The specialty pharmacy and home infusion drug market continues to burgeon along with an aging Baby Boomer population requiring increased Medicare services and specialized care, most notably in oncology and neurodegenerative diseases. In an effort to streamline costs, payors have prioritized alternative deployment methods and are now transitioning patients out of hospitals sooner and into less complex (and safe) treatment environments.
This week, host Andrew Maddigan, Vice President, Client Engagement welcomes Mary Jo Heglund, Director of Infusion Services at CSI Specialty Group, to discuss the current state of the infusion industry and how infusion and specialty pharmacies can manage risk and take control of their own destinies to drive success.
Tune in to Discover:
- The major challenges facing the pharmacy industry
- The changing landscape of accreditation for home infusion specialty pharmacies
- The importance of effective outcome and patient monitoring systems
- Core issues affecting the specialty infusion market
- How infusion providers can manage risks and overcome obstacles to growth
About Mary Jo Heglund, MBA, BSN, RN
Mary Jo Heglund is an experienced Registered Nurse with 30 years’ experience as a nursing educator and nursing leader. She has managed a 28-bed in-patient post-cardiac transplant unit with 35 FTE’s, supervised a medical office building build-out, and acted as General Manager of a medical building, acute care, ambulatory infusion clinic, laboratory and radiology departments.
Mary Jo has over 20 years of combined experience working in the Alternate Site Infusion and the Specialty Infusion markets. She acted as Corporate Clinical Manager and was promoted to Director of Clinical Services for OptionCare and was the Director of Clinical Services for InfuScience, a startup infusion company. At InfuScience she received Employee of the Year award as well as Core Values Champion of the Year.
Prior to joining CSI Specialty Group, Mary Jo was Vice-President for Nursing at AxelaCare. Her responsibilities included budget development and management, and obtaining and maintaining licensure and accreditation. She was responsible for the care provided to over 2500 specialty infusion patients with 450 nurses.
As a member of senior AxelaCare leadership, Mary Jo was responsible for the company’s quality program including clinical, financial and patient experience outcomes. She was lead on quality components of URAC accreditation with AxelaCare achieving a score of 100% on their initial survey. Mary Jo received her Bachelor’s degree in Nursing from Lewis University in Lockport, Illinois and her Master’s degree in Business from North Park University in Chicago.
About Andrew Maddigan
During the past 30 years, Andrew Maddigan has directed business strategy and marketing functions in a wide range of venues, including health care, education, aerospace, and energy. His previous roles have included VP of marketing for the nation’s largest not-for-profit hospice agency, VP of sales and marketing for a national specialty and long-term care pharmacy and communications director at a large urban school district.
Andrew also led marketing and strategic communications efforts for an international health care accreditation agency, serving as the organization’s liaison to the United Nations Development Program. Andrew earned his BS in Broadcast Journalism from the S.I. Newhouse School of Public Communications at Syracuse University. He earned an MS in Educational Administration from Canisius College and an MBA from St. Bonaventure University. He currently serves as VP of client engagement at CSI Specialty Group.
About CSI Specialty Group
CSI Specialty Group is a globally recognized leadership consulting firm dedicated to providing solutions that continually elevate the specialty pharmacy industry and improve the patient journey. By providing inventive consulting, workforce planning and talent acquisition solutions, we uniquely tailor our service offerings to help clients drive sustainable, accelerated growth.
As the producer of the industry’s first dedicated podcast for specialty pharmacy and the publisher of the Annual State of Specialty Pharmacy Report, CSI is at the forefront of pioneering innovative concepts to meet the changing needs of specialty pharmacy, home infusion, mail order/PBM, health systems and pharma/biotech clients across the USA and throughout Europe.
For more information about CSI Specialty Group, visit www.CSIgroup.net.
About CSI University
CSI University is the industry’s leading online training platform specific to specialty pharmacy sales professionals.
After years of conducting successful on-site training, CSI University’s online sales training course offers groundbreaking, cutting-edge and on-demand training to new and existing sales representatives of specialty pharmacies. The program is built from the ground-up to ensure individuals and entire sales teams are ready and able to take their game to the next level and optimize sales to expand their company’s foundation in the ever-changing marketplace.
