Read Advisory Board's take: 5 steps for providers to develop a home cancer care strategy

Cancer patients undergoing chemotherapy can spend "hours a day in physician offices or outpatient clinics," but research shows providing cancer treatment at home could be a more effective solution, Nathan Handley and Justin Bekelman write for STAT News. In fact, the doctors write, "it's closer to happening than you might think."

The executive's guide to infusion center business strategy

How at-home cancer care can save money

Handley, an oncologist at the Sidney Kimmel Cancer Center at Thomas Jefferson University, and Bekelman, a radiation oncologist and director of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center at the University of Pennsylvania, write that Medicare spends almost $30 billion on cancer patients within their first year of diagnosis. Hospitalizations account for 25 to 50% of that spending, depending on the diagnosis, and "chemotherapy and its administration account for a good portion of the rest."

However, Handley and Bekelman argue that "there's a better place to treat cancer": the patient's home.

"Infusions of many cancer drugs could also be given at home, moving the dominant site of cancer care from hospitals and outpatient clinics to the home," Handley and Bekelman write.

In a recent study published in the Journal of Clinical Oncology, Handley and Bekelman found providing cancer care at home can save money, without sacrificing care quality or patient satisfaction. In fact, they argue at-home cancer care could yield equal or better-quality care with better patient satisfaction at a lower cost than traditional cancer care provided in a hospital or physician setting.

Other studies have reached similar conclusions. Research has shown that treating patients with fevers associated with abnormally low white blood cell counts—which frequently happens during chemotherapy—outside of the hospital is equally as safe and effective as care inside the hospital, but costs half as much, Handley and Bekelman write.

And models for at-home care already exist in major institutions. For example, at-home care programs for skin infections, pneumonia, and other illnesses have been implemented by Johns Hopkins, Mount Sinai, Brigham Health, and Cedars Sinai, Handley and Bekelman write.

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3 steps to make at-home cancer care 'a reality'

Handley and Bekelman identify three steps that are needed to make cancer care at home "a reality."

1. Understand who needs what kind of care: Some cancer patients need care that can be provided only in a hospital, while others don't, Handley and Bekelman write. Criteria needs to be developed that can help determine who should be treated in different settings.
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3. Establish the logistics: Resources and staffing need to be established to provide effective at-home cancer care, Handley and Bekelman write. While it may seem like providing chemotherapy at home would be expensive, one study found that nursing costs for delivering at-home chemotherapy were 77% lower and total costs were over 50% lower than chemotherapy delivered in outpatient clinics.
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5. Develop new payer rules: Medicare, along with private insurers, need to develop new rules to cover at-home cancer care, Handley and Bekelman argue. Currently, physicians and hospitals are paid only for cancer drugs provided in clinics and hospitals.

"It's time to reimagine the role of hospitals and outpatient clinics in cancer care," Handley and Bekelman write. "Rather than being the routine site of care, hospitals and outpatient clinics should be reserved for the minority of cancer patients who require treatments that only hospitals and clinics can give. People with cancer will thank us for this change, from the comfort of their homes" (Handley/Bekelman, STAT News, 2/6).

Advisory Board's take

Deirdre Saulet, Practice Manager, Oncology Roundtable

There are a number of factors that make the idea of providing at-home cancer care attractive for health systems. For one, demand for it seems to be growing. The rising incidence of chronic disease among the aging population has increasingly led to overcrowded infusion centers and delays in care, while growing consumerism and price sensitivity is pushing patients towards more convenient and cheaper sites of care. Not to mention, increased pressure from private payers to move drug administration from hospital outpatient departments to cheaper sites may make home infusions an attractive alternative for health systems.

Because of these drivers, many organizations have started to offer a limited number of cancer services at patients' homes. However, the barriers mentioned by the article's authors, especially inadequate Medicare reimbursement, mean that providers need to carefully consider the timing and scope of these services. Here are five key steps for developing a thoughtful strategy:

1. Align with your organization's goals. Home infusion strategy will vary depending on where health systems are in the transition to risk. In a fee-for-service environment, home infusion can be leveraged to free capacity in busy infusion centers and potentially attract patients with more convenient care. But, as providers take on more responsibility for costs and outcomes, home infusion can support strategic goals by shifting care to less expensive settings, reducing inappropriate ED utilization, providing robust and convenient support to patients, and even reducing complications.
2. Evaluate demand. It is critical to understand your market, especially your local competitors' strategies and if local payers are actively steering patients to lower-cost sites of care for infusion. It's also important to estimate how many of your patients are eligible for home infusion therapy. While this eligibility will vary based on clinical factors like diagnosis and acuity, good candidates will also have a strong support system at home and a demonstrated ability to understand instructions. However, not all patients will feel comfortable receiving care at home, so providers will need to understand their patients' attitudes and willingness. In fact, a few Oncology Roundtable members have told us that their single biggest barrier to at-home care is patients' hesitation.
3. Carefully weigh the finances. Despite its potential to improve quality of care, increase capacity, and decrease costs, the profitability of home infusion therapy is uncertain. Key variables include payer mix, local payers' reimbursement policies, and patient volumes. For organizations operating in a primarily fee-for-service environment, home infusion often represents a break-even business at best. For health systems at risk for cost and quality, home infusion therapy is a more attractive business opportunity.
4. Determine a best course of action. Organizations who chose to run their own home infusion business, must be deliberate with the services they provide. This decision should be based on how they want to position themselves in the market, and informed by assessing the strengths of their competitors, as well as the needs of their patients. For many organizations, partnering with existing home infusion providers in their market might be more feasible. Under this model, it's important to take a principled approach to selecting partners.
5. Ensure quality and safety. Hardwiring care coordination is particularly important given the many moving parts involved in delivering care across multiple settings. It's equally as important to create protocols for when home infusion providers check in with patients. Cancer patients often have extra needs so organizations must create customized care plans for each patient to ensure they receive the support they need.

For more detail on the factors changing utilization of home infusion therapy and how to craft the right strategy for your organization, check out our report on the Home Infusion Market and Strategy.

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To learn more about the changing landscape of the infusion center business, download our Executive's Guide to Infusion Center Business Strategy.

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