In the era of rapidly rising health care costs, health plans as well as patients are actively seeking ways to reduce costs while maintaining quality of care. At the same time, we are experiencing a “decentralization” of health care delivery, with increasing numbers of health services being delivered at sites distant from the hospital, including the patient’s home.
For most of the modern history of medicine, a principle reason for hospitalization was the need for intravenous medication. However, advances in infusion technology, coupled with the emergence of skilled nursing have made home infusion a reality. It is a reality that carries with it a number of advantages worth considering, and certain barriers yet to be breached.
The Infusion Market
According to Grand View Research, the market size of home infusion therapy worldwide was $13.0 billion in 2015. The market has been expanding rapidly in recent years for a number of reasons, including increasing numbers of elderly, and the existence of large underserved populations.
In addition, in recent years we have witnessed rapid growth in the number of infused specialty drugs, along with an increase in the number of expensive “orphan drugs”, many of which are infused.
The healthcare reimbursement model has been shifting from the fee-for-service model to a more value-based global payment model. The emergence of safe and effective “smart pump” technology has further expanded access to home infusion to a wider segment of the American population. In this context, home infusion is likely to become an even more desirable treatment modality.
Market forces aside, there are a number of practical benefits that make home infusion an attractive option for patients requiring intravenous medication. A 2016 systematic review of 13 published home infusion studies revealed equivalent safety of home infusion compared with hospital infusion with respect to adverse events such as allergic reactions and other side effects. A study published in early 2017 showed that home infusion of a specialized drug for the treatment of Gaucher disease was just as safe as infusion in hospital or a clinic.
Reduced Hospital Stays
The longer a patient stays in a hospital, the greater the risk of hospital-acquired infection. This is especially the case for patients with compromised immune systems, many of whom require infusion therapy with IVIG to alleviate their symptoms. Home infusion allows patients to receive some or all of their therapy at home, while reducing the harms associated with hospitalization.
The 2016 review cited above also assessed outcomes of home infusion versus hospital-based therapy. In all cases, the outcomes were at least equivalent. In some cases, the outcomes were better with home infusion. For example, patients with hemophilia receiving intravenous clotting factor at home showed a 40% reduced likelihood of hospitalization for bleeding complications.
Several recent studies have examined the cost savings associated with home infusion. In a July 2016 study of patients treated with infusions at home for cellulitis, 97% of patients were able to avoid costly hospitalization. Another study, published in 2016 by a Dutch group, showed that patients with Crohn’s disease could be successfully treated at home with a cost savings of $58 per infusion.
Barriers to Home Infusion
The advantages of home infusion with respect to safety and efficacy are becoming clear and convincing. However substantial barriers to widespread adoption remain to be addressed.
The major barrier is Medicare reimbursement. Although Part D reimburses for the cost of most infused drugs, the costs of pumps and services needed to deliver those drugs are not covered. As a result, patients are required to pay out of pocket, driving many to receive therapy in outpatient hospital centers or skilled nursing facilities. The good news is that the 21st Century Cures Act, signed by outgoing President Barack Obama, may provide cost relief. The new law includes a home infusion therapy benefit beginning in 2021.
In areas that are geographically close to major tertiary care medical centers, the tendency is to deliver care at the hospital, or at least at a location affiliated with the hospital. The resistance to adoption of home infusion here is not so much based on cost or safety, but on the force of habit. In underserved areas, the advantages of home infusion are likely to appear more immediately obvious. With time, financial and other pressures are likely to creep in to the over-served areas as well.
Putting Patients First
Home infusion therapy is likely to succeed in the long run because most patients prefer being cared for at home. It is well known that people recover more quickly and more completely in familiar surroundings. The movement toward home and away from hospitals is likely to be driven as much by patient preference as by the emergence of smart pumps and skilled nursing services.