On July 11, 2019, the Centers for Medicare and Medicaid Services (CMS) proposed a rule change that would potentially alter the manner in which home infusion services are provided and reimbursed. The new proposal may affect many segments within the home health industry, one of which will be home infusion therapy. In order to understand why this could be a game changer, it’s helpful to take a look at the history surrounding this niche product and its services.
What is home infusion therapy?
The National Home Infusion Association defines home infusion therapy as “any medication or hydrating solution that is given intravenously (IV), injected into muscles or administered into the area around the spinal cord (the epidural space) is defined as an infusion therapy”.
Up until the mid-1980s, all infusion therapy was administered in hospitals. Skilled nurses were required to perform infusions, and patients routinely needed cardiovascular monitoring or physician oversight to ensure safety. At the time, this type of treatment was only offered within a hospital setting.
As medical costs continued to rise, efforts to find solutions to mitigate infusion therapy expenses started to surface. Over the course of the next 30 years, extensive research was conducted around the safety and efficacy of administering infusion therapy outside of the hospital. The conclusions from this research established that infusion therapy provided in the home is safe, efficacious and cost-effective. It was also determined that patients overwhelmingly prefer care delivered at home.
The 21st Century Cures Act
In order to turn affordable home infusion care into a reality, payment structures would need to be revised. By 2015, the worldwide home infusion market was valued at $13 billion. This surge was fueled by a combination of the growing aging population and the development of new medications and delivery devices. However, this upturn eventually stagnated due to payment bottlenecks, stemming from CMS.
In an attempt to remedy the situation in 2016, the US Congress enacted the 21st Century Cures Act. This Act altered coding rules, allowing routine home infusion therapy to be reimbursed. Evidence presented by the Congressional Budget Office detailed the billions of dollars CMS would save with home infusion. Notwithstanding the new regulations and data figures, implementation hit a snag when the act was amended, delaying new reimbursements until 2021.
The Patient-Driven Groupings Model
The recently proposed amendments are intended to accelerate implementation of the new home infusion reimbursement model. The proposal would allow skilled providers to perform maintenance infusion therapy, i.e., medications that a physician prescribes for an extended period in the home.
These changes also bring to light a relatively new reimbursement concept known as the Patient-Driven Groupings Model (PDGM), which reorganizes payments in terms of 30-day episodes of care. According to an extremely complicated formula (even by CMS standards), PDGMs are further subdivided into 432 case-mix groups, created for the purpose of calculating payment.
According to CMS, the new PDGM system will result in payment increases to home health agencies of 1.3 percent, amounting to $250 million in 2020. However, this increase will be offset, to a certain extent, by a reduction in aggregate payments at the expense of “rural add-on payments” that are expected to decrease by $40 million in 2020.
The new legislation would also grant therapist assistants, in addition to infusion therapists, authorization to perform in-home visits and infusions under certain circumstances. The hope is that this regulatory relaxation will make more resources available to skilled therapists who provide care in the home.
Concerns expressed by the home care industry
While many are optimistic regarding the effects of the new changes, there are those within the home health industry who have strong reservations. Some critics have pointed out that the proposed rule changes may actually reduce reimbursements to home health providers by 2021. The new rule will also update the reporting requirements for home health providers. It remains to be seen whether these changes will prove to be more or less burdensome to the industry.
CMS tries to smooth the path
In preparation for the time and resources needed to implement the new home infusion benefit, CMS is recommending that the long list of home infusion medications be consolidated into three groups, where each group would receive a single unit of payment. However, while it seems as though CMS is seeking to simplify the process, they may instead be complicating their own simplification efforts with a “geographic adjustment factor” designed to account for regional differences in business costs.
CMS also proposes to increase the reimbursement for initial home infusion visits. This is a positive development for home health agencies, because the initial visit invariably requires more time on the part of the therapist in terms of preparation, administration, and importantly, patient education. To compensate for this increase, CMS proposed slightly decreasing reimbursements for subsequent visits.
The glass half-full
Compared to the 1980s, patients today requiring infusion therapy are receiving much better treatment. Patients with chronic infections, chronic pain, and even cancer, are receiving the care they need at home, where they feel most comfortable, which may improve their quality of life. Home infusion therapy has continually proven to be safe, treatment-effective, and cost-effective, to the benefit of the patient.
While the regulations around the current reimbursement model are complicated and have bred discord in Congress around funding and future rule changes, the good news is that patients have more access to life-enhancing therapies than ever before.