Even drugs that can be prepared the night before, such as paclitaxel and carboplatin, carry a risk of anaphylaxis, so doctors have been concerned about nurses being prepared to treat such adverse reactions in a home setting. “As a country, we’re starting from zero,” said Dr Kubal. “You would need the nurses and pharmacists ready and the delivery mechanisms and the regulatory safety concerns addressed. If you’re starting a Blue Apron or Amazon for home infusion — that takes a long time to get right.”
Even if the oncology field worked out all the kinks of home delivery — and mobilized a cadre of trained nurses — the bigger challenge is motivating insurance companies to create a workable payment model for home care. “There is no payment infrastructure in place,” said Dr Kubal. “As an oncologist, I’d have to find the company to deliver it. I’d have to go through extra steps to get it approved and covered, and that’s harder for me to do.”
Dr Bekelman acknowledged that new approaches in physician prescribing, ordering, and insurance reimbursement are needed for home infusion to work on a wide scale. As part of the Penn Medicine pilot program, team members sat with oncologists to understand the hassles of prescribing infusions at home, considering that electronic medical record systems didn’t always offer the option to order medicines to be given at home. The team found workarounds, such as faxing prescriptions, to streamline the process.
As for insurers, including the Centers for Medicare & Medicaid Services, they should design drug benefits that aren’t defined by where a medication is delivered, Dr Bekelman said. “In order for this to scale beyond COVID-19, there has to be reform so that patients’ copays are unaffected one way or the other,” he said. For the pilot program, administrators made sure patients received financial counseling so they didn’t encounter any unexpected out-of-pocket costs from their insurance companies.
Raphael Rakowski, cofounder and CEO of Medically Home, a company that provides technology and services for health systems to deliver medical care to patients at home across 5 states, is looking to expand into the cancer space. His team is developing a model that shows insurers the value of home-based cancer care. “If you deliver services like chemotherapy at home, overall costs should be lower,” he said.
When treatments are delivered in a hospital or outpatient infusion center, insurers end up absorbing fixed costs, such as rent and utilities, in addition to administrative staff. In a study published in Supportive Care in Cancer that looked at the total costs associated with 200 days of chemotherapy delivered at home, researchers found these costs were 50% lower than if the medications had been administered in an outpatient clinic.
Dr Kumal doesn’t think home care will replace the role of infusion centers, considering that some patients enjoy going to a brick-and-mortar facility. “They get a feeling of community, friendship, and family with other patients and nurses,” he said. However, in the future, he believes that home-based care could provide a valuable additional service for patients. “Some patients will want to receive medications at home, and others will want to come back for the enriching experiences that cancer centers offer,” he explained.
Yet according to Dr Bekelman, if the early results from Penn Medicine’s pilot program are any indication, most patients with cancer like receiving their medications while sheltering in place. “In the beginning, they were a bit concerned, but once patients experienced it at home, they couldn’t imagine going back to the old way. They realized it was just as safe and effective and much more convenient than coming into the hospital,” he said.
Lüthi F, Fucina N, Divorne N, et al. Home care—a safe and attractive alternative to inpatient administration of intensive chemotherapies. Support Care Cancer. 2012;20:575-581.