How home infusion providers can help hospitals deliver on value-based care
Succeeding in the new era of value-based payment programs requires hospitals and health systems to create better, more coordinated care delivery systems. The ultimate goal is to achieve the Institute for Healthcare Improvement’s Triple Aim: improved patient care experience, improved health among specific patient populations and reduced costs through reductions in wasted dollars on quality markers such as preventable readmissions.
Quality post-acute clinical partners are integral to achieving these goals, just as they are to models such as the newly implemented Medicare program mandating bundled payments through its Comprehensive Care for Joint Replacement (CJR) model. As of April 1, 2016, hospitals are accountable for controlling healthcare costs associated with hip and knee replacements post-discharge and assuring that patients get the care they need in the most cost-effective setting.
Noting that 39% of Medicare spending associated with hip and knee replacements (which includes the full episode of care up to 90 days after discharge) is tied to post-discharge care and readmissions, a recent analysis by Avalere concluded that hospitals should focus their attention on improving efficiencies and containing costs tied to post-discharge care.1
Quality home infusion providers can play a pivotal role in this new era by supporting enhanced clinical collaboration, improved patient outcomes and cost efficiencies through the management of patient populations at risk for joint replacement surgery. That ranges from pre-hospital regimens and discharge facilitation to post-discharge care to avoid readmissions. This article shares clinical insights from Option Care home infusion experts on managing care for patients with hemophilia and other bleeding disorders, a patient population at risk for joint replacement.
The High Cost of Hemophilia Treatment
According to the medical literature, about 90% of people with severe hemophilia experience damage in one to six major joints due to bleeding into the joints.2 This frequently results in the need for joint replacement surgery, which carries a heightened risk of bleeding and infection for patients with hemophilia and other bleeding disorders.3 This is a population, therefore, that requires careful management pre- and post-surgery to reduce length of stay and preventable readmissions. A look at optimized care for hemophilia patients serves as a good example of how home infusion clinical providers can be a valued partner in ensuring optimal outcomes for all stakeholders working toward Triple Aim goals.
People with hemophilia A are missing a blood clotting protein that is necessary for normal clotting. Treatment of hemophilia A involves infusion of factor VIII, which helps clot blood and stop bleeding. Many people with Hemophilia A receive factor VIII two to five times a week to prevent or reduce bleeding. Treatment success is evaluated by assessing the annual bleed rate (ABR). The fewer the bleeds, the more successful the treatment.
Hemophilia is one of the most expensive chronic diseases to treat at an estimated cost of $2,000 per dose4; annual cost of factor per patient is estimated at $200,000.5 This leads to significant cost for health systems when hemophilia patients aren’t discharged quickly after joint replacement or other procedures, and require factor during their stay.
Collaborative clinical management to reduce complications such as bleeds and infections reduces costs and benefits all stakeholders – patients, health systems, providers and payers – most notably supporting patients’ ability to lead normal and healthy lives.
Benefits of Collaborative Clinical Management
To demonstrate the value of integrating a home infusion provider as a partner with health systems within a value-based payment model, consider study data presented by Option Care at the World Federation of Hemophilia (WFH) 2016 World Congress.6 The study demonstrates the value of a high quality home infusion care model, showing achievement of cost savings by optimizing treatment dose. Optimization means dispensing the targeted dose without providing more than required while also achieving a lower than average ABR.
The Option Care study presented at WFH included 77 hemophilia A patients receiving home infusion of factor VIII. Patients in the study received an average of 102 units of factor VIII per week, vs. the national average of 108 units per week (resulting in savings of $21,165 per patient per year).7 Most importantly, outcomes were not affected: patients achieved an ABR of 1.7, comparing favorably to the average ABR of 2 to 5.8
The research illustrates that when home infusion providers work with prescribers to monitor bleeds and collaborate on clinically appropriate optimization of treatment dose, the outcome is less than the average use of factor VIII with excellent outcomes. This saves payers – including Medicare, Medicaid and managed care insurers – significant costs without negatively impacting annual bleed rates.
