A cost containment program targeting home infusion drug therapy - includes related information

Physician Executive, Nov, 1994 by John W. Richards, Jr., William J. Taylor

Finally, key indicators have been identified that have served to improve the claims analysts' and case managers' index of suspicion regarding which types of cases to send for evaluation. As media reports of fraud and abuse, price gouging, doctor deals, referral kickbacks, and inappropriate care increase, the price for home care will decrease. As outpatient care comes under increasing scrutiny by payers and government agencies, it is likely that prices will decrease even more.

Conclusion

Significant cost reductions can be achieved by incorporating protocols and programs to prospectively monitor and retrospectively audit providers of HDIT. These data, if applied to the total HDIT market, indicate that approximately $1.48 billion could be saved by managing the provision of HDIT and the costs associated with it.

However, as we have seen over the past four years, providers who abuse the system are likely to continue their efforts. Thus, although their methods will change, there will continue to be a need for monitoring the companies that are contributing to the health care industry's problems.

Selected Case Examples from the Study

* 9-year-old male, HIV , Dx pneumonia, on ceftazidime and IgG. Provider charge $4,997 per day, R&C $2,485 per day, cost reduction of $2,512 per day, $40,900 over the course of treatment.

* 40-year-old male, myeloid leukemia, post-bone marrow transplant, on gamimmune N 42.5 grams IV weekly for 16 weeks. Provider charge $103,173, R&C $60,418, cost reduction for 16 weeks $42,418.

* 36-year-old female, with breast cancer, on chemotherapy, Provider charge $1,81 0, R&C $826.48, cost reduction $983,52, for chemo course 5,280.

* 29-year-old male, HIV , cytomegalovirus and anemia, on Gancyclovir and Erythropoletin. Provider charge $4,359.60, R&C $2,138.50, cost reduction $2,221, 10, for course of therapy $78,156.

* 35-year-old male, malnutrition secondary to HIV, on total parenteral nutrition. Provider charge $13,276.77 for 1 0 days, R&C $4,000, cost reduction $9,276,77. (Claimant had already been on therapy for 5 months, and therapy went on for several more months. Including a refund for therapy already received, the total cost reduction was $123,206.

* A patient was given prescriptions for an extended supply of several medications consistent with the treatment of AIDS and AIDS-related problems (e.g., Neupogen 240 vials, Cipro 360 caps) He was told to have them filled and to bring the full supply to the doctor's office. Provider charge $82,976, R&C $38,796, cost reduction $44,180, However, the real question was appropriateness of dispensing these quantities, and the case manager dealt with this issue first.

* 19-year-old female with unknown diagnosis was being started on total parenteral nutrition at home. The consult originally was for pricing. However, the clinician involved felt there had to be more to the story for two reasons. It's unusual and can be dangerous to start total parenteral nutrition at home, and the diagnosis was not recorded. The clinician placed a call to the case manager to request more information. As it turned out, the patient was 7 months pregnant and suffering from hyperemesis. The physician had never used total parenteral nutrition but was told by the local provider that it was okay to do it this way. The case manager suggested hospitalization to assess the patient and to begin total parenteral nutrition in a controlled environment. The patient's potassium was 2.1 on admission. The savings in terms of the health of the mother and the baby are unknown.