Navigating insurance presents a challenge, but pharmacists improve stakeholder access and provide in-home care.
Physicians and health care providers often have to explore different avenues of therapy outside of the traditional inpatient hospital stay and outpatient infusion center. Home health services, and specifically home infusion, is an alternative, cost-effective avenue that affords patients the liberty of receiving treatment in their home.1
The home infusion market has grown over the past decade, and it is estimated that the US home infusion market will reach $20.6 billion by 2027.2 One of the biggest drivers of market growth is the aging population, with the US Department of Health & Human Services stating that more than 49.2 million individuals over the age of 65 live in the United States.2 The COVID-19 pandemic also positively affected the growth of the home infusion market, as many patients elected to receive treatments at home.2
Why Home Infusion?
The home infusion space represents a large range of pharmaceutical services provided in the outpatient setting, typically in a patient’s home. The home may be a preferred site of care in certain clinical situations, such as if a patient requires extended intravenous therapy but does not warrant the level of hospital inpatient care. Home infusion also can positively impact a patient’s quality of life. It is safe and is associated with good outcomes.3,4
Financial drivers are often at play in home infusion, with some payers mandating the switch. Alternatively, home infusion may be a benefit of a health system insurance plan, may be affiliated with a health system, or may be part of a shared risk model in an Accountable Care Organization.
Home infusion also benefits the patient by supporting continuity of care after hospital discharge or between provider office visits. Many hospitals, community pharmacies, home health organizations, hospices, and specialized infusion companies provide home infusion services as a treatment option for their patients, with services that cover a wide array of chronic and acute conditions.1,3
What Is Involved in Home Infusion?
The home infusion process typically requires coordination among multiple entities, including patients, physicians, hospital discharge planners, health plans, home infusion pharmacies, and, if applicable, home health agencies.1,4 In certain situations, there are efforts to move treatments out of a clinic, and recent advances in equipment and techniques have made this possible.
Services provided by home health or infusion companies include medication, equipment, and supplies. Nursing services are also utilized to train, educate, and deliver therapy to the patient. Pharmacists work within the home infusion company to receive prescriptions, prepare and dispense medications, and provide clinical care and counseling services. Some examples of diseases and disorders that are commonly treated through home infusion include gastrointestinal diseases and disorders, dehydration, congestive heart failure, infections, rheumatoid arthritis, multiple sclerosis, hemophilia, immune deficiencies, and nutrition support.
Navigating Insurance for Home Infusion Services
Providing home infusion therapy involves not only delivery of medication, but it also requires professional services, equipment, and supplies to ensure safe and effective administration of the therapy. Reimbursement for home infusion varies widely across payer plans and may include per diem services. Insurance goals include optimizing a patient’s access to care and minimizing their out-of-pocket liability, meaning it covers payment on drugs, equipment, supplies, nursing, and per diem services.5
Commercial insurance typically structures benefit plans to increase access to care and has taken a favorable stance toward including home infusion benefits. Medicaid coverage varies state by state and often has prior authorization requirements.
Medicare’s fee-for-service program has made strides in recent years but still has not yet fully recognized the benefits of covering infusion therapies in a patient’s home. In December 2016, the 21st Century Cures Act was enacted into law to establish a new Medicare home infusion benefit.3 One flaw of this act is the lack of reimbursement of professional services and acknowledgement of the day-to-day clinical efforts that go into managing a patient. According to the National Home Infusion Association (NHIA), “by reimbursing only on days when a nurse is present in the patient’s home, which is typically once a week, this policy significantly shortchanges these essential pharmacy-related professional services by removing $150 million in reimbursement from the benefit.”6
Most infusion drugs are covered by the Medicare Part D prescription drug benefit, and the Centers for Medicare & Medicaid Services (CMS) has stated that it does not have authority to cover the infusion-related services, equipment, and supplies under Part D. Because of this, many Medicare beneficiaries receive infusion therapy in hospitals and skilled nursing facilities, which can result in a significantly higher cost to Medicare and be inconvenient for patients.
Under Medicare Part B, there is coverage for certain therapies (such as parenteral and enteral nutrition) administered using durable medical equipment (DME). This covers a select few therapies and only under very specific conditions. In October 2020, CMS announced a proposed rule to broaden coverage for home infusion DME, specifically for external infusion pumps, to increase access to home infusion drugs.4
For home nursing visits necessary for beneficiaries receiving infusion therapy, there can be Medicare Part A coverage under Medicare’s home health benefit only if the patients are serviced by a Medicare-certified home health agency. They also must be considered homebound and in need of intermittent (not 24-hour) home nursing.7
The NHIA continues to advocate for the expansion of services and for full reimbursement, particularly for pharmacists and other clinical and professional services. In their first payer summit, held in fall 2022, they encouraged payers to establish specialty networks that include locally based, full-service infusion providers; require the coordinated provision of infusion supplies, equipment, and services; and add codes for ambulatory infusion suites to contracts.8 They also recommended expansion of services including codes for placing and managing vascular access devices, which would shorten hospital stays and minimize emergency department use.8
A Pharmacist's Role
Pharmacists provide valuable services in the home infusion setting. In addition to their medication dispensing activities, pharmacists perform extensive medication reconciliation, develop care plans, conduct clinical monitoring, and provide patient education and on-call services. They also coordinate and communicate with other health care professionals and serve as a liaison between the patient and other care teams.9 In addition to the normal local, state, and federal laws, some states also require special training for preparing sterile preparations.9
As the population continues to grow and the home health market continues to expand, there will be a need for pharmacists to be trained in the infusion setting. As more therapies are approved and quality outcomes are seen for home infusion patients, the market will continue to increase, and pharmacists and home infusion companies should rise to meet the demand.
About the Author
Joanna Lewis, PharmD, MBA, is the 340B compliance coordinator at Baptist Health in Jacksonville, Florida.