Skip to main content

Applying Business Principles to Everyday Practice

Web Exclusives - Practice Management
Meg Barbor, MPH

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.”

Related Items
Artificial Intelligence and the Future of Healthcare
Fop Johnson
Web Exclusives in Practice Management
Artificial intelligence tools and applications have shown great promise in delivering higher quality healthcare, but current offerings are at various stages of maturity and capability and are not yet in widespread use.
CMOM-HEM/ONC Course: A Valuable Resource for Practice Managers
Ina Huang
Web Exclusives in Practice Management
In the evolving landscape of today’s healthcare industry, more and more demands are being placed on practice managers and their staff.
The Flaw in Infusion Scheduling
Web Exclusives in Practice Management
In reality, scheduling appointments with significant lead times, often weeks or months before the actual appointment, may actually cause more problems and serve fewer patients.
Identifying the Problem Is Key to Quality Improvement in Cancer Care
Meg Barbor, MPH
Web Exclusives in Practice Management
“There are a number of ways to go wrong when you’re trying to improve something,” said Kaveh G. Shojania, MD, Director, Centre for Quality Improvement and Patient Safety, University of Toronto, Canada, and Editor-in-Chief, BMJ Quality & Safety, who delivered the keynote address at the 2018 ASCO Quality Care Symposium.
FDA Perspective: Reducing Cost, Increasing Access to Cancer Care
Chase Doyle
Web Exclusives in Practice Management
In a time when the country feels more politically divided than ever, there is broad consensus that Medicare should be allowed to negotiate prescription drug prices directly with drug makers, and that the FDA should expedite approvals of generic cancer drugs to lower patients’ out-of-pocket costs.
One Oncologist’s Firsthand Experience with Serious Illness: What Your Patients Want
Meg Barbor, MPH
Web Exclusives in Practice Management
There’s really only one way to identify how patients are coping with serious illness: by asking them, according to Thomas J. Smith, MD, FACP, Director of Palliative Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.
Harnessing the Power of Data Collection and Coordination in Oncology Practice
Meg Barbor, MPH
Web Exclusives in Practice Management
Business intelligence is the process of collecting data from disparate systems—internal and external—and turning it into information that is meaningful and actionable toward achieving strategic goals.
MIPS: How to Be Successful Today and in the Future
Toni Gress
Web Exclusives in Practice Management
The McKesson value-based care team employs a combination of tactics to help practices in The US Oncology Network achieve success in the Merit-Based Incentive Payment System (MIPS). One of the challenges with the new MIPS program is the need to focus on the current year’s performance, while taking steps to ensure that practices are successful in future years.
Oncology Practice Landscape in 2018: ASCO Survey Shows Interactions with Payers Top Concern
Eileen Koutnik-Fotopoulos
Web Exclusives in Practice Management
Oncology practices are challenged by day-to-day operational functions, which are often related to payment, reimbursement, and competition, according to the new survey titled “The State of Oncology Practice in America” from the American Society of Clinical Oncology (ASCO) on the oncology practice landscape in the United States.
FDA Commissioner Outlines New Plan to Increase Biosimilars by “Balancing Innovation and Competition”
Eileen Koutnik-Fotopoulos
Web Exclusives in Practice Management
FDA Commissioner Scott Gottlieb, MD, has been outspoken about the critical need to reign in drug prices. Biosimilars are crucial for improving patient access to biologic drugs at an affordable cost. Biologics are now key in the treatment of cancer and autoimmune conditions. But cost remains an obstacle to access to drug therapy.
Last modified: June 11, 2020