Switching Infusion Rx to Pharmacy Benefit May Limit Patient Access

May 28, 2015

by Amanda Conschafter, blog editor

Insurers have a new strategy for reducing the costs of injectable and intravenous prescription drugs: switching these medication from patients’ medical benefit to their prescription drug coverage. But the shift may limit patients’ access to necessary medications – and drive more to seek care in a hospital rather than their regular physician’s office.

Most patients currently receive certain injected or IV medications – including biological medicines, such as infliximab for rheumatoid arthritis or Crohn’s disease – at their physician’s office. Under new insurance mandates, however, patients would get these medications directly from a specialty pharmacy.

At present, physicians purchase and maintain an inventory of injectable and infusion medications in their offices. They then bill the cost of the medications to individual patient’s insurance companies when they’re administered. Known as “Buy & Bill,” this process requires office staff to order, maintain inventory records and bill medications accordingly. For complex biologics, physicians also take on the risk of safe, effective preparation and administration of these drugs.

Physicians choose to do so, however, so they can monitor their patients’ treatment in a safe and familiar environment. They then use the medication margin – the cost difference in what they pay and what they bill insurers – to offset the expenses associated with providing injectable medications and monitoring complex infusions.

With specialty pharmacies handling these medications, however, physicians will receive only the standard fee-for-service reimbursement for infusion services. The compensation may not justify the staff required for these services – causing physicians to discontinue their use.

And when community physicians no longer provide infusion and injectable medications, their patients face limited options. Many resort to a traditional hospital setting, though transportation and logistics can be challenging for elderly patients or those in rural areas. Moreover, infusion in a hospital setting is – ironically – more expensive than infusion in a community care setting. Thus, insurers may find that they have not only limited patients’ options but also increased the very expenses they wanted to reduce.

In Massachusetts, where several insurers have announced mandates to move injectable and infusion medications to pharmacy benefits, the state legislature considered but ultimately rejected an amendment earlier this month to postpone the change for one year. The time would have allowed regulatory agencies to investigate the mandate’s impact on patient safety and access.

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