A strategy for home infusions has historically been an important consideration for plan sponsors. However, evolving dynamics—including increased consumer demand and more stringent regulatory requirements—have shifted what was once an important consideration to a critical necessity.
What are home infusions?
Just as primary care, behavioral care and some forms of acute care can be delivered in the home, so too can infusion therapy. Home infusion therapy involves the administration of drugs or biologicals either intravenously (into a vein) or subcutaneously (under the skin) to an individual at home. These infused medications can include a wide spectrum of specialty treatments for conditions like cancer or hemophilia, as well as more common treatments like infused antibiotics.
In addition to the drugs (e.g., antivirals and immune globulin), equipment (e.g., pumps and IV poles) and supplies (e.g., tubing and catheters) needed to perform home infusions, nursing services are also required. These can include everything from training and educating the patient and caregivers on safe administration to providing other supportive medications or assistance, such as flushing the patient’s IV line with saline.
What’s driving a heightened focus on home infusion therapy?
Demand for more flexibility and choice around how care is delivered has been on the rise in recent years, with 78% of consumers saying they would be very or somewhat likely to use alternate types of care, including a clinician visiting the home.
And according to Evernorth’s 2022 Health Care in Focus Report, plan sponsors are adapting in response:
- 22% of HR decision-makers and 17% of health plan leaders said they’re permanently increasing access to medications through home delivery post-pandemic.
- 30% of HR decision-makers and 5% of health plan leaders confirmed they’re prioritizing home care over the next two to three years.
In addition to increasing consumer demand, physicians sounded off in a recent survey that they believe 15-40% of care across several categories—including as much as 40% of infusions—could be effectively provided at home.
On top of these trends, the Centers for Medicare & Medicaid Services (CMS) enacted new requirements in 2021 that expanded coverage of home infusion therapy to include not just the treatment, but a broad spectrum of the associated nursing and monitoring services rendered.
How home infusions can pose complex challenges
Overall, the home infusion process can be a complicated ecosystem that requires close coordination among multiple entities, including patients, physicians, hospital discharge planners, health plans, home infusion pharmacies and—if applicable—home health agencies.
With so many parties involved, disconnected data is a major challenge that can contribute to an array of prescribing, administration and/or coding errors. For instance, prior authorization requests and drug claims are typically submitted by the provider, yet come through to the plan separately.
Such issues tend to be exacerbated when plan sponsors try to manage all aspects of their home infusion program with limited internal resources. Today, if plans are managing home infusion claims at all, most rely on inefficient processes, such as:
- Manually approving services rendered once the drug is approved without carefully cross-checking for accuracy.
- Having two separate teams manually managing the services and drugs, respectively.
Alarmingly, many plans aren’t actively managing home infusion on a comprehensive basis whatsoever. This means they’re likely incurring unnecessary expenses and putting members at risk of experiencing delays in care.
And the recently enacted CMS requirements around home infusions only magnify their responsibility to tighten up controls. That’s because non-compliance with CMS rules can result in a number of penalties ranging from monetary fines to payment suspension. In certain extreme cases of non-compliance, plan sponsors have faced civil litigation and even ceased operating as a result of such consequences.
The anatomy of a comprehensive home infusion solution
To effectively drive savings, eliminate fragmentation and ensure compliance, plan sponsors should focus on a few key areas when building out their home infusion strategy:
- Utilization management – To ensure the safest, most cost-effective drugs are authorized
- Claims management – To maximize claims processing accuracy, timeliness and consistency
- Network management – To optimize comprehensive home infusion coverage and access for members
- Clinical governance – To provide expert, cross-functional oversight and feedback
This model has generated an average savings of $5.35 per member per month for plans that have implemented Evernorth Home Infusion Therapy Complete to date.1 It’s also helped plans mitigate the need to over-allocate internal resources with manual work like authorizations and billing, which in turn can help increase bandwidth to support other areas of strategic importance that might otherwise have been neglected. As a result, processes are streamlined and information gets processed more easily, quickly and—most importantly—with greater precision.
How it works: Evernorth Home Infusion Therapy Complete in action
By leveraging Evernorth Home Infusion Therapy Complete’s automated approach, one health insurance plan successfully removed the burden of reviewing drug and service authorizations independently and coordinating billing manually. As a result, it was able to shift three clinical, full-time employees from manual home infusion therapy management to more strategic, site of care initiatives for their organization.
In another instance, the solution helped a plan seamlessly fix what could have been several costly coding mistakes. The results? $5,467.69 in savings for a single patient claim and the patient avoiding a delay in starting therapy.
For a more detailed illustration of how the Evernorth Home Infusion Therapy Complete generated these outcomes, click here to view our infographic.
Manual errors can unfortunately be common when data is fragmented across a highly complex category of care that calls for a higher degree of coordination. And with the new CMS requirements, the consequences for these errors are perhaps more onerous than ever before. Luckily for plan sponsors, there is an answer for every challenge they’re now faced with. The best one being a complete home infusion solution that accounts for virtually all of them.
1 Evernorth book of business, Q4 2021-Q1 2022