Similar to the U.S. health care system at large, the actual and projected rise in the costs of medical care within the Department of Defense (DoD), TRICARE Management Activity, and Veteran’s Administration (VA) health care systems is marked and unsustainable. Over 40 percent of the requested fiscal year 2011 budgets for these departments is allotted for medical care, a total of over $90 billion.1 The Center for Strategic and Budgetary Assessments (CSBA) projects annual increases of 5 to 7 percent, a rate anticipated to double health care costs every 10 years.2
Many factors contribute to the growing utilization of VA medical resources, including veterans of the Iraq and Afghanistan wars, demographic changes in the eligible/enrolled population, the gradual expansion of healthcare eligibility to more than 500,000 previously ineligible veterans by 2013, rising health care costs, and increased per capita expenditures.
Table 1 Medical Programs, Budget in $Billion1
Table 2 Unique Patient Services in #Million1
According to the Congressional Budget Office, current trends in enrollment and resource utilization indicate a 3.6 percent annual growth in demand for VA medical services, totaling 88 percent real growth (or $66 billion), by 2025.3 Today, 16 million of the approximately 23.2 million veterans are not enrolled in the VA system. Of the 6 million-plus who are enrolled, most receive only half of their medical care (in dollar terms) from the VA. Coverage by such plans as Medicare, Medicaid and TRICARE, as well as out-of-pocket expenditures, provides relief from direct VA reimbursement. As enrollment increases, as is likely given the rising health costs in the civilian sector, and as the current population of veterans age (today approximately 40 percent of veterans are age 65 or older), the costs could be even higher.4
Opportunity, arguably responsibility, to explore options to decrease total costs of care is vitally important. Key cost drivers, and thus a focus on potential areas of intervention, include pharmaceuticals and site of care. The drug market continues to expand, particularly specialty pharmaceuticals for which there are limited generics options. Site of care, inclusive of hospital brick and mortar, long term care (LTC) or skilled nursing facilities (SNF), outpatient clinics, infusion suites, physician offices and home, must be evaluated for most cost-effective option.
Table 3 Anticipated VA Acute Care Services, in $Billion1
Site of Care Opportunity – Home Infusion
Home infusion services are currently covered for VA beneficiaries who require infusion or injectable drugs when the home is the most appropriate site of care. The opportunity, then, exists in effectively maximizing utilization. Home infusion services from an expert accredited provider has proven more cost-effective overall than inpatient care, be it in hospital, LTC or SNFs, averaging approximately $150-$200/day as compared to an average hospital day of $1500-$2000/day.
Identifying appropriate candidates for home infusion and effective infusion providers, evaluating inpatient and emergency department (ED) overutilization, and prioritizing analysis for alternate-site care for more patients provides significant opportunity to contain total costs of care.
The clear goal of home infusion is to maximize clinical and economic outcomes for appropriate patients for whom an alternate site of care is not only an option, but a true benefit. Home infusion provides the opportunity for appropriate use of hospital days/resources. This incorporates, for example, appropriate or “on time” discharge. Patients are often kept in the hospital for one or several days for which home therapy may have been a better option. Given that the hospital day is the most significant contributor to hospital cost, hospital length of stay (LOS) is a key focus for intervention. For example, a LOS study for patients with community-acquired pneumonia (CAP) determined that a half day decrease in the hospital LOS saved over $1200 per episode. For CAP alone the cumulative savings is up to $1.37 billion.5
Efficacy was also demonstrated by the Portland VA hospital which measured the delivery of acute medical care at home, in this case in an elderly (>65 years) patient population and compared outcomes with inpatient care. Four diagnoses were included and home services included infusions(s) for many patients. Sixty percent of the patients for whom Hospital at Home was offered opted for it. Outcomes included a decreased risk of clinical complications, better physical functioning, illness-specific quality of care, patient and caregiver satisfaction, decreased length of stay (3.2 vs. 4.9 days) and decreased costs.6,7
Opportunities exist to avoid hospital admission for certain patients who present to the ED. Often, typically after therapy is initiated in the ED, remaining doses can be provided at home. Hospital avoidance, whether through an ED diversion program or with referral from a physician office or other outpatient setting, is an option for some patients. With the right policies and procedures, first dosing of antibiotics, for example, or total parenteral nutrition (TPN) may be possible.
Appropriate candidate selection is essential. Patients and their caregivers must be willing, prepared and capable. Detailed pre-discharge teaching specific to each patient’s therapy, equipment and responsibilities must be taught and successfully return-demonstrated. The patients must have a suitable, safe environment; for example clean home and with electricity, access to 911, storage for supplies and drugs, etc. The prescribed therapies, too, must be realistic for home infusion.
The benefits are numerous and significant. Home infusion supports appropriate resource utilization, positive clinical outcomes and positive economic outcomes. As referenced above, the cost of an average hospital day may be 10 times the cost of the average home infusion days.
