Providing employees with infusion therapy requires navigation of some tricky situations: high-cost pharmaceuticals and provider administration charges. Coupled with a need to ensure the quality of care is maintained, this can be tricky indeed!
Since infusion therapy can have a considerable impact on your pharmacy plan spend, understanding what infusion therapy is and how this impact occurs can be vital to ensure your cost containment strategy is effective.
What is Infusion Therapy?
In brief, infusion therapy is “…a method of putting fluids, including drugs, into the bloodstream. Also called intravenous infusion.”[1]
The Problem
Infusion therapy generates significant revenue for clinics and outpatient facilities. Many providers who specialize in infusion therapy will purchase the medication to be infused at one price but then charge the patient (and their insurance!) a much higher price to infuse that same medication. This means the amount being charged is not commensurate with the medication’s value and/or the risk of the infusion. In the industry, this practice is often called “buy and bill.”
Example: We (GBS) receive numerous requests from providers to infuse 10mg of REMICADE® (infliximab) HCP (“REMICADE®”). These providers seek to charge the plan upwards of $10,000 for this medication and its infusion. REMICADE® is actually a fairly low-cost medication. In comparison, 10mg of REMICADE® can be purchased directly from a pharmacy for less than $250 and there are many companies that provide home infusion of this REMICADE® for $400. Thus, the approximate cost of the medication combined with the cost of the infusion service totals a more realistic cost of $650.
As the above example makes evident, providers who want to charge $10,000 are drastically marking up a relatively low-cost drug medication for infusion through an IV drip. Some clinics have even started refusing to accept outside medications even when filled through normal pharmacy channels to protect their extremely strong profit margins. Health plans are often stuck paying these huge mark ups and thus can find it difficult to maintain a sustainable plan for their employees. This difficulty can be compounded by even higher medication costs. For example, we’ve had providers attempt to infuse a typically $30,000 drug for nearly $100,000.
How can we balance the needs of plan members who require this type of care with the need for a sustainable employee benefit plan? The answer: a three-step process!
Triggers, Sourcing, and Member Engagement & Education
Members are a stakeholder in your employee benefit plan and must work with said plan to help it remain affordable and sustainable. Members that refuse to work with the plan will needlessly drive up plan cost which, in turn, will increase the employees’ premiums. An affordable health plan is an excellent recruitment and retention tool for your company, but plan sponsors and plan members must work together if they want to maintain the plan’s affordability.
Step 1
Trigger. Establish a trigger within the precertification process that alerts the plan when a high-dollar medication is about to be infused.
Step 2
Sourcing. The plan needs to have a legitimate alternate source to provide this medication. Likewise, the plan must have access to an organization that will provide the infusion service on a stand-alone basis (i.e. only performing the infusion).
Step 3
Member Engagement and Education. Though this is the final step in the process, it is just as important as Steps 1 and 2. Trying to educate plan members about all the facets of the employee benefit plan at open enrollment can be difficult. Members quickly forget much about what is being conveyed to them as soon as they leave the benefits meeting. That is why the plan must include member outreach in the workflow. Once a trigger sends an alert, a knowledgeable medical professional (who has a thorough understanding of infusion therapy) should then perform this outreach (i.e. engagement). Since the professional understands this type of care, they will be able to help the member secure the medication(s) and the infusion service they need at an affordable cost.
All three (3) of the steps above must be completely embedded within the workflow in order to function properly. Having a source for lower cost medications and infusion service along with a quality engagement process could prove to be futile unless the plan has an automated trigger built within the workflow.
We understand that effective cost containment is essential for plan sustainability and that without it a company may be unable to offer a plan at all. By working together with members and plan sponsors using meaningful embedded tools, we can help keep costs lower and your plan more sustainable.
[1] National Cancer Institute: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/infusion