Home infusion has been around for over 30 years, but it is a service that has never really taken off. Effective infusion drugs have been developed for acute conditions, but home infusion has been relegated to less glamorous uses such as parenteral nutrition, analgesics, and antibacterials for chronic situations.
Part of the problem may be that home infusion is perceived as a service coming from providers that might have inadequate controls and variable quality.
“The challenge has been to get the medical community’s acceptance of this as a safe and effective method of care,” says Paul Mastrapa, president of Walgreens Infusion Services. Walgreens claims to be the country’s largest home infusion provider.
Home infusion will not become widespread until physicians feel that the procedure is safe for their patients, says Don Liss, MD, a senior medical director at Independence Blue Cross in eastern Pennsylvania.
The company sees potential for home infusion to overcome its narrow role but there are also important hurdles that stand in the way.
Walgreens says home infusion is expanding. “Home infusion is targeting a wider range of medications for acute situations like pain management, chemotherapy, and hydration. We also take care of patients awaiting transplantation and those in late-stage heart failure,” says Mastrapa.
He says his company has been credentialed by Elan Pharmaceuticals to administer Tysabri (natalizumab), which is restricted by an FDA REMS (risk evaluation and mitigation strategy) program. The company also administers Remicade (infliximab), another biologic.
Greg Gambescia, who manages the self-injection and infusion therapy programs at Independence Blue Cross (IBC) in the Philadelphia area says that additional medications, some of them complex, are working their way into home infusion, but that usage is not yet significant.
A move to complex medications, particularly for acute conditions, would be a step up for home infusion.
Walgreens is trying to demonstrate that taking that step is feasible and that alternate settings, including the home, are a viable alternative to costly hospital outpatient departments and doctors’ offices. The company has implemented an intensive pharmacist-led therapy management program for intravenous immunoglobulin therapy, one of the few high-cost complex medications in home infusion.
While Walgreens paints a positive picture of home infusion, the treatment’s future depends on several critical factors, including acceptance by prescribing physicians.
“Over the past couple of years, several new infusion drugs have been introduced for chronic diseases, but they have been used primarily in controlled settings,” says Don Liss, MD, a senior medical director at IBC.
“As physicians gain experience with these drugs, we may see them used in the home, but that change will occur primarily because physicians have become comfortable with the safety of the home setting.”
Another critical factor is Medicare, which does not cover home infusion for most patients. The medications are covered under Part D and the infusion pumps are covered under Medicare’s durable medical equipment benefits, but the nursing services are not covered. “It’s a broken benefit,” says Mastrapa.
A 2010 GAO report reviewed coverage of home infusion services by health plans and found that they effectively managed these services. It recommended that Medicare “conduct a study of home infusion therapy to inform Congress regarding potential program costs and savings, payment options, quality issues, and program integrity associated with a comprehensive benefit under Medicare.”
The home infusion trade association has consistently but unsuccessfully tried to get Congress to pass home infusion legislation.
Most private payers cover hands-on home infusion, which is the cost of a nurse. Mastrapa says that health plan benefit structures often encourage infusion in a higher-cost setting. “A patient may have a 20 percent [coinsurance] requirement for home infusion but only an office visit copayment for infusion services in a doctor’s office,” says Mastrapa.
Private health plans do not pay for the expanded pharmacist services that Walgreens has brought to IVIG therapy.
The expansion of home infusion will depend on acceptance by prescribing physicians and on well-thought-out coverage policies by Medicare and private health plans.