GOING HOME

Since the 1980s, patients needing home therapy really had few options. To receive their medication meant they generally had to remain in an inpatient setting until the completion of that therapy. Cost effectiveness and cost-containment in the health care field brought about a heightened awareness, which is when clinicians began looking for ways to reduce costs or eliminate them altogether.

To better understand how far the options have come, take a quick look at infusion therapy, which is the administration of medications using intravenous subcutaneous and epidural routes into the bloodstream, under the skin and into the membranes surrounding the spinal cord.

Among the therapies administered via infusion are antibiotics, chemotherapy, pain management, parenteral nutrition and immune globulin.

"These are people who don't have the need, nor is it medically necessary for them to be hospitalized," said Chris Mayeax, a registered pharmacist in Natchitoches, La., and specialist in home infusion. "The patients need the medication, but they can be at home and have the medicine administered by a registered IV professional."

Mayeax's background is clearly defined in treating patients and administering their medication at home. Though there are some nationwide companies, infusion therapy has a local flavor no matter where a patient has settled, he said. For instance, Mayeax's Causey Pharmacy has a staff of three nurses who administer IV treatment to patients in the local area.

"Once the physician has initiated treatment and the patient is stable and can be at home, we begin infusion therapy," Mayeax said. "The biggest benefit for the patient other than being at home is the fact that costs are lower. People also have to understand, however, that not every patient is a candidate for infusion therapy."

To understand why some patients receive infusion therapy, an examination of pain management is needed. There are various methods of managing pain though the reasons and objectives of pain management remain the same. It is critical to focus on maximizing pain relief, minimizing central nervous system effects, and preventing and providing early treatment for any adverse effects that do occur.

There are numerous ways to deliver pain management medication.

Subcutaneous: A small needle or catheter is placed into the subcutaneous tissue, usually in the abdominal area, though the thigh and upper arm may be used. There are disadvantages such as volume restrictions, frequent catheter resites and tissue irritation with high drug concentration. Consider, however, the advantages, which include quick catheter placement, ideal for short-term post-operative pain, and a catheter flush is not required.

Intravenous: One method of intravenous pain management is to use a catheter, usually placed in the hand or arm, that is primarily used to deliver pain medication for short or long term (catheter type varies depending on length of use). Another method is surgically placing a catheter under the skin, which can be used for pain management of any duration. Some of the advantages of intravenous pain management include rapid pain relief, no volume restrictions and a wide choice of analgesics. The

The biggest benefit for the patient other than being at home is the fact that costs are lower. People also have to understand, however, that not every patient is a candidate for infusion therapy.
disadvantages include catheter occlusion, risk of sepsis and catheter flush may overdose the patient.

Epidural: This method is prevalently used as a treatment of chronic back and lower body cancer pain. A catheter is placed in the abdomen and a needle is used for access. Surgically placed epidural catheters are used for long-term pain management. The medicine is then absorbed into fat or blood cells. There are advantages, which include enhanced potency/pain relief, no need for a catheter flush, prolonged analgesic effect and the catheter placement matched to focus on the pain. As with other methods, there are disadvantages, including the risk of meningitis, motor impairment with anesthetics, limited home health support due to interpretation of nursing regulations and volume restrictions.

AIDS therapy: Cytovene for AIDS patients suffering with CMV-Retinitis is available as well as other therapies to combat the AIDS virus and to reduce pain. This pain management procedure should be explored with a person's own personal physician.

Who gets infusion therapy?

Diagnosis commonly requiring infusion therapy include infections that are unresponsive to oral antibiotics; cancer and cancer-related pain; gastrointestinal diseases or disorders which prevent normal functioning of the GI system; congestive heart failure; immune disorders; and growth hormone deficiencies and more.

Administration of infusion therapy has been proven safe, and it is an effective alternative to inpatient care for many disease states and therapies. However, Mayeax said a thorough patient assessment and home assessment are always performed prior to therapy.

An ideal candidate for infusion therapy could be a person suffering from the prolonged battle with cancer and who is undergoing chemotherapy.

While cancer puts up a stubborn fight in a long battle, technology is offering more in the way of battling the disease, and now even winning the war. Chemotherapy is one of the many weapons that slows the progress of advancing cancer cells, and sometimes it is so potent that the cancer completely retreats. Just as weapons of war are improvised to achieve the most effective results, oncologists take the same approach in fighting cancer.

Advantages of home treatment

Physicians now realize the significant effects of home chemotherapy treatments. Even though the treatment of cancer is complex, home treatment is increasing in number and effect. According to the American Cancer Society, nearly 9 million Americans have faced a diagnosis of cancer.

Oncologists and cancer researchers alike recognize the benefits and effectiveness of home chemotherapy. Beliefs are that patients heal faster, respond better to treatment and experience fewer anxieties when supported by family members and treated in familiar surroundings. Patients treated at home tend to participate more actively in their own care, thus increasing the likelihood of compliance.

Treatment at home also is more cost effective than the inpatient setting. Inpatient therapy is extremely expensive and limits a patient's activities. Another benefit of home therapy is the reduced risk of nosocomial infection. The greatest advantage of home chemotherapy is that many patients can resume some of their normal daily activities.

Cost is the big question

Sooner or later in the health care field, the real issue is cost. Perhaps the biggest question of infusion therapy is: Will Medicare cover the cost? Short and sweet, the answer is no. The real answer, however, is that certain therapies are covered when administered using durable medical equipment (a mechanical or electronic infusion pump). Only a select few therapies are covered and only under very specific conditions. These conditions include antiviral therapies, some chemotherapy, some inotropic therapies (i.e., dobutamine) and some pain management therapies.

