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Providing care beyond hospital walls is a growing trend for 340B hospitals. One service that health systems provide outside of the hospital setting is home infusion care. On our first episode of 2023, we are joined by David Klinger and Seth Gazes from Geisinger Health to hear how 340B hospitals can establish home infusion care and the 340B considerations they should keep in mind. Prior to the interview, we provide an update on the 19th drug company to restrict 340B discounts for drugs dispensed at community and specialty contract pharmacies. We also recap drug manufacturer 340B overcharge notices in 2022.
340B Insight provides members and supporters of 340B Health with timely updates and discussions about the 340B drug pricing program. The podcast helps listeners stay current with and learn more about 340B to help them serve their patients and communities and remain compliant. We publish new episodes twice a month, with news reports and in-depth interviews with leading health care practitioners, policy and legal experts, public policymakers, and our expert staff.
Speaker 1 (00:04):
Welcome to 340B Insight from 340B Health.
David Glendinning (00:13):
Hello from Washington DC and welcome back to 340B Insight, the podcast about the 340B drug pricing program. I'm David Glendinning with 340B Health. Our guests today are David Klinger, System Director of Pharmacy Operations and Compliance for Geisinger Health in Pennsylvania, and Seth Gazes, who is System Director for Strategy and Planning at Geisinger Pharmacy.
(00:38):
340B Health Systems provides significant amounts of care to patients at sites outside of the hospital, including in patients' homes. Geisinger is a longtime leader in providing home infusion services for patients with cancer and other conditions that require IV treatments. We wanted to hear from Dave and Seth about the 340B considerations that health systems should take into account when operating a home infusion program. Before we go to that discussion, let's take a minute to cover some of the latest news about 340B.
(01:20):
In mid-December, the pharmaceutical company, Biogen, announced it would start restricting hospital's access to 340B discounts on two of its major therapies used to treat multiple sclerosis. Starting February 1st, Biogen says it will stop providing 340B pricing to hospitals on interferon products, Avonex and Plegridy when distributed through contract pharmacies with limited exceptions. The announcement means that Biogen will become the 19th company to impose 340B restrictions that the federal government has deemed unlawful. Three federal appeals courts are considering lawsuits over such restrictions and are expected to issue decisions in the coming months.
(02:03):
In the final days of December, the Health Resources and Services Administration hosted the last of 33 notices for 2022 from drug companies acknowledging 340B overcharges and announcing refunds. This shatters the previous record of 17 such notices that drug makers filed in all of 2021. And the first such notice already has been filed for 2023. This sharp uptick in companies announcing overcharges and refunds comes from reviews of quarterly pricing data reports that drug companies must submit to HRSA to help populate the 340B ceiling price website. 340BK hospitals can use this website to ensure the drug makers are charging them the correct amounts for eligible purchases. Please visit the show notes to learn more.
(03:00):
And now for our feature interview with Dave Klinger and Seth Gazes. Geisinger is one of the many health systems that send their health providers out to meet patients where they are, including those who benefit from receiving infusion treatments outside of the hospital. There are 340B considerations health systems must plan for when offering home infusion treatments. Myles Goldman sat down with Dave and Seth to learn more about these factors and about Geisinger's success in this growing area of patient care. Here's that conversation.
Myles Goldman (03:32):
Thank you, David. I'm joined by Dave Klinger and Seth Gazes from Geisinger. Dave and Seth, welcome to 340B Insight.
David Klinger (03:40):
Pleasure to be here.
Seth Gazes (03:41):
Thanks, Myles. Excited to have the conversation.
Myles Goldman (03:44):
Well, I'm excited to have both of you joining us. Providing care beyond the hospital walls continues to be a growing trend for 340B hospitals, and one of those areas is in home infusion care. I'm looking forward to diving into this topic and what it means for 340B. But first Dave, tell us about Geisinger and the patients and communities it serves.
David Klinger (04:06):
Sure, thank you, Myles. Geisinger Health consists of approximately 10 hospital campuses, oh throughout a 46 Pennsylvania County region. It also includes a little over 130 clinic sites as well as has close to 500,000 Geisinger Health Plan members that we do total care for. Additionally, this care center also has about 24,000 employees, and through fiscal year 20 has been able to provide close to 900 million in total community benefit as an organization.
Myles Goldman (04:41):
And let's get into one of those areas of care Geisinger's providing, which is the home infusion program. Seth, tell me more about it and what prompted Geisinger to start it.
Seth Gazes (04:51):
Yeah, so in terms of Geisinger's home Infusion program is 30 plus years old, really started in the post-discharge space or around antibiotics and nutrition. And I think in most recent years, has transitioned into more of the specialty and biologics arena. Originally was servicing an underserved population, perhaps most likely having trouble accessing healthcare services. So leveraging our unique market possession and relationship with the community started providing those services closer to the patient.
Myles Goldman (05:30):
And can you talk just a little bit more, Seth, about what some of those challenges are that patients are facing, where they might benefit more to be provided their infusion treatments outside of the hospital?
