Health systems contacted by Modern Healthcare declined to specify which medications or patient demographics were suited—or unsuited—for home infusion, saying the treatment is individualized. They use it to address chronic conditions such as cancer, gastrointestinal diseases, heart failure, immune deficiencies, hemophilia, multiple sclerosis and rheumatoid arthritis.
The practice translates to possible savings. In the home setting, providers don’t incur overhead costs, meaning no facility fees or ancillary service charges for which patients could be responsible down the line.
“There’s almost no more expensive way to get care than in a hospital-based facility,” said O’Connor.
Registered nurses typically oversee the home infusion process, but in some cases, lower-cost employees such as licensed practical nurses can step in.
“By moving the patients to the outpatient setting and at home, it allows for us to save chairs in the infusion center and save beds in the inpatient [setting], so there are cost savings that way as well,” said Caroline Jones, a clinical pharmacist at Charlottesville, Virginia-based UVA Health.
Some infusion specialists say the at-home model can have diminishing returns, however, especially in rural areas where nurses may not be able to get to patients as quickly.
ContinuumRx is moving away from its original home infusion business model to open more ambulatory infusion clinics with scheduled appointments across its three-state footprint. Nurses doing home visits average three to four patients a day, while those in the clinics average 20 patients over an eight-hour shift, Hartman said, balancing out any overhead costs. About 15% to 20% of ContinuumRx’s patients are treated in the clinics, he said.
Related: What the Option Care Health-Amedisys deal says about home care
Reimbursement gaps also pose complications. Medicare began offering home infusion therapy coverage as a permanent benefit in 2021. While this has made it easier for more patients to access home infusion treatment, Medicare per-diem rates don’t always account for the rising price tag of drugs and equipment, said Connie Sullivan, president and CEO of the National Home Infusion Association.
For some therapies like parenteral nutrition, where patients are fed intravenously, shortages have raised drug prices by 50% since 2016, according to a 2021 report by the association.
“Cost increases have been really difficult for [the home infusion industry] because our reimbursement for supplies is bundled into a per-day payment that has to cover all the services [and] delivery costs, overhead of running a cleanroom facility, all the supplies you send to the patient for administration, and wages have gone up significantly,” Sullivan said.
Insurance companies should ensure their benefits are keeping pace with industry shifts, she said.
“We need Medicare to catch up and offer a benefit to beneficiaries that’s comparable to what younger patients have,” she said. “Patients that age into the Medicare program and have relied on home infusion for years are shocked to find that they lose their benefits when they turn 65 if they don’t enroll in a Medicare Advantage plan that offers that benefit.”
Commercial insurance payment for home infusion services is typically more well-established, offering fee-for-service reimbursement for supplies, clinical monitoring and pharmacist time with separate payments for drugs and nursing visits. But there can be gaps in some payers’ coverage, said Noah Franz, director of home infusion at Froedtert and the Medical College of Wisconsin based in Milwaukee.
“Not all plans have built in appropriate payments for an alternate site of care such as the home,” he said. “That doesn’t mean they can’t do it, but it’s just not built into their payment model where it makes it feasible … from a financial perspective to take those patients.”
Given the capital and resources required, FTI Consulting’s O’Connor said some providers find it more operationally feasible to partner with third parties that already offer home infusion services, rather than attempting to stand up or expand their own operations. UVA Health, for example, turns to other companies when patients have out-of-network insurance or live in other states.
Keeping patients safe
Some providers view implementation of a home infusion model as too potentially risky, said Dr. Felix Matthews, managing director and national lead for the academic health and research leaders practice at consulting firm Deloitte. Adverse effects, such as extravasation, or when the drug ends up outside of the vein, may not be noticed quickly enough and lead to serious—and costly—health complications.
Patients can also encounter problems if infusion sites aren’t cleaned properly, or if they experience negative symptoms as a result of the treatment.
Froedtert and the Medical College of Wisconsin’s patients have 24/7 phone access to nurses and a pharmacist in case of such issues, which can also include allergic reactions or infusion site infections, Franz said.
Related: Leapfrog Group safety grades reflect hospital struggles amid pandemic peaks
The system provides home infusion for more than 650 patients, most of whom begin their treatments in a hospital setting to rule out severe side effects before moving to the home. As the home infusion program expands, Franz said the health system is working to offer more specialty infusions for oncology, neurology and rheumatology patients receiving chronic lifelong therapies.
After patients are screened, the health system sends a nurse to the patient’s house to reiterate the care plan and show how to manage the pump and infusion line, Franz said. Patients also receive weekly home visits to reinforce safety precautions like hand hygiene, sterilization and infusion site cleaning.
If a problem can’t be solved with a call, the health system typically sends out a clinician or, in cases of severe issues, directs them to urgent care or an emergency department. Any adverse safety events involving actual or potential patient harm are documented by the pharmacy department’s safety officer through an organizational reporting system. The quality committee determines if follow-up actions are necessary, Franz said. He declined to share statistics, citing the in-progress collection of data.