As Home IVs Grow, Medicare Patients Miss Out

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OCTOBER 15, 2008

As Home IVs Grow, Medicare Patients Miss Out
By LAURA LANDRO
The Wall St. Jurnal

Growing numbers of patients needing intravenous medications are getting their treatments at home. But a gap in Medicare coverage is making it harder for older and sicker patients to swap hospital stays for home care.

Hundreds of new intravenous drugs and biologic products have come on the market in recent years to treat maladies such as infections, cancer and chronic diseases. Administering these medications at home generally costs $150 to $200 a day, far below the $1,500-to-$2,500-a-day cost of a typical inpatient hospital stay. Home-infusion therapy also eliminates the risk that patients will be exposed to infections caused by hospital bacteria that can invade through IV lines and catheters.

Eyeing the potential for savings, many private insurers provide full coverage for home-infusion therapy. But Medicare, under its two-year-old Part D program, covers only the drugs administered intravenously -- not the pharmacy and nursing services, supplies and equipment that make up roughly half the cost of home-infusion therapy. The federal insurance program for older or disabled people says it doesn't have the authority to cover costs beyond the drugs themselves. While some Medicare beneficiaries who don't have supplemental coverage can get drug infusions at an outpatient facility, most have to be admitted to a hospital or nursing home, where they are covered under Medicare hospitalization benefits.

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Legislation is before both houses of Congress that would provide the additional coverage for home-infusion services under Medicare Part B, which covers medical services such as doctors' visits and outpatient care. A Medicare official says that the government hasn't yet prepared cost estimates of the pending legislation and that the federal program is juggling many other priorities at present. "We do offer coverage, but it is not a comprehensive benefit," the official says. A study commissioned by the industry group concluded that legislation requiring Medicare to cover home-infusion services would cost about $1.5 billion over a 10-year period. But this would be more than offset by estimated savings of $7.4 billion, assuming that 10% of patients who get infusion therapy in a hospital are instead treated at home.

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Critical Homecare Solutions Inc. sometimes sends nurses to the hospital before a patient is discharged to start educating patients and caregivers on how to use equipment, says its chief executive, Robert Cucuel. The Conshohocken, Pa., company, which has about 21,000 patients in 16 states, says more than 70% of its business is covered by private insurance. But it can still be difficult for patients and caregivers unskilled in the use of medical equipment, and home-infusion nurses often have to help patients each time they visit. There is a risk of infection if proper hygiene rules aren't followed, and devices can malfunction, causing a patient to get too much or too little medication. But Mr. Cucuel says most equipment has become more sophisticated, such as pumps that carefully regulate the flow of solution and pre-filled cassettes that will dispense only the prescribed amount of medication.

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Still, a patient's out-of-pocket costs can be quite high if they are insured by Medicare, Dr. Maksym says. For example, for a five-week supply of the antibiotic vancomycin, the patient's co-payment is $100 under the hospital's contract with the Part D plan. But the federal program wouldn't cover the other costs of home infusion, which would include $9,900 for pharmacy services, equipment and supplies, and $1,400 for 10 nursing visits, he says.

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