HOME INFUSION

Tell Congress the Work Isn't Done

Medicare's home infusion gap still exists—here’s what the Hill should do next

By Connie Sullivan

Congress dipped a toe into home infusion this year when HR 4993, the Joe Fiandra Access to Home Infusion Act, was signed into law as part of a government funding package. It was a sign that lawmakers increasingly understand what providers have known: Everyone benefits when Medicare patients can receive infusion therapy at home. Patients recover in familiar surroundings, transportation burdens are avoided and the Medicare program avoids paying facility prices for care that doesn't need a facility.

But we shouldn't mistake this first step for a finish line. The Fiandra legislation addresses a very narrow slice of the population—patients with rare diseases—and does not address the root of existing access issues for Medicare beneficiaries. A much larger opportunity lies in the comprehensive reform that the National Home Infusion Association (NHIA) and Congressional sponsors are still working to deliver through the Preserving Patient Access to Home Infusion Act (HR 2172).

Where Home Infusion Coverage Is Now

Medicare’s current home infusion benefit limits coverage to a handful of drugs that require an external infusion pump, and reimbursement for services is limited to days when a clinician is physically present in the patient's home.

In practice, home infusion care is delivered across the full course of treatment—through pharmacy monitoring, care coordination, 24/7 clinical availability and ongoing communication with prescribers. Without a fair payment for those services, most home infusion providers cannot afford to service Medicare patients. As a result, fewer than 70 providers across the entire country participate in the Medicare home infusion benefit. In some states, not a single Medicare home infusion visit was recorded in the past year.

What HR 4993 Does

The Fiandra legislation builds upon the existing Medicare Part B durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) benefit—tying coverage to an electronic infusion pump—and specifies that the drug must be administered by a health care professional. This differs from the current criteria that require patients to use their pump independent of a clinician.

But in reality, most home infusion drugs do not require administration with a mechanical pump—the most common of which are intravenous (IV) antibiotics. Despite this being the single largest category of home infusion care, Medicare beneficiaries are almost entirely shut out of this option today.

A patient discharged from the hospital after a serious infection who needs two weeks of IV antibiotics to complete treatment faces a stark choice under current Medicare policy. This includes daily trips to a hospital outpatient department or placement in a skilled nursing facility. Neither option reflects what the patient's physician wants or what the patient needs.

The Fiandra legislation does not address this gap, nor does it fix the fundamental reimbursement challenge that prevents most homecare providers and pharmacies from offering services to Medicare patients under Part B.

What HR 2172 Would Change

The Preserving Patient Access to Home Infusion Act (HR 2172) changes that equation, making home a viable option for patients who can safely be treated there. The bill fixes the fundamental structural problems by removing the face-to-face requirement that ties Medicare reimbursement to days when a nurse is physically in the patient's home. It also bundles disposable supplies into the pharmacy services payment, creating a cleaner and more complete per-diem payment structure that mirrors the commercial market.

Importantly, the Preserving Patient Access to Home Infusion Therapy Act would also apply to all anti-infective agents in both Medicare Part B and D. The bill would not require the drugs to be added to DMEPOS coverage and would apply to home infusion services whether or not a pump is used for administration. NHIA has concerns that tying coverage to pump use (which Fiandra does) could drive unnecessary pump utilization, distort clinical decision-making and shift patients from Part D drug coverage—where out-of-pocket costs are now capped at $2,000 per year—to Part B, where there is no such cap on the 20% co-insurance patients owe.

Bipartisan Support

NHIA’s proposal garnered bipartisan support from members of Congress during a January hearing of the House Energy and Commerce Subcommittee on Health.

"Being a pharmacist myself, we know how important it is for patients to get care in the right setting,” said Rep. Diana Harshbarger, a bill sponsor. “For many patients, especially in rural areas like mine in East Tennessee, home infusion can improve quality of life and prevent unnecessary trips to the hospital or extended facility stays.”

Rep. Nick Langworthy, who also represents a rural district, said winter weather and harsh road conditions can make a simple infusion appointment an all-day ordeal or even lead to missed appointments.

“Missing doses isn’t just inconvenient; it can derail the treatment plan of a patient,” Langworthy said. “When Medicare doesn’t make the home option dependable, the system too often defaults patients into a more inconvenient setting, simply because it’s the only workable way to complete their treatment.”

Patients covered by commercial insurance, Medicare Advantage and other payers don’t face these challenges, pointed out Rep. Buddy Carter, who is also a pharmacist.

“I just want to point out to the committee that most private insurance companies are covering this, but Medicare is not,” Carter said. “That’s a big gap and something we need to fill in.”

A functional Medicare home infusion benefit would drive a meaningful shift toward home-based care.

What This Means for Homecare Providers

For providers delivering home-based care to Medicare beneficiaries, the stakes of this debate extend well beyond infusion pharmacies. A functional Medicare home infusion benefit would drive a meaningful shift toward home-based care—and with it, increased demand for the full range of services that support patients at home.

NHIA estimates that more than a million Medicare beneficiaries currently receiving infusion services in hospital outpatient departments could gain access to home infusion if the benefit were extended to anti-infectives. If even half of those patients shifted to the home setting—consistent with utilization rates seen in Medicare Advantage and commercial plans—the effects across the homecare sector would be substantial. Patients coming home instead of going to skilled nursing facilities need home health nursing, care coordination, aide services and the wraparound support that homecare agencies provide.

Congress has signaled that it understands the problem. Now is the moment for the homecare community to make clear that HR 2172 is exactly the commonsense solution that patients, providers and Medicare's long-term fiscal health all need.

Connie Sullivan, B.S. Pharm, is the president and CEO of the National Home Infusion Association (NHIA). Sullivan has more than 25 years of infusion industry leadership, management and clinical practice experience. Sullivan is responsible for NHIA’s advocacy initiatives and developing resources that foster innovation and promote the delivery of high-quality care. Visit nhia.org.