‘You’ve got to spend money to save money’

Thursday, September 30, 2004

BOYNTON BEACH, Fla. - If you are poor, over 21, live in Florida and need an infusion pump, don’t expect Medicaid to pay for it - even if doing so would save taxpayers money.

Florida Medicaid’s refusal to reimburse the cost of infusion pumps came to the fore following an Orlando Sun-Sentinel report about a young mother with sickle cell anemia who had been denied a pump that her doctors said would keep her out of the hospital. As a result, the woman has required almost monthly trips to the hospