Last spring, like so many other businesses across the country, Upstate HomeCare went from normal operations to shutdown mode virtually overnight as the COVID-19 pandemic slammed into the United States.
Senior Vice President and CEO Greg LoPresti sent approximately 40% of the staff of his Clinton, N.Y.–based home health care service agency, which serves the Albany, Syracuse, Rochester and Buffalo regions, to work from home. Meanwhile, the staff who had to work in person—including drivers, nurses and pharmacists—needed to readjust their model of care.
“Many of the core services we provided, like postsurgical home infusions, dried up overnight,” LoPresti said. “Meanwhile, we had more specialty and chronic care cases for patients with conditions like primary immunodeficiency and CIDP [chronic inflammatory demyelinating polyneuropathy]. The neurology practices were all open, and while they tried to minimize routine patient care to minimize exposure, patients with these severe chronic conditions had to be seen. And patients who would have gone to more traditional outpatient infusion facilities to get care came to us in droves.”
Upstate HomeCare also was in the middle of a pilot study, in partnership with pediatric gastroenterologists at Golisano Children’s Hospital at the University of Rochester Medical Center, to assess the safety and effectiveness of home infusion of anti–tumor necrosis factor therapies for pediatric patients with chronic conditions such as Crohn’s disease and ulcerative colitis. “This is standard for us, but with a pediatric population, there had been concern about doing these infusions in the home, especially for the parents, and the tendency was to be more conservative and provide it in a hospital setting,” LoPresti said. “We had identified patients for the pilot before the pandemic hit, but after that, families who were not in the pilot began asking for in-home therapy, and things ramped up much more rapidly than expected.”
The patients and families in that pilot soon discovered the advantages of home infusion: Children no longer had to be taken out of school to go to the hospital, parents no longer had to take time from work, there were fewer travel costs, and infusions could be scheduled at times most convenient for them. “It was a huge success and will be a published study soon,” LoPresti said.
All over the country, home infusion providers were stepping up to new demands for their services in a world where, suddenly, no one wanted to leave home unless it was necessary.
“We’ve seen at least a 50% increase in our patient load over the past year compared to the previous year,” said Jeston Whitsell, PharmD, the pharmacy manager for Arkansas-based Delta Medical Infusion. “We’ve also been providing care outside of our normal service area, so we’ve increased staffing with another pharmacist, another nurse and an additional driver.”
Critical Source of Support
“During the pandemic, home infusion providers have been playing a critical role in supporting health systems and patients, making sure that many patients who may not previously have been our patients receive the care they need at home,” said Connie Sullivan, BSPharm, the president and CEO of the National Home Infusion Association (NHIA). “Our providers have seen more patients than ever before. They’ve been treating more patients in categories of care that they weren’t doing as much of prior to the pandemic, such as chemotherapy and other complex specialty drugs. They’ve had to develop new policies and protocols and do additional training for nurses and pharmacists to meet those needs, and because of the way the pandemic rolls through communities in unexpected ways, it’s been costly, challenging and unpredictable to know how to respond.”
In a Feb. 9 letter to former acting Secretary Norris Cochran of the Department of Health and Human Services and acting Administrator Liz Richter of the Centers for Medicare & Medicaid Services (CMS), Sullivan asked the Biden administration to consider four recommendations to improve access to care in the home setting for Medicare beneficiaries while also improving care for COVID-19:
- Engage home infusion providers to vaccinate vulnerable and homebound populations.
- Promote home infusion for COVID-19 treatments.
- Provide all Medicare beneficiaries with access to home infusion.
- Waive in-person requirements for home infusion services during the public health emergency.
The request for home infusion access for all Medicare beneficiaries calls for the administration to address significant shortcomings in Medicare’s coverage policies. “Medicare fee-for-service is the only payor that currently does not offer a comprehensive home infusion benefit,” Sullivan said.
At present, Medicare only covers home-based drug administration services for a limited subset of drugs that are covered under the Durable Medical Equipment (DME) benefit because they are administered via an external infusion pump. For the majority of home-infused drugs, such as IV antibiotics, monoclonal antibodies and hydration with electrolytes, which do not require a mechanical pump, supplies and professional services are not covered.
