Home Health & Hospice Week

CMS says it won't dismiss nebulizers altogether under the coming drug benefit.

The Centers for Medicare & Medicaid Services seems to be backing off its aggressive stance on switching out metered dose inhalers for nebulizers, but respiratory suppliers aren't breathing a sigh of relief quite yet.

In the proposed physician fee schedule for 2005, CMS said when it starts paying for MDI medications under the prescription drug benefit in 2006, it expects a "substantial shift" of patients to the less expensive treatment modality (see Eli's HCW, Vol. XIII, No. 28, p. 220).

When the National Association for Medical Direction of Respiratory Care asked pulmonary physicians how many patients they expect to safely and appropriately switch from nebulizers to MDIs, the answers ranged widely, NMDRC executive director Phil Porte reports. Some docs said 15 percent while others expect as much as 40 percent of patients to make the switch.

Respiratory therapy suppliers strongly objected to CMS' assumption that many patients will switch to inhalers, noting that MDIs are inappropriate for many patients. And those objections seem to have registered. In response to the proposed rule, "we received many comments, studies and literature reviews on nebulizers and MDIs," CMS notes in the final physician fee schedule released Nov. 2.

CMS appears to backpedal a bit on its MDI versus nebulizer assertions in the final rule. "Even after coverage of MDIs begins in the Part D drug benefit in 2006, due to their particular circumstances, many beneficiaries will require the use of nebulizers and ... nebulizers will continue to play an important role in inhalation therapy," CMS acknowledges in the rule.

But until CMS issues reimbursement specifics for both modalities for 2006, there's no way to know if one treatment will be favored over the other, Porte says. "For 2005, it's a level playing field," he notes. "For 2006, it remains to be seen." Especially if CMS drastically changes the new dispensing fee (see story, Article 2).
Suppliers may see significantly increased medical review for nebulizers once Medicare covers less costly MDIs, suggests attorney Lisa Smith with Brown & Fortunato in Kerrville, TX.

Commenters on the proposal fee schedule challenged CMS' assertions that MDIs are more portable than nebulizers (although Medicare beneficiaries have to self-pay for portable nebulizers); that MDIs and nebulizers have equal clinical benefits; and that MDIs will be cheaper overall to beneficiaries than nebulizers.

MDI costs also might increase in 2006 after a CFC ban goes into effect, Porte points out. CFCs are an MDI propellent, CMS explains in the rule.

Editor's Note: The physician fee schedule is at www.cms.hhs.gov/regulations/pfs/2005/1429fc/master_background_1429-fc.pdf. The MDI portion is on pp. 517-518.