Considerations for opening an in-office infusion center and infusion center best practices: Infusion center procedures, processes and pitfalls

If you’re a neurologist, you can’t ignore the question: should I open an Infusion Center? And, if you have an Infusion Center, you’re asking yourself: Am I running my Infusion Center optimally and according to best practices?

With Tysabri already on the shelf, the launch of Lemtrada in late 2014, the recent launch of Ocrevus and the robust pipeline of specialty neuro infusion medications such as Radicava for ALS and the various Alzheimer’s medications, you can’t ignore how infusion is shaping the neuro space. Indeed, these specialty infusion drugs are extremely expensive. So, deciding to open an Infusion Center is not the same as deciding to offer BOTOX, in-house lab services, or many other ancillary services.

Infusion requires careful consideration and commitment. This article is intended to give an overview of the requirements, costs, and commitments a neurology practice must be willing to make in order to be successful in opening and running an Infusion Center.

What defines the term Infusion Center? If the practice has some minimum space and personnel dedicated to the business of infusion, we like to say that the practice has an “Infusion Center.” Giving a few injections a month in regularly used exam rooms likely doesn’t qualify for the term, but after all, it’s really not our call.

There is no one-sized-fits-all approach to opening and managing an Infusion Center. During our combined 25+ years managing, operating, and consulting within the Infusion Center delivery channel, we have seen just about every variety of Infusion Center model – from a small chair in a closet with a nail in the wall (for the IV bag) to a 25 chair luxury suite with heated massage chairs and a catering menu. We personally have minimum requirements that we believe offer the best chance of clinical and financial success. Our experiences coupled with great resources from the Infusion Nurses Society (INS) and the National Infusion Center Association (NICA) formed the basis of this article.

Minimum Requirements for an Infusion Center include:

You must have the patients
You must have dedicated space
You must have some dedicated staff
You must have the financial wherewithal

Infusion Requires Patients

It would seem like an obvious observation, but not every provider, practice, or specialty will have the kind of patient population that can utilize infusion therapy or the patient volume to support an Infusion Center. In order to create long term success for your Infusion Center, you must have a minimum number of treatments weekly/monthly to cover and ultimately exceed your overhead costs. Since most infusion treatments are interval dosed in bi-weekly, monthly, and longer frequencies – it requires many patients to get to a steady patient flow per day, per week and so on. In my experience, there is no perfect specialty that will always have the right patient population for an Infusion Center. While it is true that specialties like Rheumatology, Gastroenterology, Neurology, Immunology and Infectious Disease lend themselves to a higher concentration of patient disease states that utilize infusion therapy, the specialty in and of itself is not a qualifier for success.

The majority of infusion treatments are for diagnoses that are fairly rare in the U.S. population. As an example, Multiple Sclerosis affects only an estimated 400,000 people in the United States or about 0.09% of the US population according to the CDC, and not every patient with MS will need a infusible/injectable biologic medication. Other autoimmune disease like Rheumatoid Arthritis (0.6%), Crohn’s Disease (0.2%), and Psoriasis (2%) are also fairly rare.

In addition to specialty infusion medications for autoimmune disorders and chronic diseases such as MS, neurologists often prescribe infusion medications for migraine therapy. When operating an Infusion Center, you must also consider these patients when assessing potential or actual infusion patient volume.

This means that the practice geography, population density, number of providers in the practice, and other factors have an important impact on the number of prospective patients and therefore the number of treatments possible in your Infusion Center.

How many treatments do you need to break even? That depends on your commitment to the next two requirements, but in general, you need enough treatments to cover the cost of your infusion nurse payroll and the general overhead of your Infusion Center. If you have not done the math and answered the potential or existing patient population question, don’t read any further. Having a realistic understanding of your patient population is number 1 on the list. Infusion is not a “build it and they will come” business model.

Infusion Requires Dedicated Space

However tempting it is to “borrow” some exam room space in an “as-needed” attempt to minimize costs – Don’t Do It! Infusion patients need dedicated space and resources. Providing in-office infusion is not a weekend hobby. If you are not prepared to commit the space, you are probably not ready to commit the staff, or the cash needed to create a successful and robust Infusion Center.

