In an effort to lower the cost of specialty drugs, many payers have initiated site-of-care optimization strategies. By encouraging patients to receive therapies in more cost-effective settings — such as physician offices, infusion clinics, or at home — payers can reduce unnecessary expenses while ensuring members receive clinically appropriate care.
In addition to price concerns, medication compliance also plays a significant role in payers’ preference for a particular site of care. Payers obviously want their members to take their medications as prescribed, as doing so saves lives and avoids downstream medical costs. Estimates show that medication nonadherence causes approximately 125,000 avoidable deaths each year, and costs the U.S. healthcare system more than $500 billion.
Every healthcare stakeholder has an interest in keeping patients compliant with treatment. While payers can incentivize beneficiaries to adhere to their treatment plan in a variety of ways, including site-of-care optimization, some complexities exist around administering drugs in a healthcare setting vs. a patient’s home. So how do payers perceive medication compliance as it relates to the site of administration?
Payer perceptions on adherence
In an MMIT Message Monitor poll, half of responding payers—representing 50.1 million lives—said there is no difference in adherence and compliance between products administered in an office compared with those delivered in the home setting. However, one-third of payers believe that in-office administration improves medication adherence and compliance. But just because they have that perception does not necessarily mean that it’s true.
On the one hand, when patients pick up a prescription — assuming they pick it up — there’s no way to know if they are actually taking it as prescribed. Studies have found that even people taking oral cancer drugs are not always compliant with their treatment regimen.
On the other hand, when providers administer drugs, they know their patients are receiving their medication at the correct dosage and within the right timeframe. However, patients still need to actually schedule and attend their appointments. If they cannot, that also disrupts treatment regimens.
According to the American Hospital Association, 3.6 million people fail to receive medical care each year because of issues with transportation. They may also have challenges with finding and paying for childcare. While payers, providers and other healthcare stakeholders are implementing social determinants of health initiatives to address such barriers to care, challenges remain. Payers also do not have a way to calculate their return on investment for such programs.
Home infusion is one option for a lower-cost site of care, but not every drug is appropriate for administration in the home setting. Some provider groups, such as the Community Oncology Alliance, are opposed to home infusion of chemotherapy, cancer immunotherapy and cancer supportive drugs due to “serious patient safety concerns”.
Nonetheless, the COVID-19 pandemic spurred the launch of some payer-provider initiatives to allow people to receive certain cancer infusions at home. The pandemic also broadened the use of telehealth, giving providers the ability to communicate with patients at home while they are being infused.
Shift toward in-home treatments
Of course, cost savings are a key factor in payers’ preference for a particular site of care. Numerous studies have found that drugs acquired by and administered in a healthcare setting cost much more than ones dispensed via a specialty pharmacy.
A 2022 AHIP analysis found that a single treatment of a hospital-administered drug cost an average of $7,000 more than drugs procured via a specialty pharmacy, while physician-office-administered drugs cost $1,400 more. Hospitals also charged more than double (108%) for the same drugs as compared to specialty pharmacies; physician offices charged 22% higher prices, on average.
Data from Zitter Insights shows that in-office infusion of nononcology agents is used more often than administration in the home setting. Commercial payers with 85% of covered lives said they prefer particular sites of care based on which therapies are being administered. Those respondents said they favor in-home administration for erythropoiesis-stimulating agents (ESAs), rheumatoid arthritis drugs and atopic dermatitis therapies. The top preferred treatments for infusion center administration are drugs for multiple sclerosis, immunodeficiency, and hemophilia.
During a Zitter Insights survey conducted in June and July 2022, commercial payers representing almost half of covered lives said they expected the majority of their members would receive intravenous or subcutaneous treatments in the home setting by second-quarter 2023. When those respondents were asked about the shift in administration settings, commercial payers with 72% of lives replied that it was the most cost-effective option for their members. Payers said that physician-affiliated clinics are their top management priority in 2023, followed closely by freestanding infusion centers and provider offices.
Payer requests for manufacturers
When commercial payers were asked about manufacturers’ role in optimizing sites of care, one respondent requested that companies provide clear information on product preparation, handling, storage, and administration to allow for administration in as many settings as possible.
Another payer said manufacturers could encourage patients to receive infused specialty agents in settings outside of the hospital due to lower costs. Similarly, a third respondent said they wanted manufacturers to work with their plan to promote the use of preferred infusion centers that provide cost-effective services.
By recognizing and addressing payers’ site-of-care optimization preferences, manufacturers can better allay overarching cost concerns about their expensive specialty drugs and biologics. Studying the impact of particular administrative settings on medication compliance, risk management and the overall care experience might also help clarify the ideal site of care for the benefit of providers, payers and patients.