Speaker 1: Welcome to the Specialty Pharmacy podcast, your prescription for specialty pharmacy success.
Andy Maddigan: Hello and welcome to the CSI Specialty Pharmacy podcast. I’m Andy Maddigan, CSI vice president of client engagement and your host for this episode. Today I am very pleased to welcome Mary Jo Heglund who is CSI’s director of infusion services. Welcome Mary Jo.
Mary Jo Heglund: Thank you, Andy. I’m glad to be here.
Andy Maddigan: So start off with, I just wonder if you can tell our listeners a little bit about your background and I know you’re a nurse and maybe a little bit about your current role with CSI.
Mary Jo Heglund: Sure. I have worked in infusions for more years than I care to state. I started out in the infusion world in a Chicago-based company where we managed heart failure infusion patients at home. We had a census of about 30 patients. And from there I went to work for one of the national company. Most recently, prior to joining CSI, I was the vice president of nursing at Accelacare, which is now Briova infusion services.
Mary Jo Heglund: As the director of home infusion services and operations. My role is supporting any infusion projects that we’re working on that includes patient management, accreditation, any kinds of clinical marketing and growth of alternate forms of infusion working with health systems, small pharmacies, infusion pharmacies, specialty pharmacies.
Andy Maddigan: Great. So a real diversity of different stakeholder groups in the health care continuum that you were exposed to in your various roles. That’s really good. So given that and all your experience, how do you view the current state of the pharmacy industry today? What do you think the major issues are or major challenges?
Mary Jo Heglund: Well, it’s interesting because home infusion has been growing and today we’ve got both traditional therapies, antibiotics, antifungal medications, hydration, nutrition, and the ever-growing specialty infusion therapies that have come on board. These are done in the patient’s home or on a freestanding ambulatory suite that’s affiliated with a actually home infusion pharmacy or a specialty pharmacy.
Mary Jo Heglund: If we look at the dollars that are going on out there, there’s one recent report that says there’s $11 billion in spending in the US. And the third party payers and benefit… The PBMs, the insurers under major medical are really looking at deploying alternative ways to provide these medications. Certainly taking them out of the hospital, putting them into an alternate site of care and trying to infuse at the lowest cost possible.
Mary Jo Heglund: The infusion therapy market is in addition to that, some are between 9 billion and $11 billion. And CVS Caremark put out a specialty drug report that says infused drugs, so this is just in addition to regular infusion and ambulatory suites, that specialty drugs can be up to 35 billion of the specialty drug market. That’s a lot of dollars that are going on right now being spent on these medications.
Andy Maddigan: So what do you think the key issues are that are kind of driving some of the policy, some of the commercial decisions in policy given that?
Mary Jo Heglund: Well, a couple of things that are happening. Our population is aging. The baby boomer generation is heading more and more down into the Medicare world. On top of that, we have much more advanced treatment protocols, medications, biologics are coming down the pipeline very quickly. These patients that are in that baby boomer age are more educated. And with proper training and technology monitoring ability to telehealth. Patients can be seen in a less complex environment.
Mary Jo Heglund: So both the inpatient hospitals, the discharge planners are all seeing the need to get patients out of the hospital sooner due to cost, and due to potential for complications, such as infection. So patients are being moved out of the hospitals much faster. The payers, Medicare’s got DRG, the commercial contracts have fixed rates. And so they’re looking to drive patients into a lower cost, however necessarily safe environment.
Andy Maddigan: You used a word, you said DRGs?
Mary Jo Heglund: That’s a medical term for diagnostic related group and what that is is Medicare has decided that for a particular DRG, a hospital will reimburse a flat fee regardless of how many days the patient’s in the hospital.
Andy Maddigan: Okay. Some of the payers are now requiring more than one accreditation for infusion. Is that something-
Mary Jo Heglund: That is what we’re starting to see as a trend. That that is many of health systems in particular for the most part have joint commission and affiliated home infusion companies that hospitals have the joint commission. But now the payers are asking for a specialty infusion, a specialty pharmacy accreditation on top of it, which is URAC.
Mary Jo Heglund: So what’s now happening is that everything has been done from an accreditation standpoint for the physician to have to change into a much more complex system such as URAC. ACHC is the other traditional accreditation that many pharmacies and infusion pharmacies have and so they’re having to have the ACHC on top of URAC.
