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How to maximize home infusion reimbursement

Early in the COVID-19 pandemic, home infusion reimbursement rates weren't top of mind for Varner R. Richards, Pharm.D., CEO/owner of Columbia, S.C.-based Intramed Plus. Instead, he focused on how his infusion pharmacy could help local hospitals move patients home for post-acute infusion therapy.

"We evaluated close to 90 patients, and we ended up taking out 54 patients," Richards says. "All those patients had successful therapies and never had to have a rehospitalization. We saved 1,516 patient days of hospitalization, resulting in over $3 million in days saved from hospitalization."

Although the care Intramed Plus provided those 54 patients was largely unreimbursed, the program showed the value of home infusion — especially at a time when hospitals were struggling with COVID-19 caseloads. "A patient's home is a safe and cost-effective site of care for patients to continue their therapy," he says.

That said, there are challenges with Centers for Medicare & Medicaid Services (CMS) reimbursement under Medicare Part B, which provides enrollee coverage for outpatient and most home health services, including home infusion therapy.1

We talked with Richards to learn more about how infusion pharmacies can help maximize reimbursement.

A history of cost savings and convenience

Home infusion is a major industry, generating $19 billion and serving more than 3.2 million patients annually, according to the National Home Infusion Foundation's (NHIF) Infusion Industry Trends 2020 report. Overall, the industry has grown 300% in the past decade alone.2

Nearly 95% of patients who need IV medications say they prefer to receive treatment at home.3 They know it can prove expensive to go into a skilled nursing facility and inconvenient to make daily (or even more frequent) trips to an infusion center. "The logistics for the patient in a rural state like South Carolina are challenging," Richards says.

The forecast isn't entirely sunny, however. Even as the industry has grown, Medicare participation has plummeted. Fewer than 16,000 beneficiaries received home infusion therapy in 2018, a 25.2% decline since 2014. Over the same period, home infusion-related Part B spending (including drugs, pumps and supplies) dropped by nearly 58%.2

Overall, the home infusion therapy industry has grown 300% in the past decade alone.

Where reimbursements fall short

The 21st Century Cures Act, which took full effect on Jan. 1, 2021, added a new professional services benefit for Medicare Part B home infusion therapy.2

Part B home infusion now covers a limited number of approved drugs and biologicals, necessary equipment and supplies (for example, pumps and IV administration supplies), and, for the first time, professional services.

Lawmakers intended these professional services to include the home infusion provider team of clinically trained pharmacists and infusion nurses collaborating with the patient's physician to oversee the patient's therapy. The act authorized billing for professional services for each day of medication infusion. So for a continuous infusion, the infusion pharmacy could bill for professional services every day.

However, CMS' subsequent implementation rule limited reimbursement of professional services to days when a nurse is present in the patient's home, generating pushback from providers and lawmakers alike.

National Home Infusion Association (NHIA) Board Chair Logan Davis, Pharm.D., says that the policy fundamentally misunderstands how pharmacists deliver home infusion, which can jeopardize patient safety and create barriers that are already inhibiting patient access to these services.4

Rep. Earl L. "Buddy" Carter (R-GA), the only pharmacist in Congress, says that this defeats the purpose of home infusion, which is to give patients the freedom to receive infusions at home and administer them without a healthcare professional.5

Richards concurs, emphasizing that home infusion goes far beyond nurse visits. "It's very team-oriented," he says. "The pharmacist really manages the therapy collaboratively with the prescribing physician. Then, the nursing support does the training and assists with coordination with the patient's local home health agency, so they have good venous access care. Then, we monitor the patient's progress while they're on their therapy."

The potential for a legislative fix

Lawmakers in both the House and the Senate have introduced bipartisan legislation (the Preserving Patient Access to Home Infusion Act) to better align Part B home infusion reimbursements with lawmakers' original intentions. It would reimburse professional services for each day infusion takes place, not just for days a nurse visits. In the meantime, however, the CMS rule stands.5,6

"The other part [of the proposed legislation] is that it would allow nurse practitioners and PAs who have advanced practice status to order home infusion," Richards says. "Right now, the Cures Act only allows physicians to do it. Your advanced practitioners are much more viable now in healthcare in terms of being able to direct patients to cost-effective care."

Tips for maximizing Part B reimbursements

Until there's a legislative fix, Richards says infusion pharmacies can take several steps to maximize reimbursements:

  • Be a good teammate to health systems. "Referral sources like health systems have a process where they need these patients to go out quickly so they can minimize their length of stay in the hospital, which is costly," Richards says. "And they're penalized if they have a high length of stay." If you can move quickly and effectively, you can help referral sources meet their goals while meeting your own
  • Serve a diverse patient population. "You've got to balance Medicare Fee-for-Service with your other business," Richards says. "You can't just say you're not taking any Medicare patients because then you become less of a provider for your referral sources." Moreover, commercial and Medicare Advantage programs typically provide more proper home infusion reimbursements than Part B
  • Teach your patients well. "Therapy for patients to do in the home initially is overwhelming, but as it goes on, it's like, 'This is not bad,'" Richards says. By helping patients successfully handle their home infusions, you become a more trusted teammate for referral sources
  • Educate patients about cost. "A lot of times, patients will pick the site they think has the least financial impact on them, although in the big picture it may actually be more costly," Richards says. "Going to a facility, depending on whether the patient has a supplement or not, they still may have 20% to pay. They're never ever told that; their true costs are never communicated."
  • Focus on quality. "Ask: How well did we do? What did we do well? If we had issues, how can we prevent them for the next patients?" Richards says. "This is not like, 'one prescription, fill it, I'm done.' The patient's not a number; the patient is actually a patient with us."
  • Invest in your business. Registering as a Medicare home infusion therapy supplier requires additional accreditation, and you'll need to comply with additional state regulations. "That takes extra expense," Richards says. "In our company, we went ahead and put the investment in it because I feel over time the reimbursement status will probably change."

Part of Richards' optimism lies in the fact that CMS has maintained a good dialogue with the home infusion industry and NHIA despite their disagreements. "They've said, 'If you're going to change it — even though you've got a lot of letters from Congress saying we've got it wrong — you're going to have to get a legislative fix,'" he says.

When that fix comes, Richards plans to be ready to help more patients get convenient, cost-effective, in-home infusion therapy.

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