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 Annual Meeting.
“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, patients should not be given an expensive oncology drug 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 it 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.”