Four Years Later, Medicare Policy Still Fails in Home Infusion Therapy Patients

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In recent years, the COVID-19 pandemic has accelerated trends that encourage the use of home care. For example, commercial payers across the country are increasingly using “site of care optimization” to reduce the cost of infused or injected drugs by encouraging the use of clinically appropriate and convenient settings. However, nearly four years after the creation of a new Medicare benefit designed to promote access to home infusion, this vital health program is not meeting the needs of American seniors.

Nearly four years ago, I wrote an op-ed in The Hill deploring the flawed rollout of Medicare’s new home infusion benefit. As an original supporter of the legislation that created this benefit, I was disappointed that the Centers for Medicare and Medicaid Services (CMS) implementation fell short by failing to provide adequate reimbursement for professional home infusion services, jeopardizing access for Medicare beneficiaries.

The problem lies with CMS’s unnecessary requirement that a skilled professional (such as a nurse) be physically present at the patient’s home on the day of administration for Medicare reimbursement to occur. This fundamentally overlooks the goal of home infusion, which is to give patients the freedom to receive and administer their infusions at home without a healthcare professional. No other payer, including commercial plans, Medicare Advantage Plans and others, has such requirements.

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Four years later, the results are clear: CMS’s policy is failing in Medicare’s home infusion patients. Despite the creation of a specific home infusion benefit, CMS’ own data confirms that fewer than 1,300 Medicare beneficiaries took advantage of the benefit each calendar quarter between the first quarter of 2019 and the first quarter of 2021 – an anomaly compared to estimated 3.2 million patients treated annually by pharmacies for home infusion. In addition, use of the benefit within the Medicare program has declined during the public health emergency, despite an increase in use by commercial and other government payers.

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Without access to home infusion, Medicare beneficiaries are instead referred to institutional settings — increasing costs for both patients and federal taxpayers, while unnecessarily harassing patients who would otherwise not have to be in facilities to receive their care. For some patients in southeastern Georgia, this may mean driving several hours a day to the nearest facility to receive their daily IV infusion. For others, this may mean being admitted to a nursing facility or other long-term care facility for an extended period of time rather than simply receiving these infusions at home.

To address the shortcomings of Medicare’s home infusion benefit, it is vital that the reimbursement takes into account: all services needed to safely and effectively administer IV medications at home – including the comprehensive pharmacy services essential to ensure patients administer their infused medications safely and effectively. A major piece of legislation pending in Congress, the Preserving Patient Access to Home Infusion Act (HR 5067), would do just that by providing coverage for infusion services every day a drug is administered, rather than just on days when a competent professional is physically present. Gift.

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Medicare is the only major health care payer in the United States that does not have direct coverage for administering IV drugs at home, despite the overwhelming need for patients to stay at home during the pandemic and the significant potential for cost savings. It’s time for Medicare to recognize the value of home infusion and extend this benefit to ensure access for all of America’s seniors.

Rep. Earl L. “Buddy” Carter, a Republican, represents Georgia’s First District. He is one of only two pharmacists currently serving in Congress.

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