Coverage:
Think Inhalers Can Solve Medicare's Respiratory Drug Problem? Think Again, Industry Argues
Published on Sat Aug 07, 2004
CMS may force beneficiaries onto cheaper equipment - and off your rolls.
Heads up, respiratory suppliers: You could see your nebulizer patients switch to metered-dose inhalers, thanks to drastic cuts to inhalation drugs.
In the Centers for Medicare & Medicaid Services' rosy view, upcoming coverage of MDIs and their drugs under the prescription drug benefit starting in 2006 will take care of many of the access problems Medicare beneficiaries could be headed for under the inhalation drug cuts.
The argument: "MDIs are the quickest and easiest way to take inhalation medication for most asthmatics and patients with COPD," CMS insists in its 2005 fee schedule for physicians.
Medicare currently covers nebulizers and related inhalation drugs, but not MDIs. Because of those "strong financial incentives," physicians often prescribe nebulizers and inhalation drugs instead of MDIs, CMS argues.
"Since one delivery method is not clinically superior to the other ... it would not be unlikely for many beneficiaries to choose the convenience of MDIs over nebulizers" when Medicare starts covering MDIs under the prescription drug benefit, CMS predicts in the regulation published in the Aug. 5 Federal Register. "It is likely there will be a substantial shift of Medicare beneficiaries from nebulizers to MDIs beginning in 2006."
The counter-argument: Respiratory therapy suppliers strongly object to CMS' assertions. MDIs are "non-covered and potentially inappropriate," contends Clearwater, FL-based respiratory company Lincare Holdings Inc. MDI use "would cause these Medicare beneficiaries to experience a deterioration in the quality of their care and to incur significantly higher out-of-pocket costs next year" - the year before the prescription drug benefit kicks in and starts covering them.
Most COPD patients using nebulizers have unsuccessfully attempted to use MDIs in the past or their treating physicians have rejected the method, the company argues.
"It is unfair to conclude that those physicians are prescribing nebulizers merely because of reimbursement concerns," adds Brentwood, TN-based American HomePatient. Most physicians consciously make a choice to prescribe nebulizers for a clinical reason.
"CMS fails to consider what many treating physicians know from experience, that certain patients - especially the very young, very old or very sick - are unable to properly administer their drugs by using an inhaler," AHP blasts. "To see any benefit from inhalation therapy, these patients must use a nebulizer to deliver the drug."
In the proposed rule, CMS dismisses claims that beneficiaries don't have the dexterity to use MDIs appropriately. Spacers and holding chambers help patients use the devices effectively, it says. And nebulizers may require "a certain level of dexterity" as well, CMS maintains.
But those excuses are bunk, according to industry sources who believe CMS has its eye more on the bottom line than on patient care. "It would be inappropriate ... to set artificially low reimbursement levels for [...]
