Home infusion therapy gets boost from CMS

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Ben Comer Senior Manager, Health Research Institute, PwC US November 15, 2019


CMS is launching a permanent home infusion therapy benefit starting Jan. 1, 2021, a move that is in line with the federal agency’s efforts to encourage care to be delivered in the home as much as possible.

The new permanent benefit, outlined in the agency’s recent final home health payment rule, will pay for nursing and professional services for parenteral drugs or biologicals administered intravenously or subcutaneously for 15 minutes or more through a pump. Payments will be made according to the drugs administered, where geographically they were administered and other factors, according to a statement released by the agency. The agency is seeking comments on which drugs should be covered under the benefit.

In a statement, CMS Administrator Seema Verma touted the new benefit as increasing patients’ choices. “The new permanent home infusion therapy benefit increases the availability of home-based care, by giving patients the choice and convenience to receive critical treatments, such as anti-infectives and chemotherapy, safely at home instead of a hospital or doctor’s office,” Verma said.

The agency has been paying for home infusion services as a temporary, transitional benefit since Jan. 1. That transitional period will end as the permanent benefit begins in 2021, according to the rule.

While infusion therapy is often performed in inpatient settings, outpatient hospital departments, skilled nursing facilities and other provider locations, home infusions are done at home, usually with the aid of a visiting nurse. Nurses often train patients or caregivers to administer the drugs and to watch for side effects and signs of benefit. They also visit occasionally to monitor the infusion site and change dressings.

The process involves the drug, equipment, supplies and professional services, and, as the rule states, “requires coordination among multiple entities, including patients, physicians, hospital discharge planners, health plans, home infusion pharmacies, and, if applicable, home health agencies.” The new permanent benefit will pay for the professional services associated with administering the drugs in a person’s home, but the drugs, equipment and supplies will be covered under a separate, Durable Medical Equipment (DME) benefit.

The National Home Infusion Association expressed concern about the rule, arguing that pharmacists should be included in the benefit and that payment rates don’t accurately reflect the costs of caring for home infusion patients.

The rule also included a very modest bump in Medicare payments for home health agencies of about 1.3 percent for 2020.

HRI impact analysis

Moving care out of hospitals and into the home may benefit patients, in addition to lowering the cost of care. Administering drugs in patients’ homes or in physicians’ offices, instead of hospital outpatient centers, could save $4 billion per year, according to a UnitedHealth Group analysis.

But payment for home care has been a significant barrier to usage, a Commonwealth Fund study found, despite evidence of better outcomes and lower costs in the at-home acute care setting. Pharmaceutical and life sciences companies are developing new products for use at home, in therapeutic areas such as hemophilia and kidney dialysis. As funding for home health services expands, patient monitoring services and physician-led care coordination plans that connect nursing staff and DME providers will be critical to success.

The final rule’s comment period to help determine criteria for drug coverage under the home infusion benefit is open until Dec. 30.

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Ben Comer

Senior Manager, Health Research Institute, PwC US

Crystal Yednak

Senior Manager, Health Research Institute, PwC US

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