Infusion Services Success: Combating Site of Care Fragmentation & Patient Leakage
For many years, a health system’s non-oncology ambulatory infusion services had virtually no impact on financial health, often considered proverbial budget dust. Operationally, a single room with a half-dozen infusion chairs was sufficient to meet ambulatory infusion volumes. However, a robust ambulatory infusion therapy pipeline, a rise in chronic illness, pressures to reduce the length of stay, cost inflation, and patient preferences led to a tripling of the market since 2010 and a projected 5-10% compound annual growth rate (CAGR) through 2030.
Ambulatory infusions fall into two categories: episodic treatments (e.g., antibiotics, iron, fluids) and chronic therapies (e.g., treatments for autoimmune disorders, ophthalmic injections, immune globulin, asthma, multiple sclerosis, Alzheimer’s disease, and others). Initially, the complexity of infusion delivery and the need for monitoring led to most infusions being administered in hospital outpatient departments (HODs). However, the distribution of care settings is changing rapidly. A recent analysis shows ambulatory infusion distribution to be 54% in HODs, 28% in physician-office clinics, 13% in ambulatory infusion centers, and 5% in home infusion services.
Successful health systems are taking strategic actions to ensure that ambulatory infusions positively impact clinical outcomes, enhance patient experiences, and contribute to the organization’s financial health. In 2025, the focus will be on optimizing sites of care, improving patient capture and minimizing leakage, navigating policy and legislation, addressing reimbursement issues, and enhancing the overall patient experience.
Site of Service Program
Payers continue implementing strategies to move infusions from higher-cost HODs to lower-cost settings, such as pharmacy-based infusion suites, physician office clinics, free-standing infusion centers, or patients’ homes. These strategies include tiered networks, pre-authorization requirements for using HODs, white or brown bagging, and bundled payments for episodes of care. A survey of payers found that 77% have implemented a site of service program to manage medical pharmacy spending, resulting in an average reported savings of 25%. Pre-authorization requirements typically restrict the use of HODs to patients who are medically unstable, have significant comorbidities, or require monitoring or interventions unavailable at alternative sites. These trends create a pressing need for health systems to operate various sites of care to maintain or grow their market share. Furthermore, strong pre-authorization systems are necessary for health systems to navigate the complexities of site of service pre-authorization criteria and policies.
Patient Capture and Leakage
Improving patient capture (i.e., retaining patients within a health system) and limiting patient leakage (i.e., patients seek services outside the health system) of infusion services requires a holistic, proactive strategy.
Infusion Access Services
In addition to establishing site-of-service programs, all insurance providers have specific eligibility criteria that patients must meet to receive treatment. The experiences of both the patient and prescriber, particularly how effectively the infusion provider assists with obtaining infusion access, can significantly impact overall satisfaction. A growing trend among health systems is to centralize insurance authorization processes, transferring them out of individual clinics and into dedicated access services.
Infusion Patient Experience
Several factors contribute to a patient’s experience during infusion treatment. This experience often begins with scheduling a timely appointment, defined as the time from deciding to start treatment to administering the first dose. Convenience is also essential, including options for evening and weekend appointments as well as online scheduling. Other important aspects that influence a patient’s experience include the proximity of the infusion chair to the parking lot, the promptness of infusion preparation, interactions with staff, and the patient’s overall comfort during the infusion process. An emerging trend in the field is the use of analytics and improvement science to optimize the patient experience.
Infusion Locations
Historically, infusion locations were not a significant factor in health system space or geographic planning. However, the distance patients must travel to receive services is a crucial factor influencing their choice of infusion providers. Some emerging trends include the expansion of home infusion and pharmacy infusion suite capabilities by health systems, the introduction of mobile infusion centers (i.e., infusion centers on wheels), the use of technology such as tele-health and remote patient monitoring, and the formation of partnerships to expand the availability of infusion locations.
Competing on Quality
Using external infusion services can fragment care, potentially compromising both the safety and effectiveness of infusions. It is important for patients and healthcare providers to understand the benefits of having all information stored in a shared electronic health record, as well as how the choice of infusion provider can impact outcomes. Additionally, some organizations are seeking accreditation for their infusion services to demonstrate external validation of the quality of these services.
Growing Competition
The ambulatory infusion market is facing unprecedented competition. Outside firms are investing in both existing and new for-profit stand-alone infusion centers. There is also a trend of increasing merger and acquisition activity and more vertical integration. Competitors may enjoy advantages such as better access to capital, improved workforce recruitment, agility in making operational changes, and an early adoption of technology and software innovations. Additionally, many of these competitors employ sales representatives who target prescribers for referrals.
Insurance Networks
Many payers have implemented cost-sharing tiers for infusion service providers. Health systems must proactively negotiate contracts that keep them in a competitive tier. For some organizations, infusion services have not yet become a priority for contracting teams.
Legislative Landscape
Anti-white bagging
White bagging refers to the practice of a specialty pharmacy shipping medications to an infusion provider for administration. State-level anti-white bagging legislation restricts or prohibits white-bagging or prevents insurance companies from conditioning coverage on the use of their specialty pharmacy.
Proposals for Medicare Site-Neutral Payment
Federal proposals exist that include site of service neutral payments for drug administration services in off-campus HODs, including the potential to eliminate grandfathering exemptions that would expand the site-neutral payment policy to all hospital-owned sites of care away from the hospital’s main campus.
Calls to Action
- Conduct a SWOT analysis to evaluate patient capture and leakage in infusion services.
- Evaluate whether the distribution of the organization’s infusion sites of service meets current and future needs.
- Analyze how Medicare Site-Neutral infusion payment would affect the organization’s financial health.
- Develop strategy to expand health-system-based ambulatory infusion sites of care including home infusion and pharmacy infusion suites, and consider a partner in helping to accelerate growth and success of this program.
Looking for more information or assistance for your organization? Reach out to Visante today!
Subject Matter Experts: Dale Drizd and Erick Siegenthaler