The Infusion Center workflow is not the same as the practice workflow. Treating it as such will start you and your office team down a path of bad habits that commingle infusion workflow with general practice workflow. Infusions require separate and specialized patient workflows, documentation, supplies, and inventory management systems. All of these systems need a place within your practice they can call home.

For patients receiving Ocrevus, Lemtrada, or even IVIG in some instances, the infusion administration may take hours or even an entire day. So, for the sake of the infusion patients and the infusion nurse, it’s necessary to create an organized, comfortable and safe environment with a dedicated medication mixing area. When space planning, remember to allocate space for a refrigerator dedicated to storing medication, nurse working stations, a mixing area, and plumbing for a sink. Put yourself in an infusion patient’s shoes and imagine what you would want and expect from an Infusion Center, then use that as a guide to create your own Infusion Center space. For example, many Infusion Centers provide comfortable vinyl recliners, chair-side tables, adequate space between the chairs, curtains between the chairs, wi-fi, blankets, heating pads, refreshments and snacks, television, and iPads or tablets, - perhaps, a private room for those migraine patients or patients needing to be isolated.

Patient Experience

For patients suffering from a chronic disease like MS, the Infusion Center will likely become a part of their lifestyle routine. For example, patients on Tysabri will be visiting their Infusion Center every four weeks, and patients coming in at frequent intervals often become part of the Infusion Center family. Indeed, physician or nurse practitioner based Infusion Centers are generally the optimal site of care for patients needing infusion therapy. Simply stated, Infusion Centers keep patients out of the hospitals where they may otherwise be subjected to hospital acquired infections. Not to mention, hospitals are often two times as expensive as in-office Infusion Centers. So, in addition to being the most cost-effective site of care, patient persistency and compliance is generally much better. If a patient is on the schedule to be seen at the Infusion Center the Infusion Center office team will usually contact the patient ahead of time to remind them of their appointment providing an added force to ensure that patients are receiving their infusion medication at the proper frequency. With much fewer nurse shift rotations as compared to a hospital, the likelihood that the same nurse will infuse the same patient each visit is much greater in the in-office Infusion Center. This consistency in nursing helps ensure abnormalities are caught and outcomes are properly documented. For these reasons, the Infusion Center truly fills a needed gap in the healthcare delivery channel providing cost-effective, high quality care.

Infusion Requires Dedicated Staff

Even the smallest Infusion Centers buying and billing infusion medications can quickly rack up an annual spend that exceeds $1,000,000 due to the expense of the infusion medications. For many practices, the Infusion Center is the largest revenue and expense line on a practice’s financial statement. Why risk putting part-time effort into something that important to the bottom line? A practice likely has multiple staff members in multiple roles to manage patients, set appointments, and bill and collect payments. Why would anyone think that you wouldn’t need at least one dedicated team member for your Infusion Center?

Many providers each year make the decision to start in-office infusions, and in a misguided effort to reduce cost, they put the burden of managing this new service on the backs of their existing staff while requiring them to maintain their current workloads as well. Even with the best workflow, scheduling, and inventory management systems, we seriously recommend dedicating someone to have ownership of the Infusion Center as their primary role in your practice. There are simply too many balls to juggle not to have someone who can stay in touch and track all the variables required to keep patients on schedule, insurance authorizations updated, inventory in stock, and reconcile all the things necessary to treat an infusion patient and, most importantly, get paid for doing it.

If dedicating some staff to your new Infusion Center seems overwhelming, you probably are not ready to take on this new venture in your practice.

Clinically speaking, we also highly recommend that your Infusion Center be staffed with experienced infusion registered nurse(s) (RNs). These specialty biologic medications have specific and unique protocols set forth in the prescribing information that must be followed during the infusion administration so having a licensed experienced clinical professional is essential for patient safety. During our tenure as Infusion Center operators and managers, we leaned heavily into the INS resources to help develop many of our clinical protocols. We highly recommend every Infusion Center use INS and that INS resources should sit on the Infusion Center workstation shelf. Similarly, and with its mission to increase patient access to infusible medications, NICA has some great resources for the Infusion Center staff. It’s also important to remember that each specialty biologic drug manufacturer has a team of individuals available to educate Infusion Center staff on the specifics of their respective drug. Instead of reinventing the wheel, take advantage of these readily available resources.