Seth Gazes (05:43):
For people that are on infusion therapy for chronic conditions that they'll be on for the rest of their lives, you look at our geography. It could be four or five hours end to end to a hospital-based infusion center is not always tenable or easy in terms of balancing that with work and family. So being able to have those therapies if you're going every six weeks or six months or what have you, in the home or at a more convenient location, is key. And then certainly from a hospital discharge perspective, if you have somebody on antibiotic therapy, you're able to get them discharged to home one, two, or three days earlier and manage that patient out of home instead of bringing them in. Certainly at advantageous for both the patient, the payer, and the provider.
Myles Goldman (06:36):
And how many patients does the home infusion program serve? And what does home infusion treatment look like from the patient perspective?
David Klinger (06:47):
Yeah. Myles, currently Geisinger Home Infusion services around 2,000 patients across the care regions. This can include anything from IV antibiotics to different immune supportive therapies. And from a patient perspective, there's opportunities for nurses to come in and assist patients with the care and administration within their homes. Some of the instances, patients are able to manage some of their infusional drugs independently. But it does allow for, especially in cases where we have Geisinger Home Infusion nurses going in to see patients, really just an added layer of that face-to-face care to help ensure that the environment patient's in is supportive and appropriate for care.
Myles Goldman (07:32):
How do patients become part of the home infusion program? Are they referred into it or?
David Klinger (07:38):
Yeah, it's typically a referral process. The pharmacy care team as well as physician care team within the hospital will make the appropriate referrals and connections to home infusion, based on the type of therapy that they might need subsequent to discharge. Also on the outpatient perspective, there may be referrals coming in from various specialty departments that require patients to get infusional therapies that may not be appropriate or may not have an opportunity to be done in a clinic infusion site and therefore would promote more of the opportunity to get the patient's care delivered at home through the various infusions.
Seth Gazes (08:15):
I think they've covered sort of the discharge flow pretty well. And what we at Geisinger have done is positioned clinical pharmacists in those areas with two primary objectives. One is to drive patient access in those specialties, so to be a physician extender so we can service more patients with the same amount of physicians. And then two is to really help them navigate the complex site of care, prior authorization medication selection journey. And part of that journey is maybe saying, "Hey, your first two OCREVUS infusions will be at a hospital location in a controlled setting, following no adverse reactions, we're going to move you to home.", which may also be the payer policy for that drug or the payer policy may afford three or four infusions in a controlled setting.
Myles Goldman (09:16):
And Seth, how are patients reacting to receiving the infusion treatments outside the hospital setting? What feedback are you hearing?
David Klinger (09:24):
I think they have reacted very well. It can be sometimes more efficient for us from an operational perspective, to get them into a four chair suite. But in many instances, they're very comfortable at home and they're pretty reticent to moving out of the home. I think it's almost more of a challenge to convince providers around the benefits and safe of infusing these therapies at home. And part of our accrediting body requirements required us to do patient satisfaction survey. And I think, what is it, Dave? 95% of Geisinger Home Infusion Service patients have expressed their satisfaction and recommend us to family or friends.
(10:16):
Yes, I would agree.
Myles Goldman (10:18):
Is persuading providers and educating them about the benefits of home infusion, is that the greatest challenge that your home infusion program faces? Or are there other challenges?
David Klinger (10:29):
Yeah, I mean think certainly it's a challenge. I think over the last few years as Geisinger Home Infusion really has been more of a common namesake for pharmacy and the system, I think the movement towards provider acceptance, although there's still work to be done, has been enhanced considerably. I think probably one of the main challenges I think we have as a part of healthcare, and this certainly goes across other levels of healthcare, is maintaining staff. We've had, with the national nursing shortages, our home infusion service has struggled at times to maintain ample nursing resources in order to go out to the home. And certainly trying to work through improvements on, how do we help to recognize those positions. And really finding ways to enhance those jobs from a [promotionbility 00:11:22], whether it's a work-from-home opportunity, whether it's more delivery of hours that could be personalized based on the patient need.
(11:30):
I think additionally from a staff perspective, we also struggle at times with pharmacy technicians, which is another area of national shortage of staff that actually prepares the medications for home infusion. And then lastly, I think we also need to make sure we're able to maintain what's needed from a regulatory and reimbursement standpoint. Because as insurance companies change how they structure their payments as well as how they may require patients to follow a certain line of care, we obviously have to be cognizant of that as we continue to build our business model.
Myles Goldman (12:03):
What should other 340B hospitals know, when it comes to home infusion programs?
David Klinger (12:08):
I think specific to 340B, it's really understanding the environment that is within the 340B program at a given health system or facility. It's taking a look at patients eligibility, where those patients are going today for similar types of care that can be streamlined into utilizing home infusion as a contract pharmacy. That's primarily where most cases you see the connectivity, since the majority of home infusion services lie outside of the hospital in particular, and may or may not be licensed through the specific hospital that's registered for 340B. So we utilize it as a pharmacy contract model or contract pharmacy model. That really allows for just a continuation of care with referrals from hospital-based patient clinics. And then subsequently we're able then to utilize some of the drug savings that comes back to the hospital.
