Avera Health infusion program leaders thought their payer strategy was working after they instituted a “no white-bagging”¹ policy and successfully appealed site-of-care mandates. However, payers soon became unresponsive to appeals. Instead, payers started referring patients directly to home infusion or requiring white bagging. Questions mounted across the health system as an increase in Avera’s home infusion call volume exposed the scope of payer restrictions.

Collaborate to drive a holistic, proactive response

To address escalating concerns about payer infusion restrictions, Avera’s assistant vice president (AVP) of pharmacy convened key stakeholders in an interdisciplinary work group.² The AVP of pharmacy first educated the group on trends in infusion site-of-care, the impact of payer policies on health system services, as well as the options and levers available to minimize care disruption. Most importantly, the group focused on how to make sure the system was paid for infusion services despite changing trends. The group met monthly to create different workflow algorithms, modeling by payer and by drug to determine best ways to triage patients. The cross-stakeholder dialogue resulted in a holistic, proactive response to payer restrictions on infusion services.

¹“White-bagging” refers to payer policies that require specialty pharmacy sourcing for medications administered in hospital outpatient departments
²Key stakeholders represented Avera’s infusion center, home infusion, specialty pharmacy, payer contracting, and finance teams.

The work group identified the need for a “gatekeeper” to proactively address payer restrictions when patients arereferred for infusion services. Leaders created an infusion advocate role to streamline prior authorization and patientintake processes. Infusion advocates determine the optimalsite of care based on patient and payer factors. The advocates also help ensure that Avera will be reimbursedfor the care.

Infusion advocate core functions

Infusion advocates optimize site of care and ensure carecontinuity for patients. Their responsibilities include:

• Conducting pre-infusion benefit investigations
• Synthesizing payer policies, quality and safety metrics, and patient preference to determine the best setting for an infusion
• Checking scheduled infusions to ensure active authorization and manage appeals
• Collaborating with infusion schedulers to ensure care continuity for infusion patients
• Working directly with patients to facilitate financial assistance, such as enrollment in free drug programs

Maximize impact by deploying existing expertise

The infusion advocate role builds on expertise developed in Avera’s specialty pharmacy advocate program. Prerequisite competencies include prior authorizations, pharmacy benefit investigations, pharmacy billing, and health system pharmacy services. While the infusion advocates’ workflow mirrors that of specialty pharmacy advocates, infusion advocates have the added challenge of working across both pharmacy and medical benefits.

During their training, new infusion advocates meet with each of the work group stakeholders individually, across a three week period. The training covers topics such as medical benefit billing, communication, handoffs, and roles. Advocates spent time with clinic staff to better understand medical authorizations for infusions.

Before going live, infusion advocates demonstrate their ability to identify the best solutions for different patient situations by working through sample cases.

Identify opportunities ahead of payer negotiations

Collaborating in the work group enabled Avera’s pharmacy and payer contracting teams to establish a strong working relationship. Because of this mutual trust, the pharmacy AVP is now immediately notified of medication-related payer contract changes and works closely with C-suite leaders and the payer contracting team ahead of payer negotiations.

Avera’s pharmacy AVP also provides the payer contracting team with critical information to support stronger, more nuanced payer negotiations. Information includes quality data as well as financial analyses to demonstrate the hard dollar value of various contracting opportunities for the health system. One outcome of this collaboration was that the contracting team successfully negotiated to include Avera in a payer’s exclusive specialty pharmacy network.

Use pharmacy expertise to offset future challenges

Bringing in pharmacy expertise and capabilities positions Avera to preemptively address both payer restrictions on infusion services and other specialty drug management strategies. This supports Avera’s negotiations for a wide range of issues, from more favorable at-risk contracts to formulary changes for biosimilar conversions.