High Dollar Medications and Therapies: Challenges for our Families and Challenges for Us! (215)

11:30 am–12:30 pm Friday, September 6

Treatment options for children with cancer continue to grow and bring exciting opportunities for a cure in situations where there was previously no hope. Some therapies come at a very high cost. At the same time, the cost of health care in the United States continues to grow. The complexity of healthcare reimbursement includes varied payment options, including governmental programs; commercial insurance, which can range from excellent coverage to a high deductible plan; and sometimes nontraditional methods of payment, such as shared ministry programs or “self-pay.”

As costs rise and payors provide a wide range of coverage, the need for obtaining “permission” and preauthorization before treatment is growing. Healthcare organizations are needing to devote more and more resources to advanced planning and preauthorization before care can be provided. Unfortunately, nurses are being forced to “learn the lingo” around these issues and incorporate these tasks into their daily work. Nurses are now involved in understanding insurance contracts to know whether a plan is “in network” and involved in providing plans for care in advance so that high dollar medications and other components of routine care can be preauthorized, for example. Outpatient nurses may be spending time obtaining preauthorization for prescription medications and providing clinical information to insurance companies. Nurse practitioners are finding themselves engaging in “peer to peer” conversations with medical personnel at an insurance company to justify the need for requested care. In some cases, we may be forced to refer patients to a competitor institution because the patient’s and families’ coverage is “out of network” with our own facility but contracted with a competitor. This session will include a discussion of high-dollar therapies in the field and the many nuances of healthcare reimbursement strategies. The impact on nursing and the associated delays in care for patients will be considered.

Kaye Schmidt, MA RN NEA-BC CPHON®
CNE Hours: