Applying Business Principles to Everyday Practice

TOP - May 2019, Vol 12, No 2 - HOPA
Meg Barbor, MPH

Fort Worth, TX—Given the high cost of oncology drugs, it is important for pharmacists to become more business savvy regarding their practices, said Andrea Ledford, PharmD, BCOP, Oncology Pharmacy Manager, Orlando Health UF Health Cancer Center, FL, at the 2019 Hematology/Oncology Pharmacy Association (HOPA) Annu­al Conference.

“Things are becoming really complicated as a lot of changes are going through Medicare,” she added. “So pharmacists or pharmacy leaders, especially in oncology, should have a great understanding of this.”

The Inpatient Setting

When possible, an expensive oncology drug should not be given in the inpatient setting if the therapy could be given as an outpatient infusion instead. For example, if a patient is hospitalized for an infection and is due to receive a chemotherapy treatment, it is preferable to wait until that patient is discharged and then bring him or her back on the next calendar day to receive the treatment, if appropriate.

According to Dr Ledford, services received within 72 hours of admission are bundled into the hospitalization. “If a patient is discharged from the hospital and they’re sent downstairs to the infusion area to get Neulasta [pegfilgrastim] ‘for the road,’ you’re not going to get paid for that Neulasta because it’s on the same business day,” she noted.

Patients with documented comorbidities, such as visceral symptoms, are reimbursed at a higher rate and have a longer average length of stay. Dr Ledford stressed the importance of documenting these symptoms, as this will help to support a claim.

Medicare Payment Outliers

Once the average daily cost of an inpatient treatment regimen exceeds a certain threshold, it reaches stop loss. When the stop-loss threshold is hit, it allows for an extra payment of a high-cost oncology drug, Dr Ledford explained.

Temporary codes used for new and emerging technologies, which change each year, also allow for additional payments for new drugs. “This is an extra fee that Medicare will pay when the codes are included on the claim,” she said. “When we look at drugs, it’s important to know that this is here, because it’s a daily charge that can be added on.”

Observational (Short-Stay) Patients

According to Dr Ledford, “you’ve got 23 hours and 59 minutes to get a patient in and out of the hospital. Otherwise it will start to roll towards the inpatient side.”

These patients may qualify for 340B pricing, and all documentation for a claim must have been completed within the past 30 days. “At our institution, we treat our outpatient infusions as a short stay if we expect it’s going to take a longer time than what we can do in our infusion area,” she noted.

Outpatient infusion areas are “classic hospital-based Medicare Part D,” Dr Ledford said. These areas are designed to get patients in and out, and are the best setting for the use of expensive drugs. “But you have to decide at your organization what ‘expensive’ means,” she added.

The Payer Mix

Ideally, an organization should have a high number of managed care and Medicare patients and a low number of Medicaid and indigent patients; self-pay patients are negligible. “If you do have a lot of self-pay and indigent patients, make sure you have someone in a patient assistance or financial advocacy role for the patients,” she said.

If a payer mix shift occurs, the hospital bottom line will be affected quickly and significantly.

Creativity and Involvement is Key

“You want to optimize your program in order to really get the most for your reimbursement, because we really can’t afford to give our drugs away for free to everybody,” Dr Ledford said.

Building relationships with industry partners can be incredibly beneficial toward reaching this goal. “They have great resources to help you get paid, so don’t be afraid to reach out to them,” she said.

According to Dr Ledford, 340B reimbursement is a declining slope. “Be creative,” she concluded. “Get involved with reimbursement so you can really become a superhero at your hospital. It’s just so complicated, it takes a real village to work through.”

Related Items
Oncology Biosimilars: 2020 Update
Meg Barbor, MPH
TOP - July 2020, Vol 13, No 4 published on July 15, 2020 in Biosimilars
HOPA 2020 Abstracts
JHOP - June 2020 Vol 10, No 3 published on June 22, 2020 in HOPA
International Society of Cannabis Pharmacists Plans to Hold Inaugural Meeting in 2020
Meg Barbor, MPH
TOP - May 2020, Vol 13, No 3 published on May 21, 2020 in Medical Marijuana
Biosimilars Are Key Components of Oncology Today: Brush Up on the Basics
Meg Barbor, MPH
TOP - March 2020, Vol 13, No 2 published on March 11, 2020 in Biosimilars
Selecting Treatment for Relapsed/Refractory Multiple Myeloma in the Era of Multiple Choices
Meg Barbor, MPH
TOP - January 2020, Vol 13, No 1 published on January 10, 2020 in Hematologic Cancers
Genetic Profiling and Personalized Medicine in Myelodysplastic Syndromes
Meg Barbor, MPH
TOP - January 2020, Vol 13, No 1 published on January 10, 2020 in Hematologic Cancers
Engaging Patients in Their Cancer Care Through Digital Health
Meg Barbor, MPH
TOP - November 2019, Vol 12, No 4 published on November 7, 2019 in MASCC/ISOO Conference Highlights
Neurofeedback Reduces Symptoms of CIPN
Meg Barbor, MPH
TOP - November 2019, Vol 12, No 4 published on November 7, 2019 in MASCC/ISOO Conference Highlights
Oral Cancer and Sex in the Era of HPV Infection
Meg Barbor, MPH
Web Exclusives published on October 28, 2019 in Head and Neck Cancer
The Evolving Role of Precision Medicine in Clinical Practice
Meg Barbor, MPH
TOP - August 2019, Vol 12, No 3 published on July 29, 2019 in HOPA
Last modified: April 27, 2020