Nearly two years ago, the Health Care Financing Administration (HCFA) announced that Medicare would cover the cost of insulin infusion pumps for eligible beneficiaries with Type 1 diabetes. Under the new coverage policy, Medicare pays for the pump when prescribed for beneficiaries who have Type 1 diabetes. The insulin pump permits users to maintain tight control of glucose by propelling insulin from the pump reservoir through an infusion set into a catheter inserted under the skin of the abdomen or hip.

"Making the insulin pump available to Medicare beneficiaries will improve the quality of their lives. The infusion pump offers them a choice to better control their condition so that they are more active and productive," said HCFA deputy administrator Michael Hash.

How treatment works

Home infusion therapy is relatively simple followed under the direction of a physician and the attention of a registered pharmacist. The patient usually receives his or her first does of I.V. in a supervised setting, ensuring that the patient does not have significant acute side effects. If the physician feels comfortable with the response, subsequent doses may be administered at home.

The physician then provides an order to the pharmacist including the name of the medication, route of administration, dosage per body surface area, rate of infusion, type of infusion and frequency. Upon receiving this information, the home infusion provider develops written policies and procedures for preparation, handling and administration of agents. Twenty-four hour emergency support also is taken into consideration.

The home health provider has numerous responsibilities, including the necessity of the home infusion provider to document the date, time and patient response of the therapy for the

The home health provider has numerous responsibilities, including the necessity of the home infusion provider to document the date, time and patient response of the therapy for the duration of the treatment.
duration of the treatment. The home infusion provider also ensures that lab work is drawn and that the physician receives the lab results along with an update on the patient's condition.

Consumer information

Home infusion therapy is one of the most remarkable examples of transferring health care technology and services into the home care setting. When administered by a qualified provider, a home infusion therapy program is similar to a hospital-based regimen. Therapy delivered at home, however, relies on patient and caregiver involvement. The benefit of that involvement is the patient's increased comfort and flexibility throughout the course of treatment.

There are five basic components of a home infusion therapy program:

Pharmacy services -- Coordinating with the physician and nursing team, the home care pharmacist processes the prescription, prepares the drug, selects the delivery device and monitors the patient for drug effectiveness and possible drug interactions.

Nursing services - Home care and IV nurses perform skilled procedures, such as administering medication and starting IV lines. They also serve in educational and support roles and act as an advocate for the patient.

Laboratory services - Home infusion providers ensure that therapy and patient progress is monitored through regular blood draws and laboratory work. Pharmacists review lab results and consult with physicians on possible changes in treatment.

Ancillary services - Services such as patient assistance, inventory control, delivery and pump experts all contribute to a smooth-running provider operation and fast, effective patient care.

Administrative services - Extensive documentation, quality improvement, accreditation status, in-service education and program development are all spearheaded at the provider level and improve and expand upon patient services.

According to the Department of Health and Human Services (HHS), home infusion therapy is one of the fastest- growing segments of home health care. Because of the possibilities and technology, it is now possible for increasingly sophisticated treatments to be given in the home. According to a report originating from HHS's Office of Technology Assessment, a few large companies dominate the national market; however, it is mid-sized companies that maintain a strong regional presence. There are, of course, numerous small companies associated with pharmacies, home health agencies, hospitals and nursing homes that are entering the marketplace.

Medicare patients appear to be a small part of the total home infusion market. While Medicare coverage is clearly defined for enteral and aprenteral nutrition, other home infusion therapy services are covered in a fragmented way. Though Medicare covers drugs and biologicals when used with an infusion pump, carriers are given discretion in implementing this coverage.

Congress and the Office of the Inspector General have expressed concerns about physician financial arrangements with medical entities, including home infusion companies. The Omnibus Budget Reconciliation Act of 1993 generally prohibits payment by Medicare and Medicaid for services performed by clinical laboratories, durable medical equipment providers, home health agencies and suppliers of parenteral and enteral nutrition when such services are ordered by a physician who has a financial relationship with a supplier.

Size of the infusion therapy market

Annual revenues for home infusion therapy have been estimated at nearly $4.5 billion. Revenue growth rates have been stable in recent years despite a continued increase in the number of patients receiving infusion therapy. The stabilization is due to cost-containment pressure from the public and private payers, though prospects for home infusion are considered to be excellent despite the ongoing pressures.

The National Home Infusion Association (NHIA) said that revenue growth is expected well into the 21st century, this due to the number of patients receiving home therapy and an inability of the market to sustain additional pricing reductions. NHIA has projected a 5 percent growth annually.

Even with NHIA projecting some growth, there are home health workers a little more wary. Nora Goodrum, VNA's director of workplace wellness and coordinator of infusion therapy, said the Dallas market is slow. She blames Medicare's prospective payment and reimbursement program. She also sees more patients being sent back to acute care for infusion therapy. In fact, VNA used to have an infusion therapy team, but that has been dismantled and gone by the wayside, though she readily admits her numbers are only as good as work is concerned in the Dallas/Fort Worth area.

Numbers are down, said Mike Parsee, chairman of Curlin Medical in Huntington Beach, Calif. He said the market was retreating somewhat last year, though his company has better technology, and it offers quite a savings to home care agencies.

"What we have noticed is that non-professional operators have left the business," Parsee said. "Some bigger companies have left the industry, but others have taken their place."

While the multi-billion dollar industry may have retreated last year, home care professionals said there is still a market share for home health care, and manufacturers agree whether the setting is at home or in acute care.

This article originally appeared in the April 2001 issue of HME Business.

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