Andy Maddigan: Great. Has that been a challenge that has been extremely perplexing in a healthcare system world or has that been something they’ve been able to manage with relative ease? [crosstalk]
Mary Jo Heglund: I think that it is complex. The standards for URAC are very different and require a lot more attention to detail. At the end of the day, the pharmacies that are going to have URAC accreditation are going to be better pharmacies. Because of the requirements of monitoring the patient management program and having multidisciplinary people involved in the pharmacy.
Mary Jo Heglund: However, the standards are complex and time-consuming and require a fair amount of resources within an organization to go down that path, both from an individual standpoint as well as a cost standpoint.
Andy Maddigan: Okay. Tell me about some of the projects that you’re working on. Maybe not specifically, but you know the sort of stuff that you do at CSI, and how you bring your expertise to bear to assist companies.
Mary Jo Heglund: A couple of the things that we’ve been able to do at CSI, which is assist health systems with developing a patient management program, which includes tracking clinical outcomes that are appropriate to the disease state. As I said in the beginning, I managed a heart failure patient population. Those outcomes are going to be very different than, for example, in globulin or for medications for arthritis, for example. Those clinical outcomes are going to be very different.
Mary Jo Heglund: And so working with pharmacists and health systems to find the right outcomes to monitor and then helping develop patient management programs that correspond to the therapies they’re providing, which will then result in the ability to get your URAC accreditation a lot easier.
Mary Jo Heglund: I love outcomes. I think they tell so much. They help the physician, they help the health systems know how their patients are doing. The payers get some information on the quality of the organization. And the manufacturers can get drug utilization information. So proper outcomes really is a win-win across the board.
Andy Maddigan: Right. And and how does that translate to patients, our patients? Is there some transparency or visibility that a patient might be able to see the outcomes?
Mary Jo Heglund: What’s great about it is that the various accrediting agencies give scores and so patients, consumers can go and look and see how they rate. But what really helps the patients if you’re monitoring patients where the great is you’re going to be able to know that the patient is getting the right drug, the right dose, and the right frequency.
Mary Jo Heglund: And they’ll be able to then know are you truly being effective in the therapy that you’re providing to the patient? And the patient can see that because they’re symptoms are [inaudible 00:09:32]. That’s the component that’s really important.
Andy Maddigan: So as a whole, would you say that the infusion market, the specialty infusion delivery model is growing, its level, it’s on the decline? How would you characterize it?
Mary Jo Heglund: It’s definitely growing. Going back to the issues of the aging population. And the increasing focus on specialty drug development in the pipeline for some of the diseases that historically were not managed or didn’t have therapies.
Mary Jo Heglund: So Alzheimer’s disease, new meds for heart failure, and then in the next five years the oncology market. [inaudible] and diabetes is also going to have some therapeutic growth, which may fall into the infusion and specialty infusion category.
Andy Maddigan: Yeah, so that’s a very complex scenario you painted there in its growth, but there’s an awful lot to consider. What are some of the challenges that this presents?
Mary Jo Heglund: It’s an interesting question because CSI did a survey of the state of specialty infusion and wanting to know what are the challenges that are faced, and what came out loud and clear as the issues tied to the 21st Century Cures Act. And there were a lot of great things in that act, but two things came out of it. One of them, which is payment used to be made under AWP; average wholesale price, plus a percent; plus or minus a percentage. Now it’s come down to ASP, which is much lower.
Mary Jo Heglund: The other thing that happened in the Cures Act is there was a definition interpreted by CMS that says that a per diem as infusion medications are reimbursed, they’re reimbursed for both the drug and there’s a professional component. What’s happened is the definition of that professional component, is now been defined as only the day a nurse is in the home with the patient.
Mary Jo Heglund: And anybody in the world of infusion and pharmacy knows that there is so much professional coordination of care and monitoring that goes on on a daily, weekly basis. The pharmacists, the technicians, the pharmacists are reviewing how the patient did on their infusion, how they’re feeling afterwards.
