The Payer Dilemma

Specialty Pharmacy TimesAugust 2011
Volume 2
Issue 3

The debate about who should pay for specialty pharmacy nursing services continues as risks mount without adequate nursing in the infusion/ injection patient experience.

There continues to be much debate regarding who should pay for specialty pharmacy nursing services. Most manufacturers consider it to be the responsibility of the specialty pharmacy and believe that they will be reimbursed by the patient’s insurance provider. However, that is only partially true. Even if a patient does have a nursing benefit that is covered under their insurance plan, the payment structure for nursing services tends to be only a fraction of the cost of what a specialty pharmacy will have to pay a highly skilled infusion nurse.

As a result of a poor reimbursement structure, patients could typically receive inadequate nursing care that can lead to an unsatisfactory infusion/injection experience. The risks associated with inadequate nursing care can include some or all of the following:

• Missed doses due to a nurse not being able to obtain venous access.

• Wasted drug due to a nurse not being familiar with the proper technique for mixing and administering the drug.

• Decline in referrals from physician to specialty pharmacy.

• Increases in the cost of drugs and supplies due to misuse.

Traditionally, when a specialty pharmacy (SP) has to incur the cost of nursing as an operational expense, they will look to contract with a nurse or a nursing agency that provides the highest level of care at the best available fee. The SP is relying on the nurse/agency to provide the highest level of care but cannot be guaranteed it meets the need of the patient with this specialty drug. Home health care agencies do not usually have high-tech nurses on their staff due to the higher cost of salary for this level of nursing. The agencies that do provide high-tech nursing usually have higher visit fees.

Some manufacturers have decided to contract out the nursing directly. This way they are covering the higher cost of nursing services to insure patients are receiving quality care and that these patients are not missing the therapies necessary for their health. By contracting for nursing costs directly the manufacturers can also contract directly with limited nursing providers who have the highly skilled nurses on staff and maintain better control and oversight of the nursing services patients are receiving. The result of this type of model may significantly improve the level of patient care while also significantly increasing compliance and adherence.

The manufacturer not only provides these nurses with the educational tools necessary to properly administer the therapy, they also are offering the opportunity for the highly skilled nurses to grow in an area of expertise. These nurses are very eager and excited to be a part of a specialty therapy, but they have not been recognized for their level of expertise monetarily within the traditional home care reimbursement model.

Until the payers start to acknowledge the high level of skill required in the home setting to administer these specialty therapies, these highly skilled infusion nurses will not be utilized by the home health care agencies in the home setting. This has proved to be detrimental to the health of patients and may also result in a delay in the start of therapy or even a discontinuation of therapy. SPT

Ms. Gregory, RN, BSN, is founder and president of the Specialty Pharmacy Nursing Network (SPNN). She has more than 30 years of experience as an oncology/infusion nurse and combines her clinical knowledge with an entrepreneurial spirit. SPNN is one of the first specialty pharmacy nursing services to provide a nationwide network of 500 qualified nurses to meet the needs of specialty pharmacies and biotech manufacturers. The organization’s services include coordination of care, drug administration, first dosing, education, clinical outcome data collection and reporting, and on-call coverage for specialty therapies. Visit for more information.

Recent Videos
Practice Pearl #1 Active Surveillance vs Treatment in Patients with NETs