By Healthesystems
Specialty drugs continue to comprise a growing portion of costs in workers’ comp – anywhere from 5-8% of total pharmacy spend, according to recent industry data. In fact, individual therapies in the specialty category can cost up to 40 times more than traditional medications. And among the costliest medications in that category are infusibles.
Grand View Research valued the global home infusion therapy market at $35.96 billion in 2023 and expects it to grow at a compound annual growth rate of 8.1% from 2024 to 2030. In 2023, Risk & Insurance featured specialty/infusibles as one of seven drug trends to watch in an article featuring Silvia Sacalis, Healthesystems’ VP of Clinical.
Let’s look at how infusibles fit into the workers’ compensation space and their considerations related to site of care, cost, and claims management.
What Are Infusibles?
Infusibles are drugs that usually involve the administration of medication directly into the patient’s veins through a needle or catheter. Many of these medications are “biologics” – drugs derived from living organisms – which have complex storage/handling and administration requirements.
Typically, infusion therapy is reserved for conditions or diseases for which oral medication therapy may not be available or that do not respond to oral medications. In workers’ comp, infusibles may be prescribed to injured workers with occupational illnesses including pulmonary fibrosis, certain cancers, or exposure to blood-borne viruses including HIV or hepatitis C. According to the National Home Infusion Association, the most common reason for needing home infusion is due to a serious infection that requires IV antibiotics, prescribed primarily for such diagnoses as cellulitis, sepsis, and osteomyelitis.
Sometimes infusibles are lumped in with injectables, specialty drugs that are administered into the muscle or beneath the skin. In workers’ compensation, injectables can also be costly and are increasingly being used to treat injuries to joints such as knees, elbows, and hips as well as back injuries.
Common injectables for injured workers may include:
- Corticosteroid injections, which are used to reduce inflammation in tissue
- Viscosupplementation injections such as Orthovisc or Synvisc, which are used to reduce pain in patients suffering from arthritis and osteoarthritis
- Botox injections, which are used to treat neurological conditions such as chronic migraines or spinal cord injuries
Site of Care Considerations
In most cases, injured workers aren’t picking up infusibles or injectables at their local pharmacy. Rather, a medical professional must prepare and administer them in a setting such as a hospital, infusion center, or physician’s office. Note that in some instances, infusibles may be administered by a home healthcare worker and some injectables may be self-administered at home.
Due to specialized delivery and administration, infusion therapy is billed differently than pharmacy-dispensed medications. The following services are typically bundled into home infusion therapy:
- Intravenous or other solutions
- Pharmacy professional services including compounding, dispensing or administration
- Ancillary medical supplies including syringes and tubing
- Durable Medical Equipment (DME) delivery, setup, instruction, and maintenance
- Waste disposal
Because infusion services are not captured in pharmacy transaction data, it becomes more complex to capture the full impact of infusibles from a utilization and cost perspective.
Cost Considerations
As mentioned, infusibles are among the costliest medications in the specialty category. However, the cost varies greatly depending on the setting of administration.
According to the National Home Infusion Association, the cost of infusion therapy administered in the home or alternate-site care setting is usually significantly less than the cost of inpatient treatment. A Healthcare study notes that home infusion versus infusion in a medical setting resulted in savings ranging from $1,928 to $2,974 per treatment course.
A Clinical Therapeutics study on infusion therapy for rheumatoid arthritis in a hospital-based setting estimates overall costs of infusions per patient per year as ranging from $36,663 to $46,532. Meanwhile, Flexcare Infusion Centers lists the cost of infusion therapy in the non-hospital setting as $200 to $1,000 or more per weekly or monthly treatment.
Cost also varies by drug. For example, the Amaxx Workers Comp Resource Center estimates the cost of injectables as ranging from $50 to $200 per injection for corticosteroids up to $1,200 to $1,500 for a series of three injections of viscosupplementation. According to the Mayo Clinic, Botox injections cost several thousand dollars per set of injections, which are recommended every few months.
Claims Management Considerations
If an infusible or injectable is prescribed to an injured worker, here are some important questions for claims professionals to ask when making the authorization decision:
- What are your organization’s formulary rules around specialty medications?
- Have other clinically effective first-line treatments (e.g., oral medications) been tried?
- Can the drug be administered in a home health setting or even self-administered?
When managing injured worker claims featuring infusibles or injectables, claims professionals should also be on the lookout for off-label prescribing, which can present cost and care issues. For example, viscosupplementation injections may be prescribed off-label in workers’ compensation – not necessarily for osteoarthritis of the knee, as they are intended.
The Verdict on Infusibles and Injectables: Overall, infusibles and injectables can be effective forms of care for injured workers, especially when prescribed appropriately and administered in a less costly setting (such as the home). Sometimes infusibles or injectables can even be used in lieu of invasive and more expensive procedures such as surgery. However, off-label prescribing of these therapies in workers’ comp can inappropriately increase utilization and costs.