What Quality Care Looks Like
A quality home infusion partner provides excellent clinical management, assisting and collaborating with all stakeholders across the continuum of care to optimize outcomes. This involves coordination directly with the Hemophilia Treatment Center and all involved, including the patient, physician and nurses. The first step is to develop a clinically appropriate individual plan for each patient. Therapy management and medication oversight are vital, as is prompt access to medications, infusion supplies and adjunctive therapy.
Education is a key aspect of quality home infusion care. Home infusion providers must support patients in their efforts to adhere to treatment by helping them learn how to identify and treat bleeds, as well as understand the risks of not treating promptly. Home infusion nurses provide self-infusion direction and support to the patient and/or caregiver, and provide infusions to patients who are unable to self-infuse.
This high level of nursing support can reduce unnecessary visits to the emergency room (ER), and enable the immediate replacement of factor if needed. Monthly check-in calls help ensure health and improve adherence to treatment. Quality home infusion providers offer 24-hour on-call support (with access to Spanish-speaking nurses if needed), including pharmacy and delivery and physical therapy consultation.
The cost benefits arise from the home infusion team working with the patient’s healthcare provider who prescribes the therapy, as well as the treatment center to create a collaborative care plan that is clinically appropriate for the patient and cost effective. Cost is controlled through assay management (ensuring the therapy is appropriate), dose management, ER avoidance and pre- and post-operative support.
Following clinically appropriate pre-hospitalization regimens facilitates earlier discharge as well as reduced length of hospital stay. This saves payers costs – including health systems that also are payers – by preventing waste through the elimination of auto-shipment (which is key as patients often change therapy) and avoidance of giving patients more factor than required. At the same time, it’s important to ensure patients have the factor they need when they need it, so talking to them prior to shipment is key.
Quality home infusion providers also closely manage patients via their interactions with the health system. In other words, home infusion providers remain in regular contact with the patient’s physician or other healthcare provider to share information, provide updates, address issues and keep patients healthy and out of the ER as well as avoid readmissions after hospitalization. Among Option Care’s infusion patients overall, readmission after hospitalization is less than 1% annually (based on nearly 200,000 patients treated).9
As evidenced by the research on the provision of factor for hemophilia patients, this high-quality, high-touch care provided by a quality home infusion provider pays dividends for all stakeholders, including by helping hospitals deliver on value-based care.
- Seidman J. March 30, 2016. Sixty Percent of Hospitals Must Reduce Costs for Joint Replacement Under New Medicare Demo or Face Penalties. Avalere. Accessed Sept. 29, 2016.
- Rodriguez-Merchan E. Musculoskeletal Complications of Hemophilia. HSS J. 2010 Feb; 6(1): 37–42.
- Rodriguez-Merchan E. Special Features of Total Knee Replacement in Hemophilia. Expert Rev Hematol. 2013 Dec;6(6):637-42.
- Option Care data on file.
- Linney D. Feb. 7, 2011. Figuring Out Healthcare Costs for Your Child. Hemaware: National Hemophilia Foundation. Accessed on Sept. 29, 2016.
- Couden J, Dooley T and Milenski K. July 26, 2016. Pharmacist/Provider Collaboration Needed to Optimize Dosing Regimens in Order to Reduce Bleed Rates in Hemophilia A Patients on Prophylaxis Regimens. World Federation of Hemophilia 2016 World Congress, Orlando, Fla.
- B. Buckley, T. Livingston, T. Odom. S. Krishnan. Biogen Idec, Weston MA, Evaluation of Real-world and Clinical Trial-based Dosing of Factor VIII in Hemophilia A Patients. October 2014.
- Oldenburg J. Optimal Treatment Strategies for Achievements and Limitations of Current Prophylactic Regimens. Blood. 2015; 125(13): 2038-2044.
- Option Care data on file.