The infusion care landscape has changed dramatically in the past few years, and it is still changing. As spending on provider-administered medications continues to rise, health plans and employers are implementing new requirements to lower costs. Common requirements include site-of-care policies, which mandate that patients receive care from non-hospital infusion providers when safe and appropriate, and specialty pharmacy sourcing (i.e., white bagging) policies, which compel providers to source medications from a designated specialty pharmacy instead of their typical supply chain partners.
These requirements have added to the contentious relationships between stakeholders involved in infusion care. And while each stakeholder may have a share in the blame for rising drug spend, each stakeholder also can have a role to play in creating a future where patients receive infusion care in the right setting for the right price.
To further cross-sector understanding and foster a collaborative dialogue, Advisory Board recently convened a panel of experts representing the employer, health plan, health system, and private practice provider perspectives on the changing landscape of infusion care.
- Anne Ladd, Director of Purchaser Innovation, Purchaser Business Group on Health
- Robinson Ortiz, M.D., Senior Medical Director of Oncology, Cigna Healthcare
- Lindsey Amerine, Pharm.D., Director of Pharmacy, UNC Health
- Lalan Wilfong, M.D., Value Based Physician Liaison, McKesson Specialty Health
Read on for three key takeaways from the wide-ranging discussion. Members can also access a recording of the session here.
Insight 1: Health plans and providers need to enhance their communication strategies to reduce fragmentation of care for patients.
The current status quo for infusion patients includes frequent communication breakdowns around where patients can receive care. Patients are unsure of where they should go to receive infusions, and providers are unable to provide answers. This results in added stress for the patient and sometimes even delays in care. Ultimately, in patients' eyes, these breakdowns make the provider, health plan, and even the employer look incompetent.
One reason for these breakdowns is poor communication between providers and health plans. Communication between these two parties is often channeled through the provider's managed care team. The infusion care team and other providers may be left out of the loop when health plans change their coverage policies. It's common for providers to first learn that they are no longer allowed to administer a patient's medication when their patients show them their notification letter and ask questions about how they will receive their infusions.
In situations where a patient's health plan requires a site-of-care shift, providers want to ensure the patient feels informed and safe during the transition. But providers are in a difficult position without the ability to coordinate directly with the health plan. Providers can either tell the patient to call the health plan for answers or assume this responsibility on the patient's behalf. Providers and their staff spend countless hours calling health plan 1-800 numbers to identify alternative infusion providers in the patient's network and geographic location.
Health plans are beginning to acknowledge these challenges. To facilitate closer collaboration, Ortiz noted that Cigna is implementing a "hands-on" site-of-care policy. Cigna's program involves case managers who work with both patients and their prescribers to select treatment locations, submit referrals to new sites of care, and ensure new providers receive patients' orders. Case managers also leave a direct phone line with the patient and prescriber to offer support and answer questions during the transition.
Beyond this patient-specific coordination, providers have expressed eagerness to have more open lines of communication with health plans. They see opportunities to provide feedback on plan changes and collaborate on improving patient experience. Once all stakeholders know when and how policies are changing and who to call when they have questions, the system will be less likely to experience breakdowns.
Insight 2: Improving price transparency can help lower care costs. One of the most straightforward strategies is to educate providers and patients about drug costs and their down-stream cost impacts.
Providers often don't know the costs of the medications they prescribe or how the costs will impact their patients. Amerine explained that when sharing cost insight with providers, it helps to include both the cost of treatment and associated downstream costs such as for labs or other supportive agents, which contribute to the total cost of treatment with that drug. Her research found that providers don't realize that although one drug may have a higher price tag, it may have lower overall costs.
Panelists suggested that when providers have cost information available, they will take it into account. UNC Health is helping providers act on transparent cost data by including dollar signs next to treatment options in its electronic health record system. This allows its providers to have point-of-care insight into the financial impact on the patient. Ortiz shared that Cigna is taking a similar approach to support physician decisions by highlighting medications with the greatest clinical value in its prior authorization portal.
Price transparency also matters to patients. There is a misperception that insured cancer patients are not cost-sensitive because they quickly reach their out-of-pocket maximum following a cancer diagnosis. In working closely with employers, Ladd has found that it's not this straightforward. She explained that "once employees understand the association between medical expenses and salaries, there is a lot more motivation for them to engage on health care costs."
Insight 3: There is widespread interest in value-based care models as an opportunity to align incentives across patients, payers, and providers. However, these models have proven challenging to implement.
The US Oncology Network, a national network of independent community oncology providers, has been a leader in using value-based solutions to demonstrate aligned priorities between providers, health plans, and employers. Currently, 50% of its practices are engaged in contracts with two-sided risk. This incentivizes providers to lower costs while supporting improved patient outcomes. For example, the network has enrolled more than 100,000 patients in Medicare's Oncology Care Model and generated $122 million in cumulative Medicare savings. Wilfong noted that many employers are pursuing strategies, such as white-bagging, that function as "band-aids" but don't address the underlying issue of cost the way a value-based care approach does.
However, panelists highlighted several challenges to implementing value-based care solutions—especially for oncology. Given the relative rarity of any given cancer diagnosis, it's difficult for a provider to capture enough patients covered by one insurance company to demonstrate outcomes. This is further complicated by an unpredictable patient mix, given that seemingly subtle differences in cancer type can lead to dramatic variation in treatment costs. For example, employers might assume that a bundle for early-stage breast cancer might be an effective place to start. However, for a provider, the cost difference between treating hormone-based breast cancer and HER2 positive cancer can mean meeting cost goals or being underwater. In addition, solutions need to have built-in flexibility to adapt to the changing drug pipeline.
Despite the challenges, employers are still interested in pursuing value-based care models. Carrum Health and Memorial Sloan Kettering recently announced a partnership on direct-to-employer contracting for cancer care, which guarantees the total cost of care for breast or thyroid cancer for up to two years. As part of this agreement, employers will have the option to select from various bundles. For instance, one bundle will cover two years of in-person treatment for metastatic breast cancer and thyroid cancer, while other bundles will cover remote diagnosis, treatment planning, and care guidance for patients with other cancers.
The way forward
While there are still many challenges to address in infusion care, the panelists demonstrated an eagerness to tackle them head-on. Many organizations are working to identify solutions. However, this session revealed that no one stakeholder can unilaterally ensure a high-quality infusion care experience and outcomes. To achieve this goal, stakeholders must improve their communication and be open to collaboration. Ultimately, panelists conveyed optimism that this is possible and hope that it will be possible to reshape infusion care processes and reimbursement in a way that ensures patients receive the right care, in the right setting, at the right cost.