MPA | Pharmacy News

Site of Care Changes

Posted on January 27, 2017 in: Professional Practice

By Jamie Tharp, Pharm.D., pharmacy manager, University of Michigan HomeMed

 

Rising healthcare costs are triggering insurance companies to consider cost savings opportunities. One targeted area of cost containment is drug expenditures for high dollar specialty infusions. Analyses have shown infusion center therapy administration is 50 percent to 60 percent more costly than the home setting or doctor’s office, as they are able to bill for both drug costs and charge an additional facility administration fee. While many specialty infusion therapies are often safe to administer in low-acuity settings, these site of care changes will require thoughtful considerations to ensure safe and efficacious care of affected patients.

 

The payers that are currently implementing these changes are Aetna1, Blue Care Network,2,3 Priority Health4 and United Health Care5 with some payers initiating site of care changes as early as July 1, 2016. Therapies that are being targeted are most specialty infusions with an initial focus on IVIG and Remicade.®

 

Organizations responding to these site of care changes need to make the following considerations:

·         Patient Safety Considerations

o   Establish criteria for safe use of specialty infusions in alternate sites with less direct access to emergency care (e.g., anaphylaxis kits, access to 911 services, nursing care during infusion and post infusion monitoring period)

o   Establish criteria for patients requiring continuation of services in an infusion center setting (e.g., hypersensitivities, pediatric populations, induction to therapy, etc.)

o   Develop adverse reaction and response to therapy communication pathways

·         Transitions of Care

o   Develop a network of alternate site service providers

§  Assess capacity of infusion pharmacy, visiting nursing agencies and physician office provider partners to accept new workload

§  Assess provider capability to service high complexity therapy administration with prolonged infusions and on-going patient monitoring by a nurse

o   Develop standardized order sets including therapy dosing, administration and monitoring parameters to ensure consistent care across sites of care

 

Additional considerations include managing patient expectations, as many patients are fond of their infusion center routines and consider their infusions as a time for socialization and networking. As the full impact of the payer initiated site of care changes are realized, the home infusion and home healthcare markets may face initial staffing shortages while trying to accommodate these new complex and time intensive specialty infusions.

 

What’s next? Depending on your site of practice, you might consider the following steps in response to these payer changes:

  • Reach out to referral sources and find out how you may be able to assist in transitioning patients from the infusion center environment to the home or physician office
  • Assess your capacity to increase your new referral workload
  • Develop staff resources to prepare for new therapies and patient populations
  • Contact payers to fully understand policy specifics for the common plans at your pharmacy and work together with your referral sources and payers to establish criteria for identifying appropriate sites of care for different patient populations and co-morbidities.

 

References:

  1. Aetna Inc. Drug Infusion Site of Care Policy. Aetna.com. https://www.aetna.com/health-care-professionals/utilization-management/drug-infusion-site-of-care-policy.html. Accessed December 2016.
  2. Blue Cross Blue Shield and Blue Care Network Michigan. Drugs Covered Under the Medical Benefit. BCNSM.com. https://ereferrals.bcbsm.com/bcn/bcn-drugs-medical-benefit.shtml. Accessed December 2016.
  3. Anthem Blue Cross Blue Shield. Fast facts: IV sites of care. Anthem.com. https://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_e242033.pdf?refer=ahpprovider&state=wi. Accessed December 2016.
  4. Priority Health. Medical policy change for Remicade and IVIG infusions. PriorityHealth.com. http://www.priorityhealth.com/blogs/posts/provider/2016-feb/infusion-sites-of-service. Accessed December. 2016.
  5. United Health Care. Specialty Medication Administration – Site of Care Review Guidelines. UnitedHealthcareOnline.com. https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Specialty_Med_Site_Care_URG.pdf. Accessed December 2016. 

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