Home Infusion: A Golden Opportunity for Pharmacists

Home infusion pharmacy services have the potential to expand a specialty pharmacy operation with a focus on coordination of care. Here's how this niche business has changed, along with a road map for establishing a home infusion therapy service line.

In today’s pharmacy world, most organizations are doing more in order to make the same money. Even when business is up, profits can remain the same. With this in mind, navigating the arena of specialty pharmacy requires an understanding of finding a successful niche business. This niche should focus on providing the highest quality of care to patients, while also generating income for business. Pharmacies might need to look outside of their comfort zones to identify a promising opportunity that can elevate their current value.

Home infusion is one of those areas of pharmacy practice not known to many pharmacists practicing in our great profession. It is typically not covered very thoroughly in pharmacy school curricula, and most pharmacists have very little knowledge of this unique area of practice. However, home infusion pharmacy has been quietly and persistently growing over the past 30 years, and today represents a golden opportunity for pharmacists looking to supplement their current service offering. Since the provision of home infusion pharmacy services places a high focus on coordination of care, it has potential to be the perfect complement to a successful specialty pharmacy operation.

Simply put, infusion therapy involves the administration of medication through a needle or catheter. It is prescribed when a patient’s condition is so severe that it cannot be treated effectively by oral medications. Typically, “infusion therapy” means that a drug is administered intravenously, but the term also may refer to situations where drugs are provided through other non-oral routes, such as intramuscular injections and epidural routes. Diseases commonly requiring infusion therapy include infections that are unresponsive to oral antibiotics, cancer and cancer-related pain, dehydration, and gastrointestinal diseases or disorders which prevent normal functioning of the gastrointestinal system.¹

Home infusion became a viable outpatient pharmacy practice setting as Medicare reimbursement for total parenteral nutrition in the home began in the late 1970s² and early 1980s. A focus on cost containment by managed care organizations prompted exploration into alternate settings for infusion therapy, and many discovered that clinically appropriate home infusion was more cost-effective than infusion in an inpatient setting. Home infusion also became an attractive option for patients requiring long-term infusion therapy, as they had an option to get outof the hospital and continue to receive their therapy. The practice of home infusion therapy has grown from its humble beginnings due in large part to progressive pharmacists and nurses providing excellent home infusion care to their patients.

In 2001, a watershed moment occurred in the home infusion industry when the federal government’s Health Care Common Procedure Coding System (HCPCS) administrators published national standardized coding, developed by the National Home Infusion Association, for home infusion therapy services, effective in January 2002. Since then, the HCPCS per diem S-code system has been widely adopted by commercial payers and some government payers throughout the nation. The adoption of these service codes formalized the payment model for professional pharmacy services rendered by pharmacists providing home infusion therapy. While there have been many innovations in pharmacy practice over the years, the S-code system for home infusion therapy billing represents one of the few widely accepted models in which health care payers pay pharmacists for professional services rendered to patients.

As health care reform is implemented, a new wave of cost containment methods will be felt by all health care providers. One such method is the Hospital Value Based Purchasing and Readmission Program finalized by the Centers for Medicare & Medicaid Services (CMS) in August 2012. Required in part by the Affordable Care Act, this program provides payment incentives for quality care and payment reductions for high hospital readmission rates.³ As hospitals identify how to reduce readmission rates and avoid penalties, home infusion may become an even more important post-discharge therapy option for their patients.

The Golden Opportunity

As reimbursement for traditional retail pharmacy services continues to shrink, it is important for pharmacists to identify other ways to serve their patients. Home infusion therapy is an opportunity for pharmacists due to its wide acceptance by health care payers and the unmet need it satisfies in the health care delivery system. Pharmacists providing home infusion services are paid for “professional pharmacy services,” and these services include compounding, pharmacokinetic dosing, electrolyte monitoring, and more. Home infusion affords pharmacists an opportunity to practice clinical pharmacy in a community setting, and it is a golden opportunity because of its viable business model.

