Four years later, Medicare policy is still failing home infusion therapy patients

Over the last several years, the COVID-19 pandemic has accelerated trends that encourage the utilization of home-based health care. For example, commercial payers across the country are increasingly employing “site of care optimization” to lower costs associated with infused or injected drugs by encouraging the use of clinically appropriate and convenient settings. However, almost four years into the creation of a new Medicare benefit designed to promote access to home infusion, this vital health program is failing to keep up with the needs of America’s seniors.  

Nearly four years ago, I penned an op-ed in The Hill that lamented the flawed rollout of Medicare’s new home infusion benefit. As an original supporter of the legislation that created this benefit, I was disappointed that the Centers for Medicare and Medicaid Services’ (CMS) implementation fell short by providing insufficient reimbursement for home-infusion professional services, therefore jeopardizing Medicare beneficiaries’ access. 

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

Four years later, the results are clear: CMS’ policy is failing Medicare’s home infusion patients. Despite the creation of a dedicated home infusion benefit, CMS’ own data confirms that less than 1,300 Medicare beneficiaries accessed the benefit each calendar quarter between the first quarter of 2019 and the first quarter of 2021 — an anomaly compared to the estimated 3.2 million patients served annually by home infusion pharmacies. Moreover, utilization of the benefit within the Medicare program has gone down during the public health emergency, despite increases in uptake among commercial and other government payers. 

Without access to home infusion, Medicare beneficiaries are instead being directed to institutional settings — increasing costs to both patients and federal taxpayers while unnecessarily inconveniencing patients that don’t otherwise need to be in facilities to receive their care. For some patients in southeastern Georgia, this could mean driving several hours a day to the closest facility to receive their daily IV infusion. For others, this could mean being admitted to a nursing facility or other long-term care setting for an extended period instead of easily receiving these infusions in the comfort of their own homes.  

To address the shortcomings of Medicare’s home infusion benefit, it is vital that reimbursement reflects all services necessary to administer IV drugs safely and effectively at home — including the extensive pharmacy services that are essential to ensure patients are safely and effectively administering their infused medications. One key piece of legislation pending before Congress, the Preserving Patient Access to Home Infusion Act (H.R. 5067), would do just that by providing coverage for infusion services every day a drug is infused, rather than just on days when a skilled professional is physically present. 

Medicare is the only major payer of health care services in the United States that lacks straight-forward coverage for administering IV drugs at home, despite an overwhelming need for patients to remain at home during the pandemic and the significant potential for cost savings. It is time for Medicare to recognize the value of home infusion and expand this benefit to ensure access for all of America’s seniors. 

Rep. Earl L. “Buddy” Carter, a Republican, represents Georgia’s 1st District. He is one of just two pharmacists currently serving in Congress.