Patients on enteral nutrition (EN), particularly long-term users, have high mortality, high rates of rehospitalization and generally lack support and resources to manage nutrition needs. However, patients do benefit from nutrition support services aimed at preventing complications and improving outcomes.
Market forces, including reductions in reimbursement rates and the rising cost of supplies, are forcing home infusion providers to scale back non-reimbursable services such as education and multidisciplinary clinical support for home enteral nutrition (HEN) patients. This is eroding support services that benefit patients and improve outcomes.
The Value of Nutrition Support Services
A robust nutrition support program puts patients at the center—constantly reevaluating nutrition needs, reading lab results and supporting patients through logistics and challenges related to formula choices, supplies, delivery and managing complications.
Home infusion providers offer a multidisciplinary nutrition support model that includes registered dietitians (RDs), nurses and pharmacists to support the needs of this population. RDs often undertake the primary role of assessing and managing the patient’s HEN services. RDs need knowledge and expertise on enteral supplies and devices, as well as commercial and blenderized formula considerations based on patient-specific need. Next to intravenous anti-infectives, enteral patients are the second largest population served by home infusion providers.
When patients are not part of a HEN program, studies suggest they may face challenges, including lack of caregiver competence, maintenance of functional status and EN complications such as infection. Patients who develop complications while receiving HEN are at risk of malnutrition and readmission if the complications are not addressed in a timely manner. Malnourished patients have more readmissions within 30 days, higher rates of in-hospital mortality, a longer length of stay and a lower probability of time to discharge, with a shorter life span.
An interruption in HEN therapy is possible when a patient develops complications but may also happen because of poor care coordination and/or delivery of appropriate supplies. Unfortunately, reductions in reimbursement, increased costs for HEN products, product shortages and other factors make it difficult for home infusion providers to maintain an adequate level of profitability. The result is a commoditization of enteral food, pumps and supplies along with an erosion of the service component that is critical to avoiding interruptions in therapy and other negative outcomes.
How Did We Get Here?
One of the key contributors to the changing reimbursement landscape for U.S. providers is the Medicare Competitive Bidding program that was mandated by Congress in 2003.
The statute required the Medicare program utilize a competitive bidding process as opposed to the fee schedule payment methodology. After a round of bidding by providers serving different geographical areas, a payment rate was determined. "Winning” bidders willing to accept the new rates could continue to supply enteral formula, supplies and equipment to Medicare beneficiaries. All other suppliers were excluded from providing enteral items in the corresponding geographic competitive bidding area.
HEN services were included in the initial bidding process that went into effect in 2011, resulting in an average savings to the Medicare program of 35%. By the end of the Round One Recompete that was in place from Jan. 1, 2014 through Dec. 31, 2016, Medicare spending on enteral nutrients, equipment and supplies was reduced by an average of 41%. These savings came at a high cost to home infusion suppliers who tried to compete in the enteral market. The reduced reimbursement rates shrank the pool of providers that could profitably provide HEN services as part of the program. Between 2013 and 2023, there was a 37% reduction in the number of providers nationwide.
The payment compression that began with competitive bidding continued and has been adopted throughout commercial insurance markets. Current market conditions are creating problems for providers. EN product costs have risen due to increased ingredient prices and supply chain interruptions. The cost of supplies, labor and shipping have also increased (see Figure 1). At the same time reimbursement rates remain flat—in a 2023 nationwide study of providers, 88% reported no payer increases aside from the Medicare consumer price index for urban areas adjustment.
Providers are forced to evaluate how they can provide enteral services to make an adequate profit. As a result, many have taken steps to reduce overhead costs, including scaling back HEN-related staffing from RDs to patient support personnel; scaling back on inventory by directly contracting with suppliers, which can limit formula selection; and reducing warehouse space and delivery services by utilizing drop shipment arrangements. Many are choosing to abandon the service line altogether. In 2023, one in four providers reported they were considering or actively planned to stop providing enteral formula and supplies due to cost pressures.
Opportunities for Improvement
Trade and professional groups, including the National Home Infusion Association (NHIA), are documenting challenges and advocating for changes that would allow providers to offer this service without incurring loss, thus increasing patient accessibility and improving outcomes. NHIA expects to produce a white paper on this subject in 2025 and endorses the findings in the American Association for Homecare’s white paper.
Opportunities for improving HEN viability for Medicare beneficiaries include, at a minimum, reopening the bidding process to allow providers to update their pricing to meet inflation and new supply standards. The Centers for Medicare & Medicaid should re-evaluate whether competitive bidding makes sense for EN by conducting a comprehensive study of how the program has impacted patients. Commercial plans should add reimbursement for RD professional services (HCPCS Code S9470), increase payment rates to account for increases in costs and negotiate separate pricing for specialized EN supplies. In its “Home and Alternate Site Infusion Contracting Recommendations for Payors,” NHIA advocates for enteral formula and nutrition support services to be included in infusion contracts as a covered benefit for all tube-fed patients.
NHIA believes a value-based approach to reimbursement might work for improving HEN services—the association is advocating for this approach to parenteral nutrition. Since many nutrition patients are long-term, options to base reimbursement on a longer time frame (i.e., episodic) that can factor in outcomes such as emergency department visits and hospitalizations is worth evaluating. A reimbursement model that offers more flexibility to provide the necessary care to avoid complications and utilize enhanced clinical interventions would likely improve outcomes and lower the total cost of care for patients.