Health systems urge Congress to address Medicare reimbursement for home infusion
Currently, a nurse or physician is required to be physically present in the home for providers to be reimbursed by Medicare.
Photo: Jodi Jacobson/Getty Images
Dozens of health systems, hospitals, and group purchasing organizations are asking Congress to pass legislation to address Medicare reimbursement for home infusion services.
The Centers for Medicare and Medicaid Services improperly implemented the Bipartisan Budget Act of 2018, requiring a nurse to be physically present in the patient's home for providers to be reimbursed, according to the National Home Infusion Association.
In a letter sent to congressional leaders, health systems, hospitals and GPOs, representing more than 600 hospitals and over 5,000 sites of care across all 50 states, are urging lawmakers to pass the Preserving Patient Access to Home Infusion Act.
The bill provides technical clarifications that would remove the physical presence requirement, ensuring payment regardless of whether a healthcare professional is present in the patient's home. The legislation includes essential pharmacist services in the reimbursement structure.
WHY THIS MATTERS
If implemented, the legislation would increase provider participation in the benefit and enhance patient access to home infusion, diverting care from more expensive institutional settings.
Many Medicare beneficiaries rely on IV drugs to manage chronic disease or acute conditions.
Those who are commercially insured already have this benefit.
"While commercial insurance plans provide comprehensive coverage for home infusion therapy services, seniors who are covered under traditional Medicare often do not have the option to remain at home," the letter said.
The letter cites a report released by CMS in January 2022 confirming that utilization of the benefit has been low, which "creates challenges in our ability to transition patients from inpatient care to the home setting."
CMS' data reveals that fewer than 1,300 Medicare beneficiaries accessed the benefit each calendar quarter between the first quarter of 2019 and the first quarter of 2021, compared to the estimated 3.2 million patients served annually by home infusion pharmacies.
THE LARGER TREND
Congress included provisions in the 21st Century Cures Act and the Bipartisan Budget Act of 2018 to create a professional services benefit for Medicare Part B home infusion drugs.
The intent was to facilitate patient access to home infusion by covering professional services, including assessments, education on administration and access device care, monitoring and remote monitoring, coordination with the patient, caregivers and other healthcare providers, and nursing visits.
Despite Congress' intent – as detailed in multiple letters to the agency – CMS "improperly implemented" the benefit by requiring a nurse to be physically present in the patient's home for providers to be reimbursed, NHIA said.
This fails to account for the extensive clinical and administrative services that are provided remotely by home infusion clinicians, the association said.
Home health has been expanding and the market is growing. During the pandemic, CMS allowed for acute hospital care to be provided at home. This helped hospitals that were facing an influx of COVID-19 patients. It also proved to be economically beneficial.
This week, Amazon, UnitedHealth Group and Option Care Health are reportedly in a bidding war to buy Signify Health, which offers a home health platform and in-home evaluations. The week before, CVS Health was reported as a potential buyer.
ON THE RECORD
"Hospitals and health systems understand that Medicare patients with underlying health conditions often require access to infused medications after a recent hospital stay," said Connie Sullivan, president and CEO of the National Home Infusion Association.
Twitter: @SusanJMorse
Email the writer: SMorse@himss.org
