ask hospitals to take on the job. "It is becoming more of a burden for [physicians] to manage that process, and many want to get out of it altogether," Pate said.
Guidi agrees. "Physicians are more and more turning to hospitals and asking them, 'What can we do together so that you can take this on?'"
To avoid unexpected increases in patient volume, it's important for hospital pharmacists to keep in touch with physicians who might drop their infusion service, says Fred Pane, RPh, senior director of pharmacy affairs at Premier Inc., an alliance of hospitals and health systems.
He cites an example from when he was pharmacy director of an outpatient infusion center. A physician group stopped infusing specialty drugs in their offices, and without notifying anyone, began sending patients to the hospital's infusion center.
"There were changes in reimbursement, and the next thing we know we have patients showing up at our infusion center. They did not use the hospital scheduling process and no one knew they were showing up," says Pane. "It was not good from a patient-satisfaction perspective."
Understand your payer mix
"Before I would set up anything, I would find out how I get reimbursed for these products," Pane says. "If you don't find out what you get paid, you could get buried."
Managing specialty-drug reimbursement is difficult. Specialty drugs can be covered under either a medical or an outpatient drug benefit, depending on the site of service. With so many different drug regimens and a wide range of reimbursement systems and providers, pharmacy staffs need to include individuals trained to negotiate the reimbursement maze.
Many payers require patient data and outcomes information related to specialty drugs, making it even more important to have staff prepared to track the data.
St. Jude Children's Research Hospital has three pharmacy reimbursement technicians on staff, which Pate says is helpful in managing specialty-drug reimbursement. When the outpatient specialty infusion center opens, it will have a fourth technician dedicated to specialty-drug reimbursements. "You additionally need to have the expertise to manage the reimbursement or you are going to be spending large sums of money on drugs that you are not going to be paid for," Pate said. "Reimbursement is one of the biggest issues that we will have to tackle."
Further complicating the equation are "brown-bag" policies requiring the medication to be shipped to the patient, who then must bring it to the infusion site for administration. Many hospitals are instituting "no-brown-bag" policies to eliminate the risk of administering a drug that has not been stored properly or that has had its integrity compromised. St. Jude is developing such a policy.
The downside of anti-brown-bag policies is that access to some drugs can be limited. Pane explains that in New York, Medicaid has a mandatory brown-bag policy for some specialty anemia drugs requiring that the drugs be dispensed only at retail pharmacies. "If the hospital dispenses it in an outpatient setting, they won't get paid," he says.
Targeting certain drugs and requiring them to be administered only at contracted infusion centers compromises the continuum of patient care. "When we introduce another provider into the continuum of care, it makes it difficult to manage the overall picture," Pate said.
Pate has battled with manufacturers on several occasions. In one case, a manufacturer refused to ship a drug to a patient's home because the patient couldn't afford the $5 co-pay. "We want to be able to provide all the drugs our patients need - oral, IV, or specialty," Pate said. "The specialty market is making that harder and harder to manage."