A report from one particular VA center illustrates the actual and potential cost savings.
The Jesse Brown Veterans Affair Medical Center, a 205 bed hospital in metropolitan Chicago, is currently in its first year of a contract with Coram Specialty Infusion Services, a national home infusion provider. The program is specific to antibiotic therapy for such diagnoses as osteomyelitis, bacteremia/endocarditis, pneumonia and skin and soft tissue infections (SSIs). Assessing actual data for Q3 2009 and projecting out, the medical center predicts an estimated 75 patients saving 1300 Community Living Center (CLC) or skilled nursing facility days (SNF) for antimicrobial therapy. Complete anticipated results are seen in the following table:
One cannot minimize the impact of a decreased risk of nosocomial infections, many of which are due to resistant pathogens. Every additional day in the hospital increases the risk of exposure to and contamination by resistant organisms. Patients who were recently hospitalized or who reside in a nursing home are at risk for exposure and the development of healthcare related infection. At additional costs of up to $40,000, prevention is key.
Optimizing bed utilization by maintaining bed space for tertiary care needs or decreasing need for patient diversion to civilian hospitals, is another positive consideration.
Given the established growth of the senior population and the higher associated clinical and economic costs of hospitalization, avoiding unnecessary hospital days decreases risk of injury, infection and functional decline (for example, dementia, confusion, iatrogenic illness).
Additional benefits include the ability to travel and return to work/school. Since approximately 45 percent of veterans aged 18 to 64 were active in the 2008 labor force, such opportunities are significant. Home infusion has been shown to enhance patient satisfaction and quality of life.
Based on Coram’s experience and extrapolated to the approximate 6 million VA beneficiaries, one may anticipate the following home infusion utilization:
Developing a Strategic Partnership
Critical home infusion heath care services, essentially supporting the “hospital in the home” model, require highly trained pharmacy and nursing and dietary clinicians working together with the prescribing physicians, clinical teams and case managers. A relationship with a home infusion provider must be founded on a mutual commitment to quality standards and assured, consistent service. The provider must deliver nationally, 24/7, expert nursing, pharmacy, and dietary clinicians and operations, including ongoing assessment, compliance monitoring, delivery systems and internal disease/therapy-specific training. Clear communication protocols, at the branch and, especially for patients who are traveling or relocating, inter-branch, must be proven.
Patient education, with established policies for return demonstration and specific to disease, drug and/or equipment must be clearly written and include an ongoing evaluation plan. Accountability via outcomes reporting, both internally and specific to the clinical site(s) is expected, with criteria established at the outset.
The provider must have established policies and procedures, including an emergency preparedness plan, both nationally and locally, and a proven commitment to quality service.
Home infusion support is an increasingly vital component of health care. As the nation experiences the impact of clinical resource utilization and escalating costs, home infusion must be incorporated as a cost-effective option. The benefits of home infusion have been proven and the opportunity for the VA and DoD systems is great.
Acknowledgements: I would like to gratefully acknowledge Richard J. Rooney, PharmD, Chief of Pharmacy Services at Jesse Brown Veterans Affairs Medical Center, and Lisa A. Rene, PharmD, Infectious Diseases/Home Infusion Pharmacist at Jesse Brown Veterans Affairs Medical Center for providing their study data for this article.
1. http://www4.va.gov/budget/docs/summary/FY2011_Volume_2-Medical_Programs_and_Information_Technology.pdf. Retrieved March 24, 2010.
2. www.whitehouse.gov/omb/budget/fy2009/defense.html. Retrieved June 22, 2010.
3. CBO TESTIMONY. Statement of Allison Percy, Principal Analyst, Future Medical Spending by the Department of Veterans Affairs, before the Subcommittee on Military Construction, Veterans Affairs, and Related Agencies. Committee on Appropriations, U.S. House of Representatives. February 15, 2007.
4. Veterans Day: Census Facts. Infoplease ©2002-2007 Pearson Education, publishing as Infoplease. 02 Mar. 2010. http://www.infoplease.com/spot/veteranscensus1.html.
5. Raut, M.; Schein, J., Mody, S., Grant, R., Benson, C., Olson, W. Estimating the economic impact of a half-day reduction in length of hospital stay among patients with community-acquired pneumonia in the US .Current Medical Research and Opinion, 25 (9), September 2009, pp. 2151-2157(7).
6. Naik, G (April 19, 2006). Portland Hospital Gives Acutely Ill a Homecare Option. The Wall Street Journal, CCXLVII(91).
7. CM&R 2008 HMORN Poster presentations. Abstract number PSI-45.
An abridged version of this article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition. In that version, the final table was missing a figure that caused the data to read incorrectly. We regret the error and have corrected it in this version.