April 19, 2021
At this year's National Home Infusion Association Conference, SPARx's VP of Specialty Infusion Services, Eugene Queener, presented on site of care challenges health systems and hospitals are facing due to new regulations and payor standards.
Queener began with an overview of the Specialty Pharmacy ecosystem, highlighting how patients are referred to infusion within the hospital and the necessity for each department to communicate with one another. Even when the referral is outside the hospital, each patient is touched by several areas of care.
According to Queener, 39% of specialty drug costs are billed to the medical benefit, while 61% are billed to the pharmacy benefit. Of those in the medical benefit, 37% of drugs belong in the Hospital Outpatient Department, which payors started to scrutinize years ago.
Payors began shifting the site of care to the pharmacy benefit, specifically to home infusion. This practice has expanded greatly and many drugs are now no longer available for infusion at the hospital. Instead, these drugs are being "white-bagged," and payors give the benefit to their own plans' specialty pharmacies, who then turn around and ship the drug to the hospital. This means the hospital does not receive reimbursement for any part of the drug and must also absorb the storage and handling costs.
So, why did this happen?
In short, commercial payors historically were paying 2-3x the cost for the drug at hospitals and health systems than they were for smaller providers in the same geographical regions. This cost pressure has lead many patients to be turned away from their regular care hospitals by their payors.
SPARx has the expertise and experience to help hospitals and health systems implement programs to combat this site of care shift and bring patients and payor dollars back into the organization. If you want to solve for patient access to care, gaps in therapy, optimal patient outcomes, and patient leakage from your hospital or health system, contact us to get started.