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At this point, anything could happen in Washington
It wasn’t long ago that the likelihood of any health care legislation seemed slim, at best. But recent developments on Capitol Hill have opened the door a bit more for change in federal health care legislation.
Alan Parver, JD, president of the National Alliance for Infusion Therapy in Washington, DC, says there is the chance of a prescription drug coverage that includes infusion drugs.
"The president’s proposal would cover prescription drugs on a pretty broad basis," Parver explains. "The proposals coming out of Congress by the Republicans would also cover prescription drugs, but it would be more limited. The Republicans and the administration are pretty far apart right now, and I’m not predicting they are going to reconcile those differences and come up with a drug bill that is going to be acceptable to everybody. But I think it’s becoming more likely that there will be serious consideration this year."
Not all good news
Parver notes there are concerns regarding how any legislation would cover infusion.
"Would they define infusion as including the professional services?" he asks. "If it is just delivering the drug and they don’t pay for the compounding and other cognitive services, that obviously is a very important issue to us."
A second area of concern lies in PBMs, or pharmacy benefit managers. According to a summary of the president’s proposal, PBMs would "competitively bid to manage the benefit for a particular geographic area."
"This could make it tough on providers because the PBMs would have an awful lot of leverage, and there is a concern that unless there are appropriate safeguards built in, the lower-bid PBMs would not look to pay for services and recognize these therapies as we do," notes Parver.
Also in the president’s proposal is a provision that would allow the Health Care Financing Administration (HCFA) to use competitive bidding with little, if any, restraint.
"These bills have not been written; right now, we only have summaries of what they want to do, so the extent to which this authority could be used is not clear now," Parver explains.
The good news
The president’s proposal would call for increases in parenteral and enteral nutrition reimbursement rates after the current five-year freeze expires. According to Parver, this would call for the rates to increase by consumer price index minus 1% each year from 2003 to 2007.
It looks as though inherent reasonableness may be given a closer look also.
"In light of the problems everyone seems to have had with inherent reasonableness, there is going to be an effort to try to obtain some changes in the current authority," says Parver. "The changes may relate to the procedural steps HCFA would have to go through to undertake an inherent reasonableness adjustment. A proposal that came out earlier in the year from the administration said they were going to look at something called enhanced inherent reasonableness authority,’ and it is not in the summary of the presidents reform proposal. There might be something there, but it’s not in the summary."
Lastly, Parver says relief may be on the way for many providers hit hardest in the last year or two: "It looks like there is a growing consensus that they have to give some relief to the industries that were really hit in the Balanced Budget Act of 1997: skilled nursing facilities, rehabilitation, rural hospitals, and maybe home health agencies."