Infusion Requires Financial Wherewithal

It takes financial wherewithal from a busy and thriving practice in order to have the minimum number of patients, the right space, the right staff, and the right equipment and supplies to operate a safe and successful Infusion Center.

Like any startup business, adding an Infusion Center to your practice will require that you invest some resources into the space, systems, staff and inventory needed to operate. If you want to create a better patient experience, you may want to invest additional dollars in the space itself and in the amenities offered to your patients.

Registered Nurses (RN’s) that are familiar and experienced with in-office infusion medications are (and should be) expensive relatively speaking. While your Infusion Center is getting off the ground and growing, you may even have to pay some minimum hour shifts in order to attract a consistent and reliable infusion nurse for your practice. This means that you may even need to pay some nursing hours when you don’t have enough patients to keep your nurse busy.

With regard to your medication inventory, pay your wholesale medication vendors as you receive Infusion payments from insurers which is typically within 30-45 days. Resist the urge to take long term invoice dating (90+ days) from your infusion wholesale vendors. In an effort to improve cash flow, Infusion Centers often use long invoice dating to stock the Infusion Center with buy & bill medications. While systems help greatly to reduce your extra inventory days on hand, there is always some inventory you need to own in cash so you don’t rely entirely on vendor credit to float your Infusion Center. Having more of your own “skin in the game” will help keep you focused on the kinds of tasks and processes you need to ensure that all Infusion Center workflows are correctly implemented in a way to maximize the profitability and minimize loss in your center.

Conclusion

In no way shape or form is this article meant to be a comprehensive Infusion Center policy and procedures manual or guidebook. This article is meant to give a practice, particularly a neurology practice, a high-level overview of some of the most important Infusion Center issues. Now that you’ve read this article, anyone that tells you that adding and maintaining an in-office Infusion Center is easy likely does not have the experience and expertise needed to advise your practice. Infusion Centers are complex endeavors that require a great deal of planning and sustained focus to operate safely, efficiently, and profitably.

Here is the good news – if you are good with the requirements mentioned above and you invest in systems that create process dependent workflows (as opposed to people dependent workflows), you can operate a thriving Infusion Center that will serve as a critical patient access point for not only your patients, but those of your surrounding community.

About the Authors:

Bryan Johnson, Board President, National Infusion Center Association and CEO of WeInfuse: Bryan has been living and breathing the outpatient Infusion market even before graduating from college. In 2003, Bryan founded the Austin Infusion Center and later merged his company with Innovative Infusions whereas COO of Innovative he helped lead a companywide restructuring that resulted in exponential revenue growth. Bryan has extensive knowledge and experience in both the physician-based and standalone Infusion Center delivery models. Involved early with the first injectable biologics, he has personally experienced over 25+ new drug launches. Bryan knows first-hand the challenges that providers face when administering Infusible medications to their patients. Bryan received his BBA in Entrepreneurship from Baylor University. Bryan resides in Austin, Texas with his wife, Emily, and their two boys.

www.linkedin.com/in/cbryanjohnson
@bcjohnsontx

Judy Back, RN, BSN, Nurse Liaison and Sales at WeInfuse: Judy is a Registered Nurse with extensive infusion experience. Judy co‐founded Innovative Infusions, LLC where she grew Innovative into a multisite Infusion Center company serving patients in every major demographic area in Texas. Judy served as Vice President of Clinical Operations at Innovative until late 2008. During her tenure at Innovative, Judy grew the company from a small business into a leader of infusion therapy services throughout the entire state of Texas. Following her service with Innovative, Judy worked with BBraun Medical and Equashield, LLC as nurse Educator. Judy recently joined Bryan at WeInfuse where they are breaking ground again by providing the first purpose built Infusion Center software. Judy received her Bachelor of Science in Nursing from the University of Texas at Arlington.

https://www.linkedin.com/in/judyback/

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