08. Home Parenteral Nutrition Diagnosis and Payer Trends: 2020-2023

Background: Reimbursement and primary diagnosis for home parenteral nutrition (HPN) are intertwined due to payer policies that employ diagnostic and clinical criteria for coverage of therapy. Although CMS criteria for coverage through traditional Medicare part B (MCB) became less rigid with the recent retirement of the National Coverage Determination (NCD) and implementation of the new local coverage determinations (LCD), commercial payers (COM) including Medicare Advantage Plans (MAP) may employ different and more stringent standards. Further, HPN reimbursement rates vary broadly across payer types. Changing trends in payer mix and most common primary diagnoses may be predictive of future challenges to HPN coverage access.

Purpose: The purpose of this study was to identify payer and diagnosis trends upon admission to a home infusion pharmacy for HPN therapy from January 2020 – December 2023.

Methods: A query was completed to identify all unique new admissions to a home infusion pharmacy with multiple locations nationwide for HPN therapy between January 2020 – December 2023. A new admission was included if the patient had not previously received service from this pharmacy for any infusion therapy. Resumption of care admissions were excluded. Data was analyzed to identify trends in payer mix and primary diagnosis between years. Admits were quantified by payer group and diagnosis category. Percent change in admits in each payer group category and diagnosis category were calculated between years and comparing year 2020 to year 2023.

Results: From January 1, 2020 to December 31, 2023 Medicare HPN admissions with a MAP increased from 34 to 50%, while traditional Medicare part B (MCB) admissions decreased by 16%. During the same time period, admits with other non-Medicaid, non-Medicare COM rose 7%. Traditional and managed Medicaid plans, government, and other payer types remained relatively stable across the time period.
Admits with diagnoses in the Disease of the Digestive System (K00-K95) category ranged from 52% of all HPN diagnoses in 2020 to 58% in 2023, a 6% increase. MCB as payer declined by 6% in this group, MAP increased by 6%, and non-Medicaid non-Medicare COM climbed by 6%.
K90.821 and K90.829, short bowel syndrome with colon in continuity and unspecified, respectively, rose from 0.5% to 2.7% of all TPN diagnoses, representing a 440% increase. There was a 2% increase in category R00-R99, symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified. MCB admissions rose and MAP declined by 3% each in R00-R99 admissions.

Discussion: The rise in HPN admissions associated with a MAP is consistent with statistics in the overall Medicare population demonstrating a growing election of MAP versus MCB. This is concerning for several reasons: variation in clinical criteria for coverage by plan, which may be more stringent than traditional Medicare part B, (2) MAP’s lower HPN reimbursement rates, and (3) home infusion providers ending contracts with lower HPN reimbursement rates, thus limiting choice for HPN consumers.

Increases in diagnoses of the category K00-K99 Diseases of the Digestive System suggests improvement in appropriate use of HPN and access to care for those with primary impairment of the intestines. Although a small percentage overall, short bowel syndrome (SBS) diagnoses increased by 440%, which is of interest as this group tends to have long term to lifetime dependence HPN and access to coverage is imperative for survival.
The increase in MCB admissions for category R00-R99 may be due to retirement of CMS NCD and issuance of less restrictive LCD in 2021. However, some of the top diagnoses in this category include R10.9 unspecified abdominal pain; R11.2 nausea with vomiting, unspecified; R13.10 dysphagia; and R62.7 adult failure to thrive – all of which may be non-covered diagnoses for HPN without accompanying documentation to demonstrate tube feeding failure or inability to trial tube feeding.

Improvements in nutrition support decision making may be producing positive impacts on appropriate HPN use, but changes in payer mix may ultimately result in declining access to HPN.

Conclusions: A growing number of HPN patients are admitted for HPN with Medicare Advantage Plans versus traditional Medicare Part B, and primary diagnoses in the category K00-K99 are increasing among HPN patients. Future work should analyze HPN payer and diagnosis trends across all infusion providers, as well as evaluation of impact of these trends on home infusion provider financial viability and consumer access to HPN care.