Is Your Benefit Design Encouraging Members to Use Higher-Priced Infusion Facilities?
By Angela Maas - January 25, 2013

Much of the focus on specialty drugs nowadays is on how many oral therapies either have been approved or are in the pipeline. And with good reason — these drugs present a whole new set of complications, particularly in the area of patient adherence, than injectable and infusible therapies, which had been the norm in terms of treatments up until the past five years or so for many of these conditions.

But payers shouldn’t ignore infusibles since these drugs —which are estimated to represent about one-third of the specialty pipeline — offer a somewhat different array of management challenges.

Perhaps one of the most vexing is the fact that different sites of administration — hospital outpatient departments, physician offices, home infusion and infusion suites — may file claims for vastly different reimbursement amounts for the same drug at the same dose.

In a webinar I moderated on Thursday, Mike Einodshofer of Walgreens Specialty Pharmacy and Raulo Frear of RegenceRx spoke about how some of these claims for specialty infusions given at hospital outpatient departments may be as much as 50% to 100% more than claims filed for infusions of the exact same drug administered in a physician’s office. But with some payers’ benefits structured so that a member, for example, has a zero-dollar copay for an outpatient hospital visit and 10% coinsurance for an infusion suite visit, those companies are actually encouraging their members to visit the higher-cost facility.

Are your benefit designs incenting your members to avoid higher-cost, higher-risk sites to be infused?

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