Home Is Where the Heart Is Best Cared For

This year, patients with severe cardiac issues won’t have adequate access to necessary home infusion therapies — which are often lifesaving and sustaining — despite the fact that Congress passed a new law requiring Medicare to reimburse for these therapies. That’s because Medicare finalized a rule in October that requires a nurse to be in a patient’s home for the benefit to be reimbursed, in spite of Congress’ objections.

I encounter these types of patients in my cardiology practice each and every day. Since Medicare cut reimbursement for these therapies a few years ago, hundreds of advanced heart failure patients have passed through my exam room doors, many of whom have benefited in the past or could benefit from home infusion therapies, but because of the current reimbursement, their access to care has become compromised. We can no longer prescribe the remedies for care in the home they so desperately need.

In my practice, I oversee management of some of the most critically ill patients with cardiovascular disease, in particular those with advanced heart failure. I witness their symptoms, listen to their complaints and sympathize with their path. These patients require highly specialized care in order to live even somewhat comfortable lives.

This care, in many cases, includes the use of intravenous inotropic support, which improves symptoms relating to heart failure and also assists in the support and stabilization of patients awaiting heart transplant.

About 10 percent of the almost 6 million patients in the United States with heart failure are in a technically advanced stage, which equates potentially to hundreds of thousands of patients who would qualify for inotropes.

Our ability to manage these patients in the home is now greatly restricted due to Medicare’s reimbursement cuts. It makes it much more challenging for me — as a physician and cardiologist — to provide and prescribe these much-needed therapies.

Because home infusion providers can’t sustain a business model that would require them to provide highly technical clinical services that would not cover their costs, we, as cardiologists, have found it increasingly difficult to find providers willing to deliver the care these patients deserve and have spent the past year placing patients in the hospital that could otherwise be managed in the home.

Over the years, physicians have come to rely on home infusion therapy providers because they work alongside us, in tandem with our staff, to adequately take care of our patients. Physicians have developed a strong rapport with these types of expert clinical providers, who now no longer have the resources to partner with us to facilitate care to these patients in need.

The services these providers have rendered to date go far beyond just drug administration; they extend to offering comprehensive care in the home, which has included coordination of home visits with nursing and pharmacy professionals to monitor and adjust medication dosing, IV access care, lab draws performed in the home, daily vital sign checks and other clinical capabilities. These highly qualified professionals are available 24/7 and often prevent unnecessary trips to the emergency room and costly re-hospitalizations.

As physicians, we cannot do it all; we require a team approach to the management of this critically ill population. This type of relationship is the glue that holds the care for this patient population together.

Who suffers the most?

In 2012, $30 billion was spent on heart failure patients in the United States, and the majority of those costs relate to the hospitalized patients. With the reimbursement cuts, this will only get worse.

Currently, 6 million people in the United States alone are diagnosed with heart failure, and this is expected to grow by roughly 40 percent by the year 2030. Personally, up to 20 percent of the patient population I oversee in my practice could stand to benefit from the use of home inotropic infusion therapy.

Without these therapies, patients will suffer and gravitate toward acute care settings like hospitals. It is already happening. Patients are spending more time in the hospital, thereby further taxing the health care system by utilizing more dollars.

The gap in adequate Medicare reimbursement leaves patients without treatment of the kinds of therapies that ideally minimize their time inside the hospital and at the same time allow them to maintain some sort of quality of life at home.

The transformation patients experience while on inotropes is quite remarkable. They become more physically capable of doing things that were previously very challenging or perhaps even impossible. Most are homebound and symptomatic with any form of activity, but with inotrope therapy, they can actually perform light housework, hold their grandchildren, and bath themselves, just to cite examples.

In my nearly decade as a practicing cardiologist, this is one of the most dramatic changes I have seen in the provision of care. Patients and providers are both negatively impacted, and it only stands to worsen if a remedy is not made fast. Limiting access to the therapies that are most critical in my scope of practice is like taking a hammer away from a carpenter.

Myriad stakeholders, including cardiac patient and provider advocacy groups, in addition to home infusion therapy providers of varying size, aggressively advocated for a remedy: a transitional payment for these services to amend this gap. And these advocates were successful. President Donald Trump signed a new temporary transitional payment for home infusion into law as part of the Bipartisan Budget Act in February.

Since then, though, the Centers for Medicare and Medicaid Services has so narrowly interpreted the reimbursement that advocates are again at a crossroad. Without adequate reimbursement, the costs to continue to serve these patients are completely unsustainable.

It seems we, as a nation, have taken a giant step backward. In the early 1990s, the whole purpose of the rapid emergence and acceptance of managed care was to keep patients out of the hospital. Yet, here we are, nearly 30 years later, regressing by sending them back to the hospital.

Let’s take heart and rally for change together so we can ensure we are engaged in a system that is truly focused on health care.


Dr. Andrew Darlington, DO, FACC, of the Piedmont Heart Institute in Atlanta, is board-certified in advanced heart failure and cardiac transplantation.

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