What Medicare Is Missing

To the Editor—For more than 40 years, many patients needing long-term parenteral antimicrobial agents but who are otherwise stable have left the hospital to finish their treatment at home [1, 2]. Outpatient parenteral antimicrobial therapy (OPAT) reduces hospital stays, increases patient satisfaction, and decreases costs [2–5]. Most insurers, including most state Medicaid programs, most Medicare Advantage plans, the Veterans Administration, private insurers, TriCare, and the Federal Employee Health Plan, cover OPAT. Medicare does not.

How did this happen? OPAT does not fall under any one part of Medicare (Table 1) [5]. Medicare Part A covers home nursing visits, needed for catheter maintenance or patient monitoring, but only if the home health agency has contracted with Medicare. Furthermore, the patient must stay in the home except for religious activities and medical appointments. Patients on OPAT are often active, running errands and even going to work. Part B covers durable medical equipment, including supplies needed for home infusion, but only for a small number of conditions. Part D covers most infused medications but does not cover infusion-related services and equipment. Although OPAT would save Medicare money and provide better outcomes and experiences for patients, OPAT falls through the cracks of Medicare coverage.

Table 1.

Medicare Coverage for Home Infusion Therapy^a

Part of Medicare	A (Hospital Coverage)	B (Doctors' Services, Outpatient Care, Medical Supplies, Preventive Services)	C (Medicare Advantage)	D (Prescription Drug Coverage)
Coverage for home infusion	Home nursing visits only if patient is homebound	Some durable medical equipment such as infusion pumps but only under certain very specific situations; lab tests	Some plans cover home infusion therapy, but not all enroll in the plans	Usually cover the medications themselves

^a See [5].

What can these patients do instead? Without secondary insurance, daily costs for the associated services and supplies can reach $100 (Coram Home Infusion, personal communication). Some Medicare patients use outpatient infusion centers. However, the ordering provider must either have admitting privileges at a hospital with an infusion center or have an infusion center in their clinic. Many of these centers are closed on weekends and holidays and do not allow patients to take medications or pumps home. Therefore, many outpatient infusion centers preferentially give broad-spectrum parenteral antibiotics that are dosed daily (eg, ertapenem, daptomycin, ceftriaxone). Medicare payment policies in this area can conflict with the principles of antibiotic stewardship in which patients should receive the right antibiotic, at the right dose, for the right amount of time to ensure the best chance of cure while minimizing side effects.

The final choice for many patients on Medicare is skilled nursing facilities. These may be excellent options for patients with significant other medical comorbidities. However, this is an extremely expensive option for Medicare [5]. Furthermore, for patients who are otherwise well, staying in a skilled nursing facility instead of at home with family simply because of inadequate coverage for home infusion services is unjust.

Can Medicare follow almost all other major insurers and cover home infusion services? Since at least 2001, Congressional bills have been drafted to remedy this disparity in access to needed services for the elderly. Each has failed in committee. In the current session of Congress, the Medicare Home Infusion Site of Care Act of 2015 has been presented by John Isakson (R, Georgia) in the Senate and Eliot Engel (D, 16th District of New York) in the House [6]. There are few things in medicine that save money, improve patient satisfaction, and are as safe as OPAT. Congress recently repaired the “doc fix” bill. Congress should fix this as well.