Congress attempts to intervene in Medicare home infusion reimbursements
by: Ron Lanton
With Medicare costs rising and states struggling to fund expanded Medicaid, policymakers are wondering how to continue providing patient access to necessary medications. The last few years have seen ideas such as value-based healthcare, Medicare star ratings and Delivery System Reform Incentive Payment (DSRIP) programs emerge as leading cost-containment policies. While the greater utilization of infusion therapy in Medicare can help offset higher healthcare costs, many policymakers are unsure what infusion therapy is.
According to the National Home Infusion Association, infusion therapy involves the administration of medication through a needle or catheter. It is prescribed when a patient’s condition is so severe that it cannot be treated effectively by oral medications. Typically, “infusion therapy” means that a drug is administered intravenously, but the term also may refer to treatments in which drugs are administered through other non-oral routes, such as intramuscular and epidural injections. 
The migration from inpatient stays to alternative sites of care have helped lower infusion therapy costs. Instead of receiving infusion therapy solely in an in-patient setting, patients are now allowed to receive infusion therapy in ambulatory, skilled nursing and home settings. Just as the coordination of care between payers, home infusion providers, home health agencies, physicians and hospital discharge planners is complex, the reimbursement for home infusion is even more complex. While a majority of commercial plans provide a home infusion benefit, “Medicare’s fee-for-service program (Parts A and B) does not cover the full range of services for the provision of infusion therapies in a patient’s home.
Medicare Part B does cover a limited number of drugs infused using an infusion pump but does not separately cover the clinical services necessary for the provision of infusion therapy in the home. In addition, while most infusion drugs that are not covered by Part B may be covered under the Medicare Part D prescription drug benefit, infusion-related services are not covered. Home healthcare services, including skilled nursing services, are only covered when a beneficiary meets the criteria for homebound status as defined under Medicare’s home health benefit.”
This leaves many wondering if there is a solution that helps fix this fragmented form of reimbursement. Earlier this year, the Medicare Home Infusion Site of Care Act of 2015 (S.275/H.R.605) was introduced and is sponsored by Congressman Eliot Engel (D-NY) in the House and by Senator Johnny Isakson (R-GA) in the Senate. This bill seeks to amend title XVIII of the Social Security Act to provide for the coverage of home as a site of care for infusion therapy under the Medicare program. The bill is currently in the Committee on Finance in the Senate and in the Energy and Commerce Committee as well as the Ways and Means Committee in the House. In addition to providing much needed definitions for “home” and “qualified home infusion therapy supplier,” the legislation outlines an in-depth payment mechanism for home infusion therapy.
Passing this legislation will be key to ensuring Medicare reimbursement efficiency and could also help improve quality of life for patients because many would prefer to receive infusion therapy from the comfort of their homes rather than deal with the time and reimbursement inefficiencies that exist today. However; it is getting late in the legislative calendar and with next year being an election year, it remains to be seen whether this bill will become law.
 Avalere Health; Impact on Medicare Expenditures From Expanding Coverage of Infusion Therapy of Anti-Infective Drugs to the Home Setting June 2014 http://www.nhia.org/resource/legislative/documents/AvalereFinalHomeInfusionReport.pdf