(13:07):
I think certainly, the opportunity of being able to utilize the 340B benefit across our health system has allowed us to grow programs, including things such as expansion of home infusion to some of our less served regions. Has allowed us to provide other services within the community that I think bring patients. From a nutrition perspective, Geisinger has recently started the fresh food pharmacy, which provides an opportunity for patients who may not be able to get to really healthy food choices. They can come into a specific location and get more healthy foods, especially for patients who may be diabetic or have other nutritional issues.
(13:45):
So I think as part of a home infusion perspective, home infusion and any other program that could help support patients in the community. And subsequently may provide some benefit from a 340B program perspective really just helps to support the larger cause around helping the underserved patients as we do with the benefits we see from the 340B program.
Myles Goldman (14:07):
Are there any other programs that Geisinger is using the 340B savings that are generated through purchasing drugs for home infusion?
David Klinger (14:17):
We do things such as Geisinger at Home, which helps to provide additional care for patients with caregivers coming into the home separate from a home infusion perspective. It's helped us to promote and organize programs called, 65 Forward, which really are senior centric clinics where patients actually can go on a daily basis and get everything from care from a provider to activities that they can share with other members of the community, pharmacy involvement with regards to prescriptions as well as additional care through our disease state management. We provide a copay card program in our retail pharmacies as well that helps get supported through the 340B initiatives as well as other funding sources. Just to give you a sense of some of the opportunities that Geisinger has been able to do with the effective engagement with the 340B program.
Myles Goldman (15:10):
That's great to hear. And I want to broaden out a little bit to the big picture here and just sort of look at this home infusion program in terms of, how are you measuring success and are you achieving it?
Seth Gazes (15:25):
We sort of look at nurse utilization metrics and nurse efficiency metrics. And we're really doubling down on the suite model, given the hiring and labor challenges with nursing right now. It's a much more efficient nursing model for us. And of course, there's patient satisfaction there that we look at an annual basis. We're trying to grow 20 to 30% a year with our Home Infusion program. During COVID, it was actually higher than that and I think with some of the nursing challenges, it's been a little bit lower. But that's what we aim for every year.
Myles Goldman (16:02):
Well, and I think that's a great segue into looking forward into the future. What's next for Geisinger's Home Infusion program? And what do you think, just even broadly speaking, what are the trends we should be watching for home infusion programs?
Seth Gazes (16:17):
It's interesting, so I think everyone in the infusion space is trying to go after the most profitable areas of home infusion, which is on the specialty and biologic side. That's also where a lot of the growth is. But that's really leaving a gap in the market for the traditional therapies around TPN, intervals, and antibiotics. And so that provides unique opportunity I think, for health systems to fill that gap for the community and sort of really show how they are now looking at these opportunities from a purely financial or transactional basis. And they're really looking at a total cost of care and community benefit perspective. Because a lot of the big box home infusion providers are pulling out of that traditional business 'cause it's not as profitable for them.
(17:05):
Over time, I think it'll be the thing to happen like in the CAR T and CRISPR therapy, that's probably not going to be this year or next year. But in the all years, once everyone's more comfortable with that therapy, how that could be done, if at all, at home. I think those are some of the areas of growth. And certainly the whole suite model and the retail model around home infusion and conducting those infusions. And four or six or eight chair suites with the nursing staff onsite closer to the patient in a more retail setting that's highly accessible to the patient population is also certainly an area of growth as well.
Myles Goldman (17:46):
Well, you've certainly given us a lot to think about in terms of not only where the home infusion programs are today, but where they're headed in the future. And Dave and Seth, we wish you much continued success with your own home infusion program at Geisinger and continuing to grow it. So, thank you both for your time today.
Seth Gazes (18:05):
Thank you so much, Myles.
David Klinger (18:06):
Yeah, concur. Thank you very much for the opportunity. And again, as always, look forward to further engagements.
David Glendinning (18:12):
Our thanks again to Dave and Seth for walking us through Geisinger's Home Infusion Program and offering advice to their peers on how they too might extend care further beyond the four walls of the hospital.
(18:25):
This is our first episode of Season Four of our podcast and we are thrilled to have you with us in 2023. And we hope to see you at the 340B Coalition Winter Conference in San Diego from March 27th through March 29th. The early bird registration deadline for the conference is January 30th, so if you have not already registered, please visit the link in the show notes to sign up today.
(18:50):
We will be speaking soon with 340B Health President and CEO Maureen Testoni about what she sees on the 340B Horizon for this year. If you have questions for Maureen or advice on topics we should cover in future episodes this year, we would love to hear from you. You can email us at podcast@340bhealth.org.
(19:12):
In the meantime, we wish you a very happy New Year and best wishes for the entire year ahead. We will be back in a few weeks with our next episode. In the meantime, as always, thanks for listening, and be well.
Speaker 1 (19:30):
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on Twitter at 340B Health. And submit a question or idea to the show by emailing us at podcast 340B health.org.