In a potential blow to hospitals and health systems without a strong post-acute care component, the U.S. Government Accountability Office (GAO) wants the Medicare program to consider moving more infusion therapy services out of hospital inpatient settings, outpatient departments and physician offices and into the less-costly home settings, according to the new report, "Home Infusion Therapy: Differences between Medicare and Private Insurers' Coverage." Specifically, the GAO advises, "The Secretary of HHS [the U.S. Department of Health and Human Services] should 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.
Medicare currently doesn't have a distinct benefit for home infusion therapy. Coverage is limited, particularly for non-homebound beneficiaries, under fee-for-service Medicare, as well as some Medicare Advantage plans. Consequently many Medicare beneficiaries have to receive infusion therapy services in more expensive hospitals, outpatient departments or physician offices.
In its comments responding to the report, the Centers for Medicare and Medicaid Services alluded to potential quality and fraud-and-abuse issues that could occur with an expanded home infusion therapy benefit. However, GAO interviews with five large health insurers that have commercial and Medicare Advantage business lines found that the insurers reported having a "long and positive experience" with home infusion therapy coverage. The insurers use prior authorization and postpayment claims review to manage utilization, and they employ provider networks, accreditation and complaint monitoring to ensure quality of care.
To learn more:
- read the GAO report