26 Operations & Management
Pharmacy Practice News • January 2022
Practice Models
Strategy benefits patients, finances
Aligning Infusion Services and Pharmacist Leaders By Gina Shaw
A
ligning infusion care services under pharmacist leadership can be a win-win strategy for any health system, no matter how large or small, said experts at the 2021 ASHP Conference for Pharmacy Leaders, held virtually. Nancy Palamara, PharmD, the vice president of diagnostics and therapeutics at Holy Name Medical Center, in Teaneck, N.J., shared several strategies that health systems are using to succeed in this competitive market. Although placing infusion services under pharmacy leadership can be done at any health system, regardless of size, there may still be a lack of awareness that such a model can be implemented, at least based on an informal poll of session attendees. Dr. Palamara asked attendees who at their institution had operational oversight of the outpatient infusion center and all of its staff. The most common response was a nurse manager (35%), followed by a nonclinical manager (15%), pharmacist (4%) and physician (2%); 31% of respondents said oversight was handled by a mix of those
roles, while 13% did not know. “These survey results indicate that pharmacists are not very often the ones in charge of the infusion center,” Dr. Palamara said. “We need to make the case that pharmacy is well suited to manage infusion therapy departments or office-based outpatient infusion centers. Pharmacy must ensure that hospital leaders have a full understanding of infusion services, the outpatient infusion revenue cycle and the impact of clinical factors.” She cited her own institution’s experience as an example. “Our infusion services had long been integrated with the cancer center, and the cancer center director always oversaw the infusion space. Over 25 years, that director often reported to the chief nursing officer or the chief medical officer, depending on the individual’s background.” More recently, the institution’s leadership recognized that infusion therapy needed to be a department in its own right because about 25% of its services were unrelated to oncology, including neurology, immunology, rheumatology,
‘We heard loud and clear from our stakeholders that the biggest pain point within infusion was getting the patient to the right place and starting them on an infusion.’ —Mitra Gavgani, PharmD
and other infusion categories such as a dedicated migraine program. “We spend close to $65 million annually supporting outpatient infusion services,” Dr. Palamara said. “Because we are a community hospital and do not do heart transplants and other services that produce a high inpatient drug spend, our outpatient drugs—primarily infusion—now represent about 92% of our drug spend.” When the new department was created with Dr. Palamara as its director, it was the first time that Holy Name had a pharmacist in charge. “It’s so important that pharmacy oversees your infusion revenue cycle all the way back to prior authorization,” she said. “It’s a tough battle to go back if things have been messed up in prior authorization and try to get that reversed, so we fought to get into the drug denial space.”
Educating the Finance Folks Educating financial professionals about the clinical side of outpatient infusion proved very valuable, Dr. Palamara said. “For example, most of our drugs now use weight-based dosing, where your case volume does not directly equal your expense. For a CT of the neck without contrast, your technician time is approximately the same and your scanner time and expense is approximately the same. But that’s not the case with an infused drug. “I had one of our clinical pharmacy specialists put together a presentation to show our accountant with actual
patient cases. One month, we had four patients infused with trastuzumab, and all were over 100 kilos. The previous month, we only had two patients who were over 100 kilos,” Dr. Palamara said. “That produced a significant difference in expenses month over month, and they need to understand that. Having the manager overseeing the pharmacy revenue cycle be a pharmacist has proven to be huge benefit.” With many payors now steering patients to sites of care for which they pay less for the same service, hospitals need to develop new strategies to continue to provide infusion services for their own patients, Dr. Palamara said. Medicare’s most costly “place of service” code is 22, the designation for on-campus outpatient services at a hospital—and Holy Name, like some other small- to mid-sized hospitals, only has an onsite infusion center that bills under 22. “They’re billed less for category 11, office-based services, and 12, homebased services,” Dr. Palamara noted. “But we don’t want to lose our patients to some other office-based provider who doesn’t know them like we do. Some of the drugs that have been deemed ‘safe’ to administer in the home setting—well, if you’ve seen infusion reactions, you’d understand why we don’t want those people to be at home for those infusions. Even if they are rare, when a patient has one of those reactions, you want a robust infusion center with providers who can respond to an emergency situation.” In an effort to hold onto its infusion center patients, Holy Name developed a creative strategy. It established a new office practice, Excel Care infusion services, which rents space within Holy Name’s onsite infusion center. “The