A Day in the Life

Home infusion pharmacists lead patient care teams focused on providing effective patient care in the home setting. In most cases, patients are being discharged from a hospital or other facility to the home, and care coordination is of utmost importance for these patient care teams. Once a home infusion referral is secured and a patient’s benefits have been investigated, pharmacists compound intravenous solutions based on a prescription order.

After the solutions have been prepared and the home infusion equipment has been gathered, pharmacists have an opportunity to provide patient counseling covering topics such as sterile technique, medication administration, relevant adverse effects, catheter maintenance, equipment-specific instructions, and home infusion therapy in general. As patients receive ongoing infusion therapy, pharmacists have opportunities to practice clinical pharmacy and care for their patients. A few examples of clinical pharmacy practice in home infusion include:

• Pharmacokinetic dosing: Monitoring of serum creatinine and vancomycin trough levels, and subsequent calculation of appropriate vancomycin dosing based on pharmacokinetics
• Therapeutic selection: Selection of an appropriate anti-infective for a urinary tract infection based on a culture and sensitivity report
• Nutrition Support: Monitoring of nutrition status and electrolyte levels, and subsequent adjustment of dosing for home total parenteral nutrition patients
• Multi-disciplinary care team: Coordinate with employed or subcontracted home health nurses to provide comprehensive care for home infusion patients

The Road Map

A pharmacist deciding whether to establish a home infusion therapy service line should approach the decision carefully and with a business plan. At its simplest level, a business plan would include an idea, a plan for executing upon that idea, and a statement of projected income and expenses. As a pharmacist is considering a business plan for home infusion therapy, he or she should consider the following:

1. United States Pharmacopeia <797> (USP 797)-compliant facilities

USP 797 compliance is required for sterile compounding, and appropriate facilities may be achieved by using a barrier isolator, also known as a glove box, constructing a clean room, or setting up a modular clean room.

2. Accreditation

Participation with Medicare and many health care payers requires infusion pharmacy services accreditation. Several of the most common accrediting bodies for infusion pharmacy include the Accreditation Commission for Health Care, The Joint Commission, and the Community Health Accreditation Program. These accreditation programs will require the pharmacy to have policies and procedures that meet their standards.

3. Managed Care Contracting

Home infusion therapy is typically covered under a patient’s medical insurance benefit, and most payers have home infusion therapy networks with home infusion—specific contracts. Some of these contracts will be very similar to specialty pharmacy contracts.

4. Revenue Cycle Management

Revenue Cycle Management includes insurance verification of each infusion referral, billing, and collections. Home infusion is typically billed via medical claims, as opposed to pharmacy claims, and the claims include multiple different codes.

5. Sales and Marketing

Home infusion pharmacies will not be successful without a sales and marketing plan. Pharmacies should have a full-time employee who educates the local health care community about home infusion therapy and the services a pharmacy can provide.

If home infusion services are an unmet need in your community, consider the possibilities of this rewarding chance to practice clinical pharmacy and serve your patients. Don’t let a golden opportunity pass you by.

References

1. www.nhia.org/about-home-infusion.cfm.

2. www.gao.gov/assets/310/305261.pdf.

3. http://strategichealthcare.net/wp-content/uploads/2012/08/080612-VBP-Summary-Final-2013.pdf.

About the Authors

Logan E. Davis, PharmD, is director of franchise development for Vital Care, Inc, a national home infusion franchise organization based in Meridian, Mississippi. In his role at Vital Care, Inc, he is responsible for the growth and continued success of Vital Care, Inc and its franchised pharmacies. He earned his doctor of pharmacy from Samford University’s McWhorter School of Pharmacy in 2008, and is currently pursuing a masters in business administration from Mississippi State University. Vital Care, Inc’s franchise system provides the tools, resources, and expertise required for pharmacies to successfully enter and thrive in the home infusion business. For more information visit www.vitalcareinc.com.Chris Newlin, PharmD, is projects manager and residency program coordinator for Vital Care, Inc. Chris earned his doctor of pharmacy degree from Auburn University’s Harrison School of Pharmacy in 2011 and completed a PGY-1 pharmacy residency at Huntsville Hospital in 2012.