How much does IVIG (IV immunoglobulin) cost? A friend got a stern $6,500 lesson recently, that included a lesson on home infusion, or getting intravenous medications at home instead of in the hospital.
My friend is David Contorno, a health benefits advisor who is known in the industry for devising insurance coverage for employers that avoids the traditional fully insured landscape involving Blue Cross, UnitedHealthCare, Cigna and other big companies. Instead, he works with self-insured employers, working to cover employees for less money than the traditional plans.
Contorno, founder and CEO of EPowered Benefits, in Charlotte, N.C., is also a father, and when his 13-year-old daughter became ill recently, he sprang into action — and found himself staring at a $6,500 bill for medicine that he knew he could buy for less. The problem was that his health care provider, Atrium Health, wouldn’t let him have the lower price.
To add insult to injury, when the $6,500 treatment didn’t work, he was offered a $3.53 treatment.
On the bright side, he learned about home infusion — when a medication is administered intravenously at home, instead of in a hospital or other institution that is an infusion center.
A surprise diagnosis
Here’s how it went down. His daughter, Hannah Contorno, had what they thought was a fairly routine visit to the doctor. But the next day, he was told to take her immediately to the emergency room because she had been diagnosed with Acute Immune Thrombocytopenia (ITP), he said. (I didn’t talk to Hannah, but Dave said she’d be fine with us using her name. She has worked at YOU Powered Symposium, the benefits symposium Contorno puts on, entering its second year in 2023. )
Her doctors at Atrium Health prescribed IVIG, as an infusion of intravenous medication in the hospital, with a price tag of $13,000. Contorno and his family don’t have a traditional health insurance policy, so, he told me in a phone interview, he describes himself as a cash patient.
“I called the office to schedule the infusion, and I said ‘Can you please tell me how much it’s going to cost? I pay cash,'” he said.
“They come back and said, it’s going to be $13,000, but you get a 50% cash discount. So I said, ‘OK, how much of that $6,500 is the drug versus how much of that is the administration of the drug?’ And she said, ‘Well, $410 is the administration. The rest is the drug itself. ‘
‘I’ll come in with the drug’
“I said, ‘Perfect. I already priced it out, I can get the drug for $2,300 at the pharmacy. So I’ll come in with the drug’ — you probably know that this is what’s known in the industry as white-bagging — ‘and I’ll still pay you for the administration.’
“And they said, ‘oh, no, we don’t allow that.'”
They told him it was a liability, he said, and he asked “How so?”
The reply: “It could have been in a hot car.”
He said, “This is a very stable drug. It is not temperature controlled. It’s not the summer right now. So it’s not going to be sitting in a hot car no matter what I do. So it’s my risk — I’m bringing the drug and what’s the problem?”
Тhe reply: “We just don’t allow it.”
Then he offered to call the manufacturer, buy directly, and have it shipped to the hospital as other drugs are shipped, so the liability issue goes away.
The response: “I’ve been working in this health system for 16 years, and we’ve never allowed this.”
‘Trying to make money on a drug’
Contorno says he replied: “It sounds to me like a hospital trying to make money on a drug that they didn’t research, develop, manufacture, do clinical trials on get [Food and Drug Administration] approval. Why should you be entitled to marketing the drug for so much?”
Getting no satisfaction, he said: “I was over a barrel. I had a choice, either get my daughter this medication, or she could die. That was the choice. So I literally had no choice. And I didn’t have much time to try and mess around with them, so I authorized it.”
The hospital offered him a 50 percent discount, to $6,500. Problem is, Contorno, being a health costs expert, knew that some patients could buy the medication cheaper and then pay someone at the hospital do do the infusion part.
Contorno wrote on his LinkedIn: “Question for Eugene Woods, why should you contribute to the bankruptcy of America by marking up a drug you didn’t make, and refusing to allow us to bring it in more affordably so that we don’t have to suffer financial hardships while trying to obtain life saving medicine? You look to make profit above pateints at every turn possible. As a non-profit, your mission is meant to be the opposite. Hope you sleep well in your mansion tonight. While thousands in the Carolina’s have to choose between care at your facilities and bankruptcy. You have us over a barrel and you know it. And use it. Everyday.”
Next: a $3.53 oral steroid
After the infusion was done, the wait-and-see process began. The hematologist was not satisfied with her progress, Contorno said, so he proposed an oral steroid.
The cost? $3.53.
“So here is my question,” Contorno wrote in his LinkedIn follow-up post. “Other than the obvious financial windfall for the health system, why would we START with the $6,500 treatment and not the $3.53 treatment?”
When he asked the hospital, he said, they answered, “Well, we really don’t consider the finances, we just want to give you with the best clinical advice.”
He replied, “I get that, but what if your clinical advice bankrupts me or makes me and my child homeless? Is that the outcome you really want to have?”
Beyond that, after the infusion, Contorno said, he found a home pediatric infusion service that will do the infusion for $400, and will use the medication he brings. “I can get the drug for $1,100,” he said. “It might take me a week or two to get. So next time we need to have this done, if we need it, it can be done the comfort of our home for $1,500 instead of $6,500.”
IVIG pricing issues
We have heard about IVIG pricing before. Morgan Gleason, a friend who has been prescribed IVIG, wrote a piece about the IVIG pricing variations she discovered, which we re-posted.
She found the same hospital with the same doctors, the same medication and the same nurses got $3,319 from one insurer and $20,736.37 from another for the same thing.
The topic of infusions of medications for serious illnesses has come up in relation to other medications. Erin Bricker wrote a piece for us about her use of Remicade for Crohn’s disease, describing the high costs. One of the solutions she pointed to was home infusion.
What to know about home infusion
Quite often, a home infusion service can be much less expensive than a hospital infusion center or other institution. Sometimes those home infusion centers are not covered by insurance, partly because of the interlocking agreements between hospitals and insurance companies. That didn’t matter for the Contornos, because they don’t have a traditional insurance policy.
That said, there are reasons to consider home infusion. For example, it can be much less expensive. Also, with the Covid pandemic, many patients are reluctant to enter a hospital or other institutional setting if they don’t have to.
Some institutions, like Penn Medicine, are trumpeting their advances in home care, including home infusions: Easier for the patient, less time spent in traffic or waiting, the comfort of your own home. “The push towards offering patients more clinical care inside their homes and outside of medical offices had begun before the COVID-19 pandemic,” Penn Medicine writes on its site. “But COVID turbocharged the progress and prompted even more expansion of services offered.”
Not all hospitals are eager to give up the payments for hospital infusions, which are typically higher than in-home infusions. Also, the Medicare payment procedures have often made it difficult for Medicare recipients to have in-home infusions, because the law has required a doctor or a nurse to be present for home infusion, keeping Medicare patients in the hospital for their infusions.
Cost savings, convenience and reluctance to go to institutional settings are driving an increase in home infusion. But there is some opposition, as described by OncLive, a cancer treatment trade publication, in a detailed examination of home infusion for cancer. “The American Society of Clinical Oncology (ASCO) has expressed reservations about the safety of routinely administering anticancer drugs in patients’ homes and the Community Oncology Alliance (COA) has declared its staunch opposition,” OncLive wrote.
Cancer Therapy Adviser, another trade publication, reported high success and satisfaction rates in an April 2022 article.
As in many other topics in health care, the question of who gets paid may be part of the support or opposition to a clinical practice.
To find a home infusion center, you can Google around or use this home infusion listing from the Centers for Medicare and Medicaid Services.
This C.M.S. page has information about home infusion services.
The National Home Infusion Association is a trade group for the industry.