WASHINGTON – The new Medicare drug program is denying supplies that seriously ill patients need to administer intravenous antibiotics and other medications at home. As a result, some patients are being referred to nursing homes, and others have had to go into the hospital.
Although no national estimates are available, the number of patients affected – including some with life-threatening diseases such as cancer and multiple sclerosis – could run into the thousands. One Anaheim, Calif., pharmacy says 200 of its patients are having trouble.
Medicare officials say they are aggressively addressing the problem, which they attribute to restrictions in the law that created the prescription benefit and to difficulty communicating with states, pharmacies and medical providers.
Essentially, the prescription program allows coverage of the drugs but does not pay for the medical supplies and nursing help that are necessary for the home-based treatments to be safe and effective – a policy that effectively shuts down such treatment for many patients, even though it is substantially cheaper than the alternatives. Two senators warned the agency last fall that the gap in coverage “may limit access to home infusion therapy.”
Local home infusion pharmacies say they are overwhelmed trying to help patients deal with the problem. “It’s like I’m doing triage in a MASH unit,” said pharmacist Michael Rigas, vice president for clinical affairs with Crescent Healthcare in Anaheim.
So far, the problem mainly appears to be affecting the poor. But pharmacists say many middle-class Medicare beneficiaries also could run into trouble, since they will have to pay to cover support services for their medications or find other insurance. On average, the medicines represent a little less than half the cost of treatment, which can run thousands of dollars a month, according to a pharmacy industry group.
Republican Sens. Arlen Specter and Rick Santorum of Pennsylvania wrote Medicare in October, saying the agency “has opted to define the coverage of home infusion therapy in a manner that does not include financial coverage for … professional services, supplies and equipment that are required for the safe and effective provision of therapy.”
In a response dated Dec. 27, Medicare Administrator Mark McClellan said the agency lacked specific legal authority to broaden the coverage policy and, in effect, handed the problem back to Congress.
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