The ‘Care Gap’ in the 21st Century Cures Act

The 21st Century Cures Act, signed into law by President Barack Obama, implemented many new regulations that will impact the home health industry for years to come, but like many laws, there were unintended consequences that arose—one of which will affect home infusion therapy.

Home infusion therapy consists of the administration of medication through needle or catheter in a patient’s home. Infusion therapy is usually utilized when a patient’s condition is so severe that it cannot be treated by oral medications.

The law’s side effects will mainly impact those who provide clinical services related to home infusion therapies through reimbursement cuts, Paul Mastrapa, CEO of home infusion therapy provider Option Care and a member of the advocacy coalition Keep My Infusion Care at Home, explained to Home Health Care News.

“The Cures Act cut home infusion reimbursements starting this year, but CMS (The Centers for Medicare and Medicaid) remedied that by implementing a benefit that will begin in 2021,” Mastrapa said. “The problem is now we have this four-year care gap where patients are having their access to infusion therapy threatened because providers will not be reimbursed.”

The reimbursement changes that were implemented as of January 1, 2017 included resetting the cost of infusion drugs back to the industry benchmark of average sale price (ASP) plus 6%. Prior to the Cures Act the reimbursement from Medicare was 95% of the average wholesale price (AWP) of infusion drugs. In effect, only the drug price is covered, while services are separate.

The largest group of patients that will be affected by the four-year gap are heart failure patients, Mastrapa said.

“Before the Cures Act, heart failure patients’ drug rates covered all services that were required for their condition, but in January, all service payments embedded in the drug price went away,” he added. “Now, there’s a gap before providers can get reimbursed for services. It’s basically telling providers, like us, that we will only get paid for the drug and the markups, not the actual services.”

Closing the Gap

This “care gap” was an unintended consequence in the Cures Act, Mastrapa said.

“I don’t think this was intended by to be an outcome of the Act,” he explained. “The Cures Act is a great piece of legislation. This was a problem with how it was implemented, and it needs to be fixed.”

Through the Keep My Infusion Care at Home coalition, Mastrapa and other advocates have been sharing their thoughts on possible solutions with members of the government. There is strong bipartisan support over this particular issue, which can work in the coalition’s favor, Mastrapa believes.

“To fix this we need to accelerate the service payment from 2021, maybe to 2019. We are hopeful for 2018 or 2019,” he said. “Our legislators know this is a problem. We have continued to hear that same message from legislators in the House and Senate and I believe we have the support.”

The challenge comes in finding a “vehicle” to change the legislation.

“With everything happening in Washington [D.C.] right now, it’s just about finding the right vehicle to make these changes. We are in a position now with issues of health care reform and in that way there are so many politics involved,” said Mastrapa. “This change needs to be part of a broader legislation, maybe a Medicare extender bill. Maybe it could move on its own. But it will be a challenge nonetheless. Unanimous is not a word I would use in Washington these days.”

Even with the struggle ahead Mastrapa is confident the consequence can be fixed to allow providers to be reimbursed for services provided to home infusion patients, and ultimately ensure patients receive the care they need.

Written by Alana Stramowski

Alana Stramowski