Mary Jo Heglund: So looking at those outcomes, they’re communicating with the physician and so there’s a lot of work going on. If the professional fee is only going to be the day the nurse is there, which doesn’t really compensate the pharmacy for the services that are provided. So we’ve now got a lower drug rate as well as not a professional services fee, and we really have the ability now to not have the funding to support our operation. That is probably the largest challenge.
Mary Jo Heglund: The other side to this is that this only applies to the Medicare patients that has therapies covered under Medicare. So that is a limited medication that are in that category and everything else then falls under the Part D, which is also a challenge. Because the cost of the drugs are up and reimbursement for that down. And the patients have a larger out of pocket, again, you got an aging population, and they’re not able to afford that component.
Andy Maddigan: Right. What are some of the ways that providers now are managing those challenges or are in need of managing them better perhaps?
Mary Jo Heglund: One of the ways to address this is I’m much more than just what you do in your local pharmacy, but it’s about working with NHIA and the lobbying that’s going on to our various congressmen and senators to try to get this law changed. Because if the CMS interpretation of the law. So that’s one of the things that we can do as professionals.
Mary Jo Heglund: The other thing that’s happening is infusion providers are starting to develop in return infusion suite to provide that controlled environment for many of the medications. It’s middle ground between home and the inpatient or the bricks and mortar hospitals, infusion clinic.
Mary Jo Heglund: By moving the patient to a lower cost, but still controlled site of care, it allows for reimbursement to happen not in the home rate, but in a more contracted and it’s commercial, but at a contracted rate that that will be better and the patients will be able to be served. And so the payers are really driving this from a cost perspective, but they’re also beginning to see the opportunity for better outcomes.
Mary Jo Heglund: Again, the patients are going to do better because the patient’s supposed to get up every day or every three days, however long they’re going to the clinic. To get up, get dressed, be motivated to participate in their care.
Andy Maddigan: Right. So the advice is to become more aware and become more involved on the part of advocacy and utilizing resources available through the association, NHIA and others, and taking control of your own destiny a little bit more.
Andy Maddigan: Are there threats that exist that providers are not aware of that they should be preparing for? What sort of advice would you give? What are some of those areas and what should they be doing about them?
Mary Jo Heglund: Every infusion pharmacy or specialty pharmacy should have a specialty infusion strategy component to their business plan. By doing that, you’ll identify the resources that you have within your organization. You will identify who are your competitive risks. Is there another hospital on the street that you’re possibly going to lose patients to? Is your hospital referring patients to one of the national companies and possibly, and you lose patients out of your control because you aren’t doing patient management.
Mary Jo Heglund: Health systems without a doubt has to have a solid home infusion strategy, need to understand the prescribing patterns of the physician. So many of the prescriptions are not written as discharges from the hospital, but through the physicians offices and looking to see what medications might be within an LDD. And then partnering with the pharmacies that aren’t included in the limited distribution network that will allow you to still have some component of the patient and share that patient. And won’t lose the patient completely.
Mary Jo Heglund: And knowing and looking at your managed care contracts. See if you’ve been carved out of a contract or how you can be carved into a contract for a specific therapy to having a really good analysis of your managed care program and knowing that contracts are difficult to get without that URAC accreditation.
Mary Jo Heglund: So going down that path and at least investigating is it worthwhile? Are you going to be able to add on especially for [inaudible] to current contracts that you have? If you have the URAC accreditation. Those are some of the things that you can do proactively within your organization and obviously like you said, Andy being involved and knowing what’s around from a professional standpoint and how to make a difference from that perspective.
Andy Maddigan: Right. Good advice, definitely. So that’s about all the time we have today. So with that I want to say thank you to Mary Jo Heglund for sharing your insights with us and audience. And we look forward to having you join us again some time, hopefully not in too distant future.
Andy Maddigan: If somebody has a question or wants to get in touch with you, Mary Jo, how would they do that?
Mary Jo Heglund: My email is Mary Jo, M-A-R-Y, J-O @csigroup.net is probably the easiest way to reach me and then I can answer your questions or return your call.
Andy Maddigan: Excellent. Great. Well again, thanks. Thanks very much and thanks to our listeners for joining us on the CSI Specialty Pharmacy podcast, I encourage you to visit our website, csigroup.net and going there, and you can download a free copy of our 2019 State of Specialty Pharmacy report. And until next time, have a good day.
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