Chicago, IL—Inpatient chemotherapy is often considered a financial loss, and according to Ali McBride, PharmD, MS, BCPS, BCOP, Clinical Coordinator, Hematology/Oncology, The University of Arizona Cancer Center, Tucson, transitioning chemotherapy to the outpatient setting can be beneficial to patients and providers.
Prices vary slightly depending on the type of hospital, but a 1-day inpatient stay typically costs close to $2000.
“When you start looking at inpatient versus outpatient reimbursement, that should be the motivator to move you in the right direction to transition to outpatient chemotherapy,” said Dr McBride at the 4th Annual Hematology/Oncology Pharmacy Association Oncology Pharmacy Practice Management Program.
Inpatient reimbursement falls under diagnosis-related group codes, which often translates to lack of reimbursement for high-cost therapies. It also does not allow for billing of waste or the ability to access patient assistance. Outpatient reimbursement, on the other hand, is based on a buy-and-bill philosophy in which eligible institutions may be able to purchase therapies under the 340B Drug Discount Program, creating an incentive to utilize cost-savings, he said. Outpatient reimbursement also allows for the charging of waste, and for patient assistance programs with financial counselors and navigators available to address these programs with oncology pharmacists in the outpatient setting.
Advantages and Disadvantages
Inpatient chemotherapy does tout certain benefits, such as allowing for the critical management of patients who require constant monitoring, as well as high-dose methotrexate protocols for patients with leukemia, lymphoma, or sarcoma. However, according to Dr McBride, outpatient chemotherapy allows for safe and easy drug administration, facilitates tracking and control of treatment costs, and respects patients’ wishes to avoid hospitalization. Perhaps most importantly, outpatient chemotherapy is associated with decreased overall costs compared with inpatient chemotherapy administration.
“Under the Oncology Care Model and CMS [Centers for Medicare & Medicaid Services] pilots, they’re looking at overall costs. It’s no longer just about the chemotherapy; it’s everything from A to Z,” he explained.
Dr McBride and colleagues developed a practice model for implementation in which they evaluated trends for inpatient and outpatient chemotherapy.
“When we looked at our overall costs, we saw several targets, including rituximab and clofarabine,” he said. Both drugs are high-cost medications used very frequently in the inpatient setting, often without being accompanied by patient assistance programs, which Dr McBride called “an easy motivator for change.”
The investigators found that drug waste was not being billed in the inpatient setting, drug replacement programs were not being used, and patients were often waiting until the next day to start their treatment, thereby adding a full day to their inpatient stay.
“All of these factors came into play for our decision to move forward in addressing these high-cost drug therapies,” Dr McBride added.
Making the Transition
To get “buy in” for transitioning from inpatient to outpatient chemotherapy, Dr McBride stressed that everyone—including physicians, advanced practitioners, fellows, and nurse coordinators—should be involved in the discussion of the outpatient chemotherapy process. Financial counselors should address patient assistance programs, including housing assistance.
“We found we were paying for 11 rooms every day at a local hotel for patients going into transplant. These were often not being used, so we can now use those beds for patients staying in the area receiving outpatient chemotherapy,” he noted.
Criteria, such as location and access to transportation, should always be established for patient selection in the outpatient setting.
“You never want to treat a patient in the outpatient setting [who] you think may have compliance issues or may cause risk to themselves,” he said.
Lastly, oncology pharmacists should be brought into the clinic and given a direct role for mitigating some of these changes.
After implementation of their practice model—the key piece being the transition of rituximab to outpatient administration—Dr McBride and colleagues observed no complaints from physicians about the change in practice, and they found that inpatient stays and inpatient chemotherapy costs decreased. They also found an increase in adherence to, and use of, their specialty pharmacy.
“This was unexpected and became a very important piece that really helped the revenue stream for our specialty pharmacy site,” he said. After evaluating the overall cost-savings for rituximab, his team was able to save approximately 700 inpatient bed days through this transition.
In the outpatient setting, clinical ambulatory oncology pharmacists should work to address chemotherapy orders appropriate for inpatient or outpatient treatment, provide chemotherapy counseling for new patients, direct oral oncolytics and supportive care medications to the specialty pharmacy (to make sure that, at the start of chemotherapy, patients actually have their drugs), and evaluate and monitor chemotherapy orders for continued treatment and dose modifications.
“The biggest implementation piece that came away from this, was that we increased the role and focus of clinical ambulatory oncology pharmacists,” said Dr McBride.