key: cord-0971476-wk7jxsho
authors: Streifel, Amber C; Sikka, Monica K
title: The Urgent Need for Medicare Reimbursement for Home Infusion Antibiotics amidst a Pandemic
date: 2020-05-28
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa658
sha: f4608bf280185da351d33dfeabfd09a13180ee1c
doc_id: 971476
cord_uid: wk7jxsho

The Centers for Medicare and Medicaid Services should immediately update current policies to include reimbursement for Medicare patients receiving intravenous antibiotics at home. The majority of these patients are over the age of 65 and at increased risk for severe illness due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Requiring them to travel to an infusion center, stay in a skilled nursing facility or remain in the hospital longer than necessary to receive treatment results in avoidable risk of exposure amidst a pandemic. Current policy has significant implications for increased cost and harm to both these patients and the US healthcare system.

A c c e p t e d M a n u s c r i p t 4 Outpatient parenteral antimicrobial therapy (OPAT) is the administration of intravenous (IV) antibiotics in the outpatient setting. These settings include skilled nursing facilities (SNFs), infusion centers, hemodialysis centers, and the patient's home. OPAT programs reduce costs and improve patient satisfaction by decreasing hospital length of stay for patients with severe infections requiring long courses of antibiotics. 1 Despite the established benefits of OPAT, care coordination for this service has historically been complex due to costs of antimicrobials in the United States and variable coverage among different health insurance providers. The COVID-19 pandemic has amplified these challenges given the urgent need for social distancing to protect patients from unnecessary exposure. Moreover, discharge to SNFs and long-term care facilities poses an even greater risk due to rapid spread of infections in these settings. Multiple outbreaks of COVID-19 in SNFs have already been reported. [2] [3] [4] Though the majority of private insurance companies and most state Medicaid programs cover home infusion, there is a gap in Medicare coverage. 5 Home infusion for Medicare patients leads to high out-ofpocket costs, forcing these patients to continue therapy at a SNF or infusion center. This is concerning as the majority of Medicare patients are over 65 years-old and at increased risk for severe COVID-19

infection. 6 The current pandemic highlights the importance of Medicare reform to include reimbursement for IV antibiotics via home infusion.

Home infusion is a safe and recommended practice for the elderly receiving OPAT. 1 Administration of antibiotics at home has been shown to be cost-effective with estimated costs being half that of completing antibiotics in the hospital. 7 One study showed consistently lower costs associated with home infusion with savings between $1928-$2974 per treatment course. 8 

A c c e p t e d M a n u s c r i p t 5 antibiotics are capable of administering antibiotics at home, however. Patients or a family member must be able to infuse the antibiotics in a safe home environment. At our institution, the infectious diseases team assesses the patient's ability to participate in home infusion, and nurse case managers finalize disposition based on insurance coverage.

To qualify for Medicare coverage, individuals must be over the age of 65, however, individuals diagnosed with end-stage renal disease requiring intermittent hemodialysis and people who have qualified for Social Security Disability Insurance for at least 24 months may also qualify for coverage. While this legislation represents potential progress, these changes are needed urgently, especially as A c c e p t e d M a n u s c r i p t 6 the United States begins phased re-opening. Additionally, although work on a vaccine against SARS-CoV-2 is underway, it is unlikely we will have access to a vaccine for at least a year, necessitating protection of our older patents via social distancing whenever possible. 9 We aimed to reduce unnecessary hospital days for prolonged IV antibiotic treatment for patients at our institution as spread of the virus and limited testing capacity made the hospital a likely place to acquire infection. Additionally, for patients without skilled needs being treated in SNFs, we actively changed antibiotic regimens to alternative agents, like oral antibiotics or long-acting agents to allow discharge home. Although antibiotic therapy at an outpatient infusion center may not be as high risk as inpatient stays at the hospital or a SNF, it still may mean increased costs to patients for transportation. These infusion centers often service immunocompromised hosts receiving chemotherapy or biologic agents, making effective social distancing even more integral for this setting. 6 Reducing the number of patients presenting to healthcare settings such as infusion center waiting rooms is of increasing benefit given data that suggests that SARS-CoV-2 persists in aerosols and on certain surfaces. 10 We evaluated outpatient settings for the 144 adults admitted to our OPAT program from October through December of 2019, prior to the first US case and the declaration by the World Health Organization of SARS-CoV-2 as a pandemic on March 11, 2020. We compared patients covered by Medicare or MedAdvantage plans to patients with any other non-Medicare insurance coverage (Figure1). 25% of our Medicare OPAT patients received antibiotics through home infusion compared to 60% of those with other insurance. We acknowledge that administering IV antibiotics at home would not have been appropriate for all of these patients, but the disparity between these groups represents a significant and avoidable harm to the Medicare population.

The discrepancy between Medicare and other insurers for coverage of antibiotics by home infusion has long been a frustration for ID providers and patients. 11 The COVID-19 pandemic illustrates that it is M a n u s c r i p t

IDSA Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility

COVID-19 in a Long-Term Care Facility

One-Third of All U.S Coronavirus Deaths are Nursing Home Residents or Workers

COVID-19) -United States

A randomized trial of home vs hospital intravenous antibiotic therapy in adults with infectious diseases

Home infusion: safe, clinically effective, patient preferred, and cost saving

The COVID-19 Vaccine Development Landscape

Aerosol and Surface Stability of SARS-CoV2 as Compared with SARS-CoV1

What Medicare is Missing

A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t