Pharmacy leaders build a better model for infusion services

Strategy benefits patients, finances

Aligning Infusion Services and Pharmacist Leaders

By Gina Shaw

Aligning 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, 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

‘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

9 Key Data Points for Assessing Infusion-Services Readiness

1. Locations and geographic footprint 2. Scope and offerings 3. Payor contracts, incentives, restrictions and partnerships 4. Cost of goods and special drug pricing 5. Ownership and governance structure 6. Regulatory details, including licensing, credentialing and accreditation 7. Program interdependence—for example, as with oncology infusion and other clinic services 8. Efficiencies and best practices 9. Challenges and opportunities for improvement

Source: Mitra Gavgani, PharmD.

4 Principles of an Effective Integrated Infusion Strategy

1. Identify accountable leaders and champions for infusion services, empower them and engage them in planning for the future. 2. Identify barriers to successful delivery of infusion services, and ensure they are addressed by health-system leaders. 3. Proactively manage access to limited distribution drugs and payor contracts. 4. Establish shared goals and objectives to drive collaborations and reward teamwork.

Source: Mitra Gavgani, PharmD.

provider is our mid-level nurse practitioner [NP], who works with a collaborating physician, and we are able to bill that care under place of service category 11. By doing that, we are accepting lower rates, but it allows us to hold on to our patients,” Dr. Palamara said.

The new approach was launched initially with a group of about a dozen patients who were receiving an infused rheumatologic agent. “We told them that, based on the payor’s requirements, they could either choose to receive the infusion in their home or they could stay with us but that the services would look just a little different,” Dr. Palamara said. “They have to do an initial provider note and visit before each infusion with the NP, whom they already know, but other than that, things would pretty much be the same. “For the most part, they wanted to stay with us. We had one patient who is a nurse, who told us that she didn’t want the drug in her home, that she felt much safer receiving it in the hospital,” she continued. “Another patient said that they want to keep their chronic illness in the hospital, to get their treatments here and then forget about it, and not to ‘invite’ the disease into their home by getting treated there.” In some cases, Dr. Palamara acknowledged, this arrangement produces a financial outcome that’s upside-down for the hospital. “We may not even make back the cost of the drug in some cases,” she said. “Why are we fighting for these patients even at a financial loss? It boils down to quality and safety. We want to take care of our patients, and we feel it will produce a better outcome. It also can have a downstream revenue impact. If you come to us for infusion, you might also get unrelated lab work done at our lab or do radiology scans with us. If you go where your payor sends you, then you may also go out for those things. We continue to compare payment rates and see if it always makes sense to keep the patient with us. So far, the continuum of care always wins.”

A Bolus of New Infusion Patients

The new setup also has yielded an additional bonus: allowing Holy Name to take on new infusion patients whose physicians are not on staff at the hospital. Located just four miles from the major medical centers of New York City, Holy Name has many patients who live near the hospital but travel to the city to see world-renowned specialists. “Those patients would love to come to our hospital just for their infusion, but you have to be on our medical staff to write orders,” Dr. Palamara said. “Now that we have the new office practice, our nurse practitioner can collaborate with the outside treating physician and assume their care for the infusion side of things.”

In a larger health system, a strategic, standardized approach to optimizing infusion site of care can maximize quality of care for patients while improving opportunities to capture revenue, said Mitra Gavgani, PharmD, the vice president of pharmacy services for Johns Hopkins Home and Community-Based Services, in a separate session at the conference. “Hospitals and health systems have been providing infusion therapy successfully for a long time, but with new therapies coming to market, innovative care models are needed,” she noted, such as those involving the provision of care at home, and models that allow for infusing the latest gene therapies.

Doing the Site-of-Service Dance

Site-of-care (SOC) optimization is another hot provider trend that stakeholders need to understand. “This is becoming a national strategy on the part of payors,” Dr. Gavgani said. “We are seeing a growing desire for harmonization, alignment, integration and standardization. As payors are pushing care to freestanding ambulatory centers and home infusion, and also imposing more requirements for medical necessity to justify hospital-based infusion, infusion services in a health system really require a systemic approach.”

Dr. Gavgani recommended that health systems begin by assessing their current position based on infusion services-related data (box). “If you’re a health system with multiple hospitals, or a small system with reliance on local providers to support the flow of your infusions, due to the nature of the reimbursement model you will find that not all of your data is in one place,” he said. Obtaining these data “is not a small task, so give yourself plenty of time to gather and to analyze, translate and make sense of it before it is broadly shared or decisions are made.”

A Two-Year Optimization Process

As an example, when Johns Hopkins began its two-year process to optimize infusion site of care across its health system, 19 sites were involved, including hospital-based, physician officebased, nurse-managed ambulatory infusion suites, and ambulatory surgery centers. “Not all are owned by the same entity within the health system, and not all follow the same model of care,” Dr. Gavgani said. “We knew the issue was bigger than any one group in the organization could handle.”

After first identifying a large group of more than 100 stakeholders from all of the infusion centers—including CEOs of the entities, finance leaders, infusion nursing and pharmacy leaders, and patient and family advisors—who could pinpoint their biggest concerns about central management of infusion site of care, a smaller infusion therapy oversight committee was named from that larger group. Appointed by the health system’s executive leaders, the members’ role was to drive the effort toward integration.

“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,” Dr. Gavgani said. “Once the patient was in their seat, everything went smoothly, but the step of getting to the right site and navigating financial clearance was the biggest problem. There was a team at each infusion center dedicated to taking care of the patient’s needs, but what if they got a denial of coverage?”

Johns Hopkins established an infusion coordinating center staffed by nurses and financial coordinators, counselors and schedulers, whose job it is to help clinicians navigate prior authorization and utilization management. The process is still ongoing, she noted. “We were working on this effort prior to COVID-19, and implementation is still underway.”

Access a ‘Foremost Priority’

As important as those managed care issues are, it is the patient who should get the lion’s share of attention, Dr. Gavgani stressed. “Our commitment is that patient experience and access are our first and foremost priority, and we believe we can achieve that by centralizing operations and oversight, and making our infusion strategy part of our overall health-system strategy.”