Home infusion-friendly bills slated for reintroduction
Reimbursement for Part B drugs could take a hit
A pair of bills scheduled for reintroduction on Capitol Hill will attempt to move specific hospital-based services into the home health arena by allowing reimbursement for certain drugs when infused in the home. Word from California Congressman Pete Stark’s office is that he plans to reintroduce H.R. 4189 and H.R. 4190, a pair of potentially home infusion-friendly bills, in April. While 4189 is likely to pass due to Congress’ cost-savings mentality, 4190 will likely face stiff lobbyist opposition.
H.R. 4189, "The Medicare Vancomycin Home Parenteral Therapy Act," will propose to reinstate Medicare Part B coverage of infused vancomycin "if the patient’s attending physician certifies that such administration is for the treatment of an infection caused by beta-lactam-resistant gram-positive micro-organisms or by gram-positive micro-organisms in the case of a patient who has a severe allergy to beta-lactam antimicrobials."
Tim Redmon, director of regulatory affairs for the National Home Infusion Association in Alexandria, VA, says 4189 has a good chance of passing.
"They’ve taken away the vancomycin on the Part B side, so I think people understand it is costing them more money to put these folks back in the hospital and that 4189 is going to correct that," he says.
H.R. 4190, "The Medicare Coverage of Infectious Diseases Therapy Act," will propose that the Department of Health and Human Services conduct a study to consider "how payment for [infectious diseases] therapy, drugs, and services should be made to ensure maximum cost-savings to the Medicare program."
It adds that "no later than six months after the bill’s passage the Secretary shall submit a report to Congress on the study . . . and shall include in the report such recommendations with respect to coverage and payment of outpatient parenteral antimicrobial therapy, drugs, and services under the Medicare program."
4190 looks to address whether drug coverage for outpatient parenteral antimicrobial therapy could lower the overall Medicare program expenditures. But Alan Parver, JD, president of the National Alliance for Infusion Therapy in Washington, DC, says the study would have to narrow its focus before becoming reality, even if the bill passes in the current session.
"There would be some serious consideration about having to go forward with those studies because there are a lot of different drugs and diseases the drugs are used for, and it’s interesting how this would actually be implemented," Parver says.
Redmon says 4190 is likely to face stiff opposition.
"What it basically looks at is taking those certain services out of the hospital and providing them on an outpatient basis," he says. "You’re going to take from someone to give to someone else, so they may run into some politics."
Just a flash in the regulatory pan
Parver points out that the bills’ introductions last year were simply efforts on Stark’s part to get the ball rolling.
"They were introduced just to get them on the record," says Parver. "They were introduced without any expectations that they would be passed because they were introduced the last week of the session. It was just to get them on paper and get them in circulation for comment."
Congress is in at least one way no different from the health care industry: All eyes are on cutting costs. Parver notes that the central issue in both bills is their financial impact on Medicare.
"Most people will concede that this area needs reform," says Parver. "The issue is whether the approach that Mr. Stark has taken, which we generally support, is one that would be scored as a cost-saver for the program."
Parver adds that the legislative vehicle for the program is the Omnibus Budget Reconciliation Act, which will contain numerous provisions pertaining to Medicare. These provisions figure to range from very specific technical changes to broad structural changes designed to cut program expenses by more than $100 billion in the next five or six years.
Medicare Part B faces overhaul
The Clinton Administration has proposed to change the reimbursement rates for Medicare Part B drugs from the average wholesale price (AWP) to average acquisition cost. The move could prove costly for Medicare-certified agencies that provide home infusion, depending on two factors.
First, Parver says there is a problem with how pharmacies would be reimbursed.
"The draft bill would pay pharmacies what is described as a reasonable dispensing fee," he says. "Obviously, how reasonable that is, especially if there is compounding involved, is an important issue. And that’s unclear."
Second, there is the matter of calculating actual acquisition cost. Parver notes that exactly how the acquisition cost is calculated must also be addressed.
Redmon agrees, adding that acquisition costs and infusion therapy under Medicare mix as well as oil and water because Medicare does not pay for services. Both groups are awaiting clarification on exactly how acquisition costs will be calculated.
"We have to provides services [such as patient education] for liability," says Redmon. "There are certain costs involved from a service standpoint that have to be made up or paid for. It concerns me that some services may not get out there or be as readily available, but it’s unclear what acquisition cost really means."
For example, will there be a counseling fee for the pharmacy to council the patient? Right now it’s unclear, as is whether the proposed change would apply to all outpatient drugs or if certain drugs such as those used for chronic diseases go untouched.
"I don’t think any drug stands to gain," says Parver. He adds that home infusion therapies that could be affected are those that require certain enteral formulas and pain management drugs currently reimbursed by AWP.
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