Featured Health Business Daily Story, July 6, 2011 and featured in Government News of the Week, June 27, 2011

Medicare Home Infusion Bill Is Reintroduced, but Future Is Unclear

Reprinted from SPECIALTY PHARMACY NEWS, a monthly newsletter designed to help health plans, PBMs, providers and employers contain costs and improve outcomes related to high-cost specialty products.

By Angela Maas, Managing Editor
July 2011Volume 8Issue 7

Once again a bill that would fill the gap in home infusion coverage for Medicare Part D beneficiaries has been introduced in both houses of Congress. But there is no indication that the bill has a better chance of passage now than when attempts to close the coverage gap were made in 2006, 2007 and 2009. However, a pair of associations supporting the bill hopes to use the legislation to get a demonstration or pilot program started.

The Medicare Home Infusion Therapy Coverage Act of 2011 was introduced June 15 concurrently in the Senate (S. 1203) by Sen. Olympia Snowe (R-Maine) and in the House (H.R. 2195) by Rep. Eliot Engel (D-N.Y.). Co-sponsors are Sens. John Kerry (D-Mass.), Johnny Isakson (R-Ga.), Daniel Inouye (D-Hawaii) and Amy Klobuchar (D-Minn.) and Reps. Tammy Baldwin (D-Wis.) and Tim Murphy (R-Pa.). The Senate referred the bill to the Committee on Finance, while the House referred the bill to the Committee on Energy and Commerce and the Committee on Ways and Means.

When Part D began in 2006, only the drug that was infused was covered under that benefit. The nursing visit and per-diem cost — which includes all services, supplies, equipment and other related costs — were not covered. If beneficiaries do not have supplemental insurance to cover these services and cannot cover the costs themselves, then these people would have to be infused in potentially more costly settings such as hospitals, outpatient departments or skilled nursing facilities through which the service would be covered.

The situation is particularly problematic when frequent visits to outpatient infusion clinics are difficult, such as for patients who live in rural areas, the elderly and the infirm, or patients who require multiple infusions per day. The result is patient-access issues, as well as higher costs from patients being treated in hospitals and nursing homes as opposed to the home setting, contend many throughout the home infusion industry.

Bill Is Fourth to Propose Fix

The current bill takes essentially the same approach as the ones introduced in 2009 (SPN 2/09, p. 1) and 2007 (SPN 7/07, p. 1) — the drug would remain covered under Part D, but the infusion-related services, supplies and equipment would be covered under Part B. The 2006 legislation sought to shift drug coverage from Part D and consolidate all aspects of home infusion coverage under Part B (SPN 8/06, p. 1).

With some Medicare services, fraud can be an issue with bad apples taking advantage of the system. The current legislation would provide for “the development of quality metrics to ensure that Medicare beneficiaries are treated in a high-quality, cost-effective manner,” points out Jason Scull, senior program officer of practice and payment policy at the Infectious Diseases Society of America (IDSA).

Scull tells SPN that IDSA is working with the National Home Infusion Association (NHIA) to get the bill passed. However, he says “we think that what the CBO [i.e., Congressional Budget Office] would estimate as its cost would make it unlikely.” The CBO’s scoring methodology has long been a point of contention for backers of similar bills because it is not dynamic. The CBO “cannot score cost savings in Part A that would accrue in Part B,” he explains.

However, if the bill does not pass, the IDSA and NHIA hope that it would spur another action. According to Scull, the groups hope that the legislation would be “a means to try to get a demonstration or pilot program started.” He adds that “I’m not saying there isn’t a chance of it getting passed. But the Affordable Care Act was probably the best chance” for that to happen, and a comprehensive home infusion coverage provision was not included in that law.

A 2010 General Accountability Office study (GAO-10-426) found that health insurers surveyed offer comprehensive home infusion coverage for their commercial plans and some Medicare Advantage plans (SPN 7/10, p. 12). In addition, the report said that “health insurer officials we talked to asserted that infusion therapy at home generally costs less than treatment in other settings. Hospital inpatient care was recognized as the most costly setting. One insurer estimated that infusion therapy in a hospital could cost up to three times as much as the same therapy provided in the home.”

That report recommended that “given the long and positive experience health insurers reported having with home infusion therapy coverage, further study of potential costs, savings, and vulnerabilities for the Medicare program is warranted.”

The reintroduction of the legislation “offers a common-sense solution to improving patient care while providing much-needed relief to the Medicare crisis,” says NHIA President and CEO Russell Bodoff. “We urge Congress to fully consider” the 2010 GAO study, he adds, “which clearly demonstrated that home infusion therapy provides costs savings and quality patient care, with no unusual utilization. With the increasingly urgent need to reduce Medicare spending, this legislation and the GAO study findings represent an ideal opportunity for Congress to help find vital Medicare savings, while providing exceptionally high-quality patient care.”

The GAO study also noted that “industry experts project the home infusion market will continue to grow steadily, with one expert predicting growth to about $16 billion by 2012.”

Thomas Slama, M.D., IDSA president-elect, notes that “Medicare beneficiaries who need antimicrobial infusion services often must be admitted to an extended-care facility, where they are less comfortable and more likely to be exposed to hospital-acquired infections that increase the likelihood of treatment failure and avoidable readmission. Not only is this unnecessary, inconvenient and difficult for the patient, but it also is costly to the Medicare program.”

According to Slama, “A home infusion therapy benefit under Medicare would achieve what Dr. Donald Berwick of the Centers for Medicare and Medicaid Services refers to as the Triple Aim — improved care for individuals, improved population health, and lower per capita costs of health care — by reducing hospital stays, limiting complications, and decreasing costs.”

“The proposal is reasonable, and the rationale is sound,” Elan Rubinstein, Pharm.D., founder and principal of consulting firm EB Rubinstein Associates, tells SPN. “However, this is politics. The House Republicans want to privatize Medicare, not expand it. So it seems to me that given Republicans control the House, Republican ideology will likely trump reasonable/rationale thinking. There is good reason to think that ideology will win, given what’s happened in Republican-controlled states” over issues such as abortion, worker rights, voter registration and taxes, he says.

“So, while I’m not a Washington watcher, the chance of passage in the House is probably low. The Senate is less crazy. As I understand the process, the House and Senate need to individually agree to move the bill forward before it goes to conference for the differences to get worked out. So if the House blocks it, it’s not going anywhere, right?” Rubinstein says.

F. Randy Vogenberg, Ph.D., a principal with the Institute for Integrated Healthcare and strategic pharmacy adviser to the Business Group Pharmacy Collaborative, tells SPN that “my gut reaction is that this will go nowhere due to bad timing despite the fact it should move forward. There may be some CMS relief in the meantime, but that is uncertain too due to the overall debacle and politicization of Medicare now.”

Such relief, he says, could take the form of CMS providing “some program coverage modification(s) through their rule making around payment/reimbursement policy. That would provide relief to members as well as providers for home care services. Given the current economic and political climate in the Beltway, however, that is not too likely either.”

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