The Cost of Patient Noncompliance
For the practice-based infusion suites and stand-alone Infusion Centers, keeping patients compliant with their treatment schedules results in better clinical outcomes and improves the financial health of their business models. While treatment compliance is important with traditional oral medications or therapeutic injectables, it is paramount with specialty injectables and IVIG therapies.
Specialty medications, including biologics and IVIG, carry a substantially higher cost than traditional therapeutic injectables. These medications mostly treat patients with Chronic Autoimmune Diseases who require frequent, interval-based treatments. The combination of high cost and chronic repeated interval scheduling raises the stakes for practices who manage these medications in the in-office infusion suite or stand-alone Infusion Center.
Patient vs. Office Caused Noncompliance
Most offices are well aware of both the causes and remedies for patient noncompliance. Patients routinely miss or have to reschedule their treatment appointments due to life events – car trouble, vacation, illness, financial hardships, etc. Offices attempt to mitigate these common patient issues through appointment reminders, availability of office hours, and patient payment plans.
While patient-caused noncompliance is important, my experience has taught me that office-caused noncompliance is a much larger and more complicated problem to solve. I define “office-caused” noncompliance as any action or lack of action by the office team, that does not allow a patient to keep their scheduled treatment appointment.
The primary causes of office-caused noncompliance:
- Incomplete or inadequate insurance benefit investigation
- Poor process for obtaining and maintaining insurance pre-authorization or referrals
- Poor process for re-verification / eligibility checking
- Poor inventory management – both for Buy&Bill and Specialty Pharmacy
- Lack of a proper chair-based patient scheduling system or process
Before we take a look into a few of these issues, I want to talk briefly about why it is so important to minimize office-caused noncompliance.
Why Anyone Should Care About Treatment Noncompliance
There are compelling data studies on the clinical implications of not keeping a patient on the precise FDA-approved treatment schedule for a specialty and/or biologic medication. Very small variances in the treatment frequency can reduce or remove the efficacy of the medication entirely. For this writing, I am not going to dive too deep into the clinical implications of noncompliance as I feel like those consequences are well-known and well-documented. Just know that there are significant clinical advantages to keeping patients on their prescribed treatment schedule. All stakeholders, and especially the patient and the insurance company, have a vested financial interest in getting as much clinical benefit from these expensive medications as possible.
In this writing, I want to highlight the cost of noncompliance to the practice, distributor, and medication manufacturer.
The Cost of Noncompliance
Many specialty biologic medications are dosed on a frequency interval of every 2, 4, 6 or 8 weeks. With these dosing intervals, patients can expect to receive anywhere from 7 to 27 treatments per year if they remain compliant to their scheduled appointment dates. As described above, there are many patient-caused and office-caused reasons why a patient may receive less than their yearly total number of treatments.
The high cost of these medications also generates high reimbursement and revenue values per treatment. With any luck, most offices will have commercial insurance or Medicare reimbursements that are higher than their medication costs and allow them to retain some margin for their hard work.
For the in-office infusion suite or stand-alone Infusion Center, missed treatment target dates will result in lost treatment dates per year – meaning lost revenue and margin.
The infusion office is not the only one to lose in this story. If the office is underperforming and causing treatments to be missed or pushed back, that means the medication manufacturer and the office distributor is losing as well. Fewer completed treatments mean fewer vials sold and delivered to the office. All stakeholders in the medication delivery channel have a vested interest in maintaining the highest levels of patient treatment compliance (clinically and financially).
Let’s look at an example to put this problem and the dollars in perspective:
Medication “X” given IV over 1 hour, every 4 weeks for 1 year
Treatments per Year:
$5,000 per treatment
Medication X Payment:
$5,300 (6% margin)
Total Office Revenue:
$5,420 per treatment - $75,880 per year
Total Office Margin:
$420 per treatment - $5,880 per year
Using these example values, every single lost treatment opportunity will cost the office $5,420.00 in revenue and $420 in margin, which can quickly become a material loss for the practice, as evidenced by the following annual example.
Let’s assume that this example office has 100 “Medication X” patients and 10% of them lose a single treatment per year:
Treatments per year:
100 patients X 14 possible treatments per year = 1,400 treatments
Lost Treatments @ 10%:
140 treatments lost
Lost Revenue Opportunity:
$758,800 per year
Lost Margin Opportunity:
$58,800 per year
Using these example annual values, a 10% loss rate in treatments on this single medication would cost the office over $750K in lost revenue and nearly $60K in lost margin.
In addition, the Medication Distributor for this office will have lost $700,000 in revenue. I am not informed of the margin that this would cost the distributor or medication manufacturer, but if they are reading this I am sure they could put those numbers together quickly.
That’s a lot of money lost in our example, but how realistic is it that an office could let 10% of possible appointments slide on a single medication per year?
Consider this – on a medication with a dosing frequency of every 4 weeks that begins on January 1st – if each appointment has rescheduled an average of 1 day per appointment (Wednesday to Thursday for example) the possible treatments per year move from 14 to 13. Increase that average to 3 days and the treatment loss increases from 14 to 12.
