The Government Accounting Office looked at differences between Medicare and private plans’ coverage of home infusion therapy. (GAO Report) Infusion is used to deliver certain drugs that cannot be taken orally or with a single injection. These are often antibiotics, pain medicines, anti-arthritic agents or cancer drugs. While infusion used to be done solely in facility settings, it now can often safelybe performed in the patient’s home, which is usually cheaper than an inpatient setting. Medicare’s FFS coverage of infusion is balkanized and confusing. Medicare has also suffered from fraud and abuse in infusion services. Medicare Advantage and commercial health plans tend to have a more seamless benefit and have managed it effectively to control costs.
The commercial plans used a variety of cost and quality control techniques, again in contrast to Medicare FFS. They credential and require accreditation of providers, they limit their networks, they monitor and edit claims for potential fraud and abuse, conduct provider education and they often require prior authorization. As a result, the plans GAO surveyed reported low levels of fraud or abuse. GAO recommended that HHS study and propose to Congress a comprehensive home infusion benefit and consider some of the tactics used by private health plans.
Since many new drugs, and almost all the really expensive ones, are biologics which often require infusion, home infusion will become a more significant component of health spending and will need careful management. Once again, private plans are well ahead of government payers in effectively managing both the cost and quality of care. The lesson should be clear to everyone.