Medicare Compliance & Reimbursement

The official word on respiratory therapy.

Heads up, physicians. Patients who need and use nebulizers may be forced to switch to metered-dose inhalers, thanks to drastic cuts to inhalation drugs.

In its proposed 2005 physician fee schedule, the Centers for Medicare & Medicaid Services says it will cut reimbursement rates for inhalation drugs albuterol sulfate and ipratropium bromide, as well as payment rates for nebulizers under code E0570 (nebulizer, with compressor).

The upcoming coverage of MDIs and their drugs under the prescription drug benefit starting in 2006 will counteract any access problems, according to CMS.

"MDIs are the quickest and easiest way to take inhalation medication for most asthmatics and patients with chronic obstructive pulmonary disease," CMS insists.

Plus, financial incentives drive many physicians to prescribe nebulizers and inhalation drugs instead of MDIs, CMS argues, because one is "not clinically superior to the other."

The counter-argument: The shift to MDIs could create a quality-of-care vacuum and higher out-of-pocket costs next year.

"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," according to a statement by Tennessee-based American Home Patient. "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, CMS says. And nebulizers may require "a certain level of dexterity" as well, the agency 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 nebulizers to force a migration of patients to MDIs beginning in 2006," AHP says.

Lesson Learned: New coverage changes could inhibit care for patients who need nebulizers. 
  Editor's Note: Medicare Legislation & Regulation will not be published next week. The next issue will be dated September 17.