The federal government has made huge progress in lowering regulatory barriers in order to accelerate access to health care during the coronavirus crisis, including allowing patients to talk with their doctors by telemedicine visits. But one group of particularly vulnerable patients has been left out: Medicare beneficiaries needing access to infused or injected drugs that generally must be administered by clinicians in doctors’ offices or hospitals.
These drugs, which treat everything from cancer to lupus to osteoporosis and multiple sclerosis, can’t be self-administered at home. As a result, countless patients are blocked from access either because their doctor’s office is closed or is limiting services or because many hospitals have shut down access to treatments not related to COVID-19. Even when medical facilities are open, patients can be fearful about going in for treatment and risking exposure.
In recent a COVID-19 regulation, the Centers for Medicare and Medicaid Services took an important first step in allowing physicians to send a nurse to a patient’s home to administer treatments and supervise the visit via telehealth, but many practices don’t have the personnel or portable equipment to do that.
Home health and home infusion service providers could temporarily fill this immediate need during the pandemic by buying and billing for the injection or infusion drugs, but current Medicare rules preclude this except in very limited cases. Although CMS allows doctors to contract with home health and infusion providers and supervise them via telehealth, many independent practices do not have the bandwidth or financial wherewithal to set up and manage new contracts needed to implement these types of arrangements.
The patient groups that are most vulnerable to COVID-19 are the same groups that need these specialty drugs because they are older, on Medicare, and have other underlying health complications, including immune disorders. They are missing treatments and therefore are at risk for greater health complications.
Dr. Andrea Singer of MedStar Georgetown University Hospital in Washington D.C., told us she estimates that up to 75% of her patients needing their next dose of osteoporosis treatment will have trouble getting it, placing them at increased risk for bone fractures. Facilities like hers that are open are taking extraordinary precautions to keep patients safe, but patients are still reluctant to come in despite these added safety procedures.
Commercial and Medicare Advantage plans have greater flexibility than fee-for-service Medicare for home infusion and injection of drugs which may provide some patients with more options during the COVID-19 crisis.
But without more flexibility from CMS, the majority of Medicare patients who are on the fee-for-service program are blocked from having home infusion companies or home health agencies administer the Part B drug they need. To ensure that physicians have the most flexibility to make the best choice for their patient during the pandemic, the CMS guidance could require a physicians’ order for the drug to be administered by one of these outside agencies.
A bipartisan group of members of Congress recently asked CMS to help seniors further on this important issue. More than 180 members of the House of Representatives and 30 senators have sent letters to HHS Secretary Alex Azar and CMS Administrator Seema Verma saying, “Unfortunately, Medicare beneficiaries in need of medical care or treatment for issues unrelated to the pandemic too often face a grueling decision, whereby they must choose between forgoing the services and medications they need by staying home or, alternatively, seeking care in a hospital setting or physician’s office.
“Many of these providers will be unavailable for patients not presenting with COVID-19-related illness, if not closed altogether, and even providers still providing other services may expose beneficiaries to a heightened risk of infection, due to the growing prevalence of COVID-19 patients at such facilities,” the letters say.
Members of Congress say that the current “access barriers will result in medication non-adherence, triggering deteriorating health outcomes and dire consequences for some of our most vulnerable Americans.”
The safest setting to receive treatment may be at home, particularly those at highest risk of severe illness from COVID-19, they conclude.
Sheetal Sheth, a cancer patient writing for CNN.com, said, “Skipping or delaying the treatment wasn’t advisable and neither was going to the clinic and risking possible exposure to Covid-19 — especially in New York City, where I live. In the end, my doctor said, it was up to me. So I had to decide, which was worse: cancer or the coronavirus?”
Patients should not have to make this choice.
CMS is being urged to expand its guidance allowing telemedicine visits and home treatment to also allow, with doctor’s orders, patients to receive in-home infusion and injection therapy that can be provided and billed to Medicare by home health or other home care service agencies.
This will allow continuity of care in the safest environment during the coronavirus public health crisis and is an important policy choice that CMS should implement so these vulnerable seniors can get needed care.