Medicare policy is failing home infusion therapy patients
© Greg Nash

In recent years, health care delivery has evolved to allow more care to take place in low-cost settings like the home. It has also moved away from strictly face-to-face visits with the doctor or nurse, as more providers are relying on multi-disciplinary teams, utilizing technology, leveraging remote monitoring, and employing other care coordination tools. And while patients and payers are recognizing the benefits of all these changes, current Medicare policy is falling short in one important area: home infusion therapy.

For 30 years, home infusion providers have been safely and effectively delivering care in the home. Home infusion therapy involves the administration of medication through a needle or catheter, and is essential for patients who suffer from a broad range of illnesses and infections that cannot be addressed by oral medications alone. These therapies allow patients with congestive heart failure, immunologic diseases, infections, and other conditions to remain home, where they are comfortable and can continue to enjoy their families and activities, as well as avoid exposure to drug-resistant microorganisms common to institutional settings.

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Congress recognized the value of the home infusion services in the Medicare program when we created a new permanent reimbursement for those services in the 21st Century Cures Act, which goes into effect in 2021. Further, in the Balanced Budget Act of 2018, we created a temporary reimbursement beginning January 2019 to ensure that Medicare beneficiaries can access these services until a permanent payment system is established. As an original supporter of both of these pieces of legislation, I can state unequivocally that Congress intended for the Centers for Medicare and Medicaid Services (CMS) to develop a more modern benefit that reflects the diverse array of professional services needed to deliver the care, and that recognizes the professional services that are performed remotely. 

Unfortunately, CMS has put forth a proposed rule that contradicts the intent of the law, provides insufficient reimbursement for home-infusion services, and jeopardizes beneficiary access to home infusion. If implemented as written, Medicare beneficiaries will have no options but to receive their infusions in more costly settings, such as hospitals or other institutional settings that put patients at risk for infection.

The problem lies in the fact that CMS is requiring that a skilled professional such as a nurse be physically present in the patient’s home on the day of administration for reimbursement to occur. This defeats the purpose of home infusion which is to give patients the freedom to receive their infusions at home and allow them to administer their own infusions without a health care professional. No other payer, including commercial plans, Medicare Advantage Plans, among others, have such requirements.  

The root of the problem is CMS’ failure to recognize the broad spectrum of professional services infusion providers utilize to deliver Medicare beneficiaries home infusion including drug preparation, clinical care planning, nursing, and care coordination—all services the law established to ensure the entire spectrum of home infusion therapy would be reimbursed.

I encourage CMS to withdraw the requirement that a nurse or other professional be physically present at the home for providers to receive payment, and to develop a definition of professional services that is unique to home infusion and ensures coverage of all the services that go into delivering infusion therapy. To not do so is violating the letter of the law.

Rep. Earl L. “Buddy” Carter, a Republican, represents Georgia's 1st District. He is the only pharmacist currently serving in Congress.