Place-of-Service Management for Infusible Drugs

San Francisco—Infliximab, a monoclonal antibody against tumor necrosis factor alpha (TNFα), is used to treat autoimmune conditions such as psoriasis, Crohn’s disease, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis. It is administered by intravenous infusion, typically at 6-to-8 week intervals, at a clinic or hospital. Infusions are given at 1 of 3 venues: (1) a hospital as an outpatient procedure; (2) a special in-office infusion site; or (3) any of a series of alternative infusion sites.

During a Contemporary Issues session at the AMCP meeting titled An Approach to Place-of-Service Management for Infusible Drugs, Kerri Miller, PharmD, strategic market director at Johnson & Johnson and RegenceRx, outlined the process used by her firms to manage the infusion of infliximab to patients in Blue Cross or Blue Cross/Blue Shield plans in 4 western states (Washington, Utah, Idaho, and Oregon).

Of the 4 states served by RegenceRx, Regence Blue Shield of Washington is the largest, and it accounts for 50% of infliximab usage. Regence Blue Cross Blue Shield of Oregon accounts for 37%, Regence Blue Cross Blue Shield of Utah 8%, and Regence Blue Shield of Idaho 6%. In these states, utilization rates of infliximab by disease state are similar to national rates. For example, national and Regence utilization rates for rheumatoid arthritis are the same (40%). For Crohn’s disease, the national rate is 30% to Regence’s 29%.

Rates were similar for psoriatic arthritis (10% national to 12% Regence), for ankylosing spondylitis (4% to 6%), for ulcerative colitis (11% to 10%), and for psoriasis (2% to 3%). The national rate was calculated using analysis of data from 72 contract managed care organizations covering 192 million medical lives with roughly 800,000 infusion events.

However, when combining infliximab utilization for rheumatic disease (rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) and gastroenterological disease (Crohn’s and ulcerative colitis), the Regence plans begin to show variance compared to national and Regence parent rates. The national rate of utilization for rheumatic disease was 57% compared to 38% for gastroenterological. For Regence, the difference was 55% to 40%, respectively. Regence Blue Shield of Washington had similar rates for rheumatic and gastroenterological (49% to 48%), while Regence Blue Cross Blue Shield of Oregon (67% to 26%), Regence Blue Cross Blue Shield of Utah (50% to 45%), and Regence Blue Shield of Idaho (56% to 41%) all had higher utilization rates for rheumatic conditions.

When combining infliximab utilization for rheumatic disease and gastroenterology disease over time, Regence Blue Shield of Washington demonstrates continued increase of infliximab use for gastroenterological disease each year. In 2007, rheumatic usage was 57%, while gastroenterological usage was 38%. By 2011, rheumatic usage was 49% and gastroenterological usage was 48%.

Most infusions of infliximab occur in an office setting. Nationally, 27% of infusions occur as inpatient procedures, while 68% occur in-office and just 5% in alternative venues. Regence Blue Shield of Washington had similar rates (30% to 68% to 2%), while Regence Blue Shield of Idaho had the most variance (12% to 84% to 4%). Regence Blue Shield of Washington also showed continued growth (from 23% in 2007 to 30% in 2011) in the proportion of procedures done on a hospital outpatient basis. In Washington, Crohn’s disease showed the greatest increase in outpatient procedures between 2007 (n=1459) and 2011 (n=1776).