In its letter, NHIA asked that CMS add coverage for the related services and disposable supplies under Medicare Part B for drugs billed to Medicare Part D when they are used in the home setting. “Under this model, home infusion providers would receive a bundled supplies and services payment for each day a patient administers the drug, which would be designed to cover the costs associated with care coordination, patient assessments, plan of care development, clean room certification and maintenance, and other services provided by the pharmacy,” Sullivan wrote. The recommended change could be easily implemented by CMS in a demonstration project for infusion medications currently covered under the Part D benefit. “This model has been overwhelmingly effective in commercial plan coverage at lowering costs by shortening hospital stays and avoiding long-term care admissions.”
Another New Benefit
NHIA also met with CMS representatives about the new home infusion therapy services benefit that was implemented in January 2021. Historically, CMS had not covered the cost of nursing components for administering home infusion therapy; the 21st Century Cures Act, enacted in December 2016, established a new benefit for home infusion therapy services, including nursing services; training and education not otherwise covered under the DME benefit; remote monitoring; and other monitoring services.
CMS’s physical presence requirement for face-to-face visits from a nurse for implementation of the home infusion therapy benefit is another hurdle reducing access to home infusion services during a time when vulnerable individuals are particularly interested in receiving home-based care whenever possible to avoid exposure to COVID-19, Sullivan noted.
“We have a lot of concerns about the rollout of that benefit and the disruption of care that it seems to be creating,” she said. “The new benefit sounds good, but it was not intended to be solely a face-to-face nursing benefit for patients who receive infusion therapy under Medicare Part B, which is, unfortunately, how it has been applied. So what is now happening is that providers are reimbursed significantly less for providing those therapies, and continuing to be able to provide that therapy depends on being able to locate a nurse when needed. There is very low enrollment at this point, and we have heard from several home infusion providers that they are struggling to find nursing care or another pharmacy to take those patients.”
Prior to 2021, she explained, a home infusion provider that is a pharmacy could partner with a home health agency for higher-acuity patients who require nursing care, such as patients with congestive heart failure. “Seamlessly, the patient would have one nurse come out to do everything that was needed,” Sullivan said. “Now the nursing component has to be part of the Part B benefit, and many home health agencies are not participating in this benefit. We are very concerned: These are some of the most vulnerable seniors in the Medicare benefit. It’s not a lot of patients, but this is a very vulnerable population.”
NHIA is working with a bipartisan group of members of Congress to reintroduce legislation from the last session, the Preserving Patient Access to Home Infusion Act, which is designed to ensure Medicare patients have access to Part B home infusion medications by, among other things, removing the requirement that a nurse be physically present in the patient’s home in order for providers to be reimbursed under the benefit.
“While the Part B benefit is important to fix, we also feel very strongly that this benefit only works for the small number of drugs that require infusion pumps,” Sullivan noted. “We are urging CMS, through the Innovation Center, to explore a more comprehensive, straightforward infusion benefit for a broad array of drugs. The pandemic has really exposed this gap in coverage, when many people would like to receive care at home or at least have the option to.”
—Gina Shaw
Cost Savings of Home Infusions Clear
We at Weill Cornell have one of the largest pediatric home infusion program. We have been doing this for close to 10 years and write home infusion orders for about 70 kids. They receive their infusions at home, college, camp and abroad while in different countries. We wrote a statement paper published in Journal of Pediatric Gastroenterology and Nutrition about this (2018; doi: 10.1097/MPG.0000000000001890).
This program requires a lot of excellent coordination that must be handled by a social worker and doctors writing the orders. We interact with nursing companies, specialty pharmacies and the infusion companies. It is time-intensive but worth it for the families. No loss of school or work, and very convenient and no traveling!
Kids have to meet certain requirements for safety for both the stability of their chronic condition and venous access. Most insurance companies are pushing for this option to do infusions at home. There are some insurance companies, however, that are trying to not pay the coordination of care fee that we are billing.
There is a small charge for care coordination performed at the prescribing doctor’s office that not all insurance companies have recognized 100%. There is a significant difference in the cost of a hospital infusion compared with home infusions. The cost savings of “at home care” should encourage all insurance carriers to recognize and pay for the coordination of home care CPT (Current Procedural Terminology) code fee.
The sources reported no relevant financial disclosures beyond their stated employment.
This article is from the May 2021 print issue.