National Infusion Center Association navigates 'shifting coverage, reimbursement landscape'
Despite bipartisan political opposition, the prices for many intravenous and injectable drugs continue to soar in the U.S., leaving patients with autoimmune diseases and their providers questioning what drugs they can still afford to access.
Volatility in the provider-administered IV/injectable drug reimbursement landscape was one of the reasons an organization like the National Infusion Center Association was formed, and continues to flourish, according to Brian Nyquist, MPH, executive director of the organization.
The National Infusion Center Association is a nonprofit patient advocacy organization formed to improve access to provider-administered IV and injectable medications for non-oncology indications in non-hospital care settings.
“Providers are operating in an increasingly pressurized atmosphere with expectations to treat more patients with higher quality care, producing better health outcomes for reduced — and in some cases, negative — reimbursement,” Nyquist told Healio Rheumatology. “As more and more legislators, decision-makers and insurers approach medical benefit reform through this lens, numerous threats are looming on the horizon that would disrupt and cripple the lowest-cost care setting for office-based infusion/injection services that some of our nation’s sickest and most vulnerable citizens rely on.”
While the oncology sector historically had “phenomenal advocacy support,” the non-oncology sector was sometimes fragmented and siloed within each specialty, according to Nyquist.
“Rheumatology, gastroenterology, dermatology, allergy, immunology, pulmonology, infectious disease, neurology and other specialties in which provider-administered IV or injectable medications are indicated were all working on the same access issues in similar ways, duplicating efforts with little to no collaboration,” he said. “NICA was formed to defragment these advocacy efforts, provide a cohesive advocacy voice for patients and their providers, and drive cross-specialty collaborative momentum behind a common goal: improve patients’ access to their prescribed provider-administered medications.”
Initially formed in 2010, NICA operated as a virtual organization on a part-time and volunteer basis by the founders until Nyquist came on board in June 2015. “By the end of 2015, NICA had a brick-and-mortar headquarters and a full-time team building and driving the organization’s full-time advocacy capabilities on a national level,” he said. “Less than 5 years later, we hosted the first conference dedicated to preserving, optimizing and expanding access to provider-administered medications; with almost 550 stakeholders in attendance.”
Nyquist discussed how the organization was able to evolve in such a way.
“Initially, the organization was exclusively focused on engaging in advocacy efforts focused on helping patients overcome the obstacles and barriers that restricted, delayed or disrupted their progression from prescription to the infusion or injection chair,” he said. “Since then, we built additional programs to meet the needs of patients and providers, including our education and resources program.”
Patients can get educated and take control of decision-making through user-friendly programs such as “Infusion 101,” “Biologics 101” or “How to Prepare for Infusion Day.” In addition, the NICA Infusion Center Locator is available to locate one of over 3,600 infusion centers all over the U.S. and Puerto Rico.
But the numbers only tell one part of the story of NICA’s success, according to Nyquist. “The accomplishments that particularly resonate and stick with us involve a strong human connection,” he said. “We never tire of hearing that NICA’s efforts enabled a patient to play with their kids again, avoid a wheelchair or continue using their hands. These have been incredible motivators for my team and me.”
Dollars and Sense
Looking closer at specific accomplishments, in 2016, in response to CMS’ proposed Part B Payment Demonstration that would have changed the drug payment rate to 2.5% of Average Sales Price plus a flat fee of $16.80, NICA immediately engaged and provided a grassroots advocacy platform through which stakeholders could amplify their individual voices into a cohesive and collective voice.
“Through this effort, over 40,000 letters were sent through the platform in the first 3 weeks, 15,000 of which occurred within 3 hours on the day of peak engagement before the Sergeant of Arms for the Senate shut down the line of communication onto [Capitol] Hill,” Nyquist said.
Other notable accomplishments include overturning two Recovery Audit Contractor audits, as well as overturning payer policies involving weight-based dosage restrictions, short-funding J-codes, down-coding CPT codes for administration services and mandated acquisition of drugs through specialty pharmacy, according to Nyquist.
NICA is headquartered in Austin, Texas, and includes a support network of nearly 200 organizations representing about 600 infusion centers that collectively support every specialty in which provider administered IV/injectable medications are indicated.
Rheumatologists are encouraged to visit the website for ways to get involved. The InfusionConfusion Forum is among the key educational materials targeted at teaching clinicians about in-office infusion and those aimed at having the conversation about injection or infusion with patients. “Additionally, all rheumatologists can take advantage of NICA’s Late-Stage Quarterly Pipeline Reports to stay abreast of potential treatment options in phase 3 and later clinical trials,” Nyquist said. “Rheumatologists can also use the legislative tracking center to understand state and federal legislation that NICA is following and quickly engage in grassroots advocacy.”
Looking ahead, Nyquist anticipates that 2021 and beyond will continue to present challenges in terms of medical benefits, both for sustainability and access to care.
“In the Part B market, proposed reform could push the delivery channel away from buy-and-bill to a private sector vendor distribution model similar to a mandated acquisition of drugs through specialty pharmacies,” Nyquist said. He added that the rise of pharmacy benefit managers and a shifting coverage and reimbursement landscape could produce the twin result of making IV and injectable drugs both less affordable and less accessible.
“Unfortunately, we have reached a point where a public charity is not enough to preserve, optimize and expand access to provider-administered medications,” he said. “As such, I am in the process of standing up a trade association that will be dedicated to identifying, addressing and overcoming threats to the sustainability of non-hospital, office-based outpatient delivery of provider-administered medications in an effort to ensure that we have a delivery channel that can not only meet the demand of today, but the future demand of tomorrow. This is particularly important as we continue to see new drugs come to market for undertreated and infusion-naïve indications.”
As for what may come further afield, the volatility of the landscape and a political atmosphere fueled by uncertainty has made NICA’s agenda for 2025 and 2030 uncertain.
“What remains clear, however, is the shift in medication technology away from small molecule, systemic-acting therapies to larger molecule, more targeted therapies like therapeutic biologic products,” Nyquist said. “The NICA team will remain tenaciously passionate and focused on ensuring that patients who are prescribed these products will be able to find a care setting, start therapy and stay on therapy until their prescriber — not their payer — determines that a different therapy may be indicated.”
He added: “Although the future will hold tremendous challenge and uncertainty, together infusion providers can be more robustly resilient against external factors threatening this critically important care model than they are individually to ensure that patients across the nation can get the right care at the right time in the most affordable setting.”
For more information:
Brian Nyquist, MPH, can be reached at 3307 Northland Dr, Suite 160, Austin, TX 78731; email: email@example.com.