Consider also the lost treatment opportunities due to delayed treatment start dates. If an office could have possibly gathered and processed a new patient order insurance prior authorization in 30 days, but instead takes 45 days to complete the authorization, they have now delayed possible treatments that year by 15 days. In most cases, that 15 days will be enough to lose 1-2 treatments that year.
Solutions to Mitigate Noncompliance
I covered common causes for Office-Caused noncompliance in the bulleted list above. I want to briefly dig into those issues and some solutions to mitigate them.
- Incomplete or inadequate insurance benefit investigation
If you start with bad or incomplete insurance information, then odds are not good that things will go well for the patient treatment process. Missing details around required authorizations, referrals, specialty pharmacy, step therapy requirements, etc. will result in a delayed treatment start, or cause a treatment pause after denials start rolling in on EOBs from previous treatments. Getting a complete and accurate benefit investigation documented on the front-end of the treatment process is critical for a positive compliance outcome.
Mitigate this issue by making sure your office team takes the time to completely and accurately complete a full benefits investigation for any new patient treatment or anytime a patient changes to a new insurance plan. Your office needs to have pre-written workflows and systems, logging, and notification processes to ensure that benefits investigations are completed timely and accurately.
- Authorization and Referral Workflow
Staying on top of the Authorization and Referral workflow is critical to getting the patient’s appointment on the schedule as soon as possible. For every day that your office team does not submit, follow up, or maintain a required part of the Authorization or Referral request process you add a day to the patient’s treatment start date.
In addition, not maintaining awareness of the expiration date or approved treatment count for an existing treatment authorization or referral will cause treatment delays as your office team rushes to get a new authorization at the last minute before a scheduled appointment target date.
Even a small practice will struggle to keep up with 100s or 1,000s of required and expiring Authorizations and Referrals manually. Mitigate these delays through great systems that take the human element (and error) out of the process of managing these tasks. Any system your office adopts must have proactive reminders and tracking of each task so you can measure, monitor, and improve your Authorization and Referral workflow throughput.
- Re-verifications and Eligibility Checking
Getting new patients on the schedule is one thing, but managing each additional visit is just as critical to maintaining treatment compliance. Before a patient is infused, the office must check each patient’s insurance eligibility and “re-verify” to ensure that each patient’s insurance status has not changed which could otherwise cause the treatment to be delayed, canceled, or not reimbursed.
Mitigate this issue by automating the bulk of your patient eligibility checks through systems equipped with batch electronic eligibility checking. If you have a system that manages the items in #2 above, then you have most of the re-verification tasks for returning patient treatments mostly covered without having to have any of your office team waste time on the phone or processing these tasks manually.
- Inventory Management
Treating patients is not possible when you do not have the inventory you need on their appointment date. Specialty injectable biologic and IVIG products are not routinely available at the nearest corner pharmacy. If the office inventory is not proactively managed, then treatments get delayed and re-scheduled, patients get frustrated and everyone loses.
Mitigate inventory issues by proactively managing your inventory needs and stock par levels. Unless your infusion suite or center is very small, successful management of inventory levels is unlikely without an electronic system that proactively assesses your inventory needs and maintains inventory stock counts on a perpetual basis.
- Patient Scheduling Systems
Offices with as few as 100 treatments per month will be managing over 1,200 patient appointments a year. Depending on your office’s infusion hours, this means you will have to accurately and efficiently schedule over a thousand appointments within a very small target window in order to keep your treatment loss to a minimum. Counting dates on a calendar, and maintaining tight and accurate treatment frequencies manually can be a challenging task for any office team member.
Mitigate this issue by using electronic scheduling systems built for managing patient treatment-based appointments. The best patient scheduling systems will be tied to the medication order and track target appointment dates for the patient based on the medication order frequency. These best systems will also have notifications, so office staff are reminded about patients who need new appointments or are passed their target dates.
If You Can’t Measure It, You Can’t Manage It
Do you know your office’s current patient compliance rate? Most offices don’t have the systems they need to track and measure the individual steps in the treatment workflow. If you can’t measure the individual processes that lead to scheduling a patient’s treatment, it is very difficult to measure the effectiveness of interventions designed to improve patient treatment compliance.
Knowing that your treatment authorization process for a specific medication or specific payer is taking 45 days on average is very helpful because it allows you to implement solutions with your office processes and staff to help drive that number back towards 30 days or less.
If you want your in-office infusion suite or stand-alone Infusion Center to reach its full financial potential, managing patient treatment compliance should be a high priority for your team. There are a few instances where all stakeholders – patients, insurance companies, manufacturers, distributors, physicians, and infusion offices – share a common objective.
Clinical and financial outcomes are best when patient treatment compliance is managed successfully. It’s an uncommon win-win for everyone.
Want to see how our Infusion Center software can help your office team measure and manage patient treatment compliance successfully? Contact a member of our team to learn how WeInfuse can help you Take the Confusion out of Infusion by requesting a demo here.