What is infusion therapy?
Infusion therapy involves the administration of medication through a needle or catheter. It is prescribed when a patient’s condition is so severe that it cannot be treated effectively by oral medications. Typically, “infusion therapy” means that a drug is administered intravenously, but the term also may refer to situations where drugs are provided through other non-oral routes, such as intramuscular injections and epidural routes (into the membranes surrounding the spinal cord).
Traditional” prescription drug therapies commonly administered via infusion include antibiotic, antifungal, antiviral, chemotherapy, hydration, pain management and parenteral nutrition.
Infusion therapy is also provided to patients for treating a wide assortment of often chronic and sometimes rare diseases for which “specialty” infusion medications are effective. While some have been available for many years, others are newer drugs and biologics. Examples include blood factors, corticosteroids, erythropoietin, infliximab, inotropic heart medications, growth hormones, immunoglobulin, natalizumab and many others.
What diseases are treated with infusion therapy?
Diseases commonly requiring infusion therapy include infections that are unresponsive to oral antibiotics, cancer and cancer-related pain, dehydration, gastrointestinal diseases or disorders which prevent normal functioning of the gastrointestinal system, and more. Other conditions treated with specialty infusion therapies may include cancers, congestive heart failure, Crohn’s Disease, hemophilia, immune deficiencies, multiple sclerosis, rheumatoid arthritis, and more.
By far, the major home infusion therapies are IV antibiotics, prescribed primarily for such diagnoses as cellulitis, sepsis, and osteomyelitis; other diagnoses include urinary tract infections, pneumonia, sinusitis and more.
Why are infusions performed at home?
Until the 1980s, patients receiving infusion therapy had to remain in the inpatient setting for the duration of their therapy. Heightened emphasis on cost-containment in health care, as well as developments in the clinical administration of the therapy, led to strategies to administer infusion therapy in alternate settings. For individuals requiring long-term therapy, inpatient care is not only tremendously expensive but also prevents the individual from resuming normal lifestyle and work activities.
The technological advances that enabled safe and effective administration of infusion therapies in the home, the desire of patients to resume normal lifestyles and work activities while recovering from illness, and the cost-effectiveness of home care are important. Consequently, home infusion therapy has evolved into a comprehensive medical therapy that is a much less costly alternative to inpatient hospital treatment.
Home infusion has been proven to be a safe and effective alternative to inpatient care for many disease states and therapies. For many patients, receiving treatment at home or in an outpatient infusion suite setting is preferable to inpatient care. A thorough patient assessment and home assessment are performed before initiating infusion therapy at home to ensure that the patient is an appropriate candidate for home care.
Do government and private insurance plans cover infusion therapy in the home and other alternate-sites?
The range of variables that must be managed by the infusion pharmacy to ensure safe and appropriate administration has led nearly all commercial health plans to treat home infusion therapy as a medical service, reimbursed under their medical benefit (rather than the prescription drug benefit) and paid for using a per diem for clinical services, supplies, and equipment with separate payments for the drugs and nursing visits. It also has led most commercial plans to require that infusion pharmacies be accredited by nationally recognized accreditation organizations. Commercial plans have used this model aggressively to reduce overall health care costs while achieving high levels of patient satisfaction.
Government health plans such as Medicaid, TRICARE, and the Federal Employees Health Benefits Program also reimburse for home infusion therapy, although for Medicaid in a few states the extent of coverage can have gaps. A major exception in completeness of coverage is, unfortunately, the Medicare program.
For infusion therapy provided in Ambulatory Infusion Suites, commercial insurers are fast recognizing the appropriateness of this infusion setting and its cost-competitiveness with other Ambulatory Infusion Center settings. Medicaid coverage varies by state. Medicare’s prescription drug plan (Part D) may cover the cost of the infusion drugs, but the costs of AIS services, supplies, equipment and nursing are not covered. The infusion therapy provider will ascertain coverage for patients and advise on the extent of coverage and patient obligations prior to start of service
Does Medicare cover home infusion therapy?
Unfortunately, Medicare’s fee-for-service program (Parts A, B and D) is the only major health plan in the country that has not recognized the clear benefits of adequately covering provision of infusion therapies in a patient’s home. Because most Medicare beneficiaries are enrolled in the fee-for-service program, when seniors and the disabled find they may need infusion therapy they often find it unaffordable to receive this care in the comfort of their home.
Providing home infusion therapy involves not only the delivery of medication, but also requires professional services, specialized equipment and supplies to ensure safe and effective administration of the therapy. While most infusion drugs may be covered by the Medicare Part D prescription drug benefit, the Centers for Medicare & Medicaid Services (CMS) has determined that it does not have the authority to cover the infusion-related services, equipment and supplies under Part D. As a result, many Medicare beneficiaries are effectively denied access to home infusion therapy and are being forced into receiving infusion therapy in hospitals and skilled nursing facilities at a significantly higher cost to Medicare and at great inconvenience to the patients. NHIA is underway with a critical legislation initiative to rectify this situation.
In Medicare Part B, there is some coverage for certain therapies administered using durable medical equipment (a mechanical or electronic external infusion pump). Unfortunately, only a select few therapies are covered and only under very specific conditions. These include some anti-infective, some chemotherapy drug, some inotropic therapies (e.g., dobutamine), some pain management and a few other therapies. For parenteral and enteral nutrition therapies, there can be coverage in Part B only if the need for the therapy is documented to be for at least 90 days and other coverage criteria are met. There may be coverage for intravenous immune globulin (IVIG) for primary immune deficiency patients but the supplies and equipment are not paid for. More specific information can be obtained by contacting the Medicare entities called Durable Medical Equipment Medicare Administrative Contractors (DME MACs). The coverage criteria for home infusion that all contractors follow are found from a DME MAC.
For home nursing visits needed 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, as well as considered to be homebound and in need of intermittent (not 24 hour) home nursing. NHIA’s Medicare legislation initiative is intended to broaden this gap in coverage too.
Some Medicare fee-for-service plan patients may have other insurance that will pick up some of the home infusion costs not covered by Medicare. A minority of the Medicare population is enrolled in the Medicare Advantage (Part C) program. Similar to most commercial health plans, many Medicare Advantage health plans cover home infusion because they recognize it will reduce their overall health care costs and achieve high levels of patient satisfaction.
Most home infusion therapy providers are familiar with Medicare’s coverage details and will advise prospective patients of their specific coverage and anticipated out-of-pocket obligations should they undertake home infusion therapy.
DME stands for Durable Medical Equipment
What is DME?
DME is equipment that:
- can be used over and over again;
- is ordinarily used for medical purposes; and
- is generally not useful to a person who isn’t sick, injured or disabled.
How do I get DME?
Your doctor must first decide that you need one or more items of medical equipment and then write a prescription for it.
Do I have to get the DME from the supplier my doctor recommends?
No. You have freedom of choice regarding suppliers at any stage in the process. You can get DME from any supplier who you choose to use.
Does Medicaid pay for all items recommended by my doctor?
Not necessarily. In general, Medicaid will only pay for equipment that meets the general definition of DME and that the department considers to be medically necessary. Although the department has a list of DME for which it routinely pays, additional items may be approved for coverage based on individual consideration. Your medical equipment supplier can assist you in requesting items that are not on this list.
Are there any other requirements?
In some situations there are additional requirements. For example, even though your doctor decides that an item is medically necessary, your supplier may still need to obtain the other approval before you can get it. Such as prior approval, notification, pre determination etc. If prior approval is required, your medical equipment supplier will know how to request it.