Late flurry on Capitol Hill holds hopes for IV providers

Legislation proposes Medicare reimbursement for IV therapy

Before Congress closed up shop in 1998, HR 4753 was introduced in the House of Representatives, which could have a huge impact on Medicare’s reimbursement — or current lack thereof — of home infusion therapy.

Section 6 of the Medicare Prescription Drug Coverage Act of 1998 deals specifically with coverage of home infusion drug therapy services. The bill proposes to provide reimbursement for "such nursing, pharmacy and related services (including medical supplies, intravenous fluids, delivery and equipment) as are necessary to conduct safely and effectively a drug regimen through use of a covered home infusion drug."

The bill also proposes general standards for what would be required of a "qualified home infusion drug therapy provider."

The proposed criteria are:

A) The entity is capable of providing or arranging for the items and services described [in the above-quoted skills and products] and covered home infusion drugs.

B) The entity maintains clinical records on all patients.

C) The entity adheres to written protocols and policies with respect to the provision of items and services.

D) The entity makes services available (as needed) seven days a week on a 24-hour basis.

E) The entity coordinates all service with the patient’s physician.

F) The entity conducts a quality assessment and assurance program, including drug regimen review and coordination of patient care.

G) The entity assures that only trained personnel provide covered home infusion drugs (and any other service for which training is required to provide the service safely).

H) The entity assumes responsibility for the quality of services provided by others under arrangements with the entity.

I) In the case of an entity in any State in which State or applicable local law provides for the licensing of entities of this nature, the entity (i) is licensed pursuant to such law, or (ii) is approved, by the agency of such State or locality responsible for licensing entities of this nature, as meeting the standards established for such licensing.

J) The entity meets such other requirements as the Secretary may determine are necessary to assure the safe and effective provision of home infusion drug therapy services and the efficient administration of the home infusion drug therapy.

Why so late?

HR 4753 was introduced in the waning days of the 1998 session with good reason, according to Alan Parver, JD, president of the Washington, DC-based National Alliance for Infusion Therapy (NAIT).

"It was clearly done to set the table for consideration in 1999," says Parver. "The thinking probably is that the National Bipartisan Commission on the Future of Medicare will be issuing a report that might well address expanded coverage of prescription drugs, and infusion would be part of that, or at least potentially part of that — and should be part of that, I might add."

HR 4753 would require home infusion provi ders to become Medicare-certified before being able to receive reimbursement, however.

"As it is now, agencies and organizations that provide enteral nutrition are considered to be suppliers, not providers," says Parver. "To be a provider, you must be certified as meeting Medicare conditions of participation, so you would be changed to provider status and have to meet quality standards, be surveyed, and have to be certified before you could be paid for treating Medicare beneficiaries."

While it is clearly too early to make any forecasts about the bill, Lorrie Kline Kaplan, executive director of the Alexandria, VA-based National Home Infusion Association (NHIA), says it’s a step in the right direction.

"This would deal with a lot of the problems we have had in the past," she says. "We have quite a bit of time to wait, but it is an exciting development. This lays the groundwork for payment for professional services, and also appears to open the door for potential expansion of coverage, but obviously they’ll have to find savings to pay for this."

HR 4753 clearly will have to overcome hurdles before becoming law. Parver agrees that the cost of the program is a primary issue.

"This is part of a broader bill that would cover outpatient drugs generally," he says. "That would be quite costly, or at least would add to the cost of the system. The question is, if Congress is not prepared to adopt the broad coverage proposal, would Congress be prepared to look at infusion therapy separately? If you look at how hard it was to fund the IPS [interim payment system] fix, you know that funding such proposals is not that easy."

The news isn’t all positive, though. The Durable Medical Equipment Regional Carriers (DMERCs) picked eight items for which they intend to change Medicare reimbursement, using the "inherent reasonableness" rule. Included in the reductions is a 16.39% reduction in the reimbursement for enteral formula, category one.

"There are a lot of serious flaws in the methodology on how those cuts have been justified," says Kaplan. "This is anywhere from 15% to 17% of the business for most of our members, and 80% of that business is category one enteral, which these cuts would specifically address."

Parver notes that any cuts invoked through inherent reasonableness are limited to 15% in one year. Although there was a comment period through the end of November, Parver says the DMERCs are well within their authority in issuing such cuts.

"The problem is that Congress gave HCFA [the Health Care Financing Administration] very broad authority to make payment adjustments like that, and HCFA delegated that authority to the DMERCs," says Parver. "There are very few statutory and regulatory hoops they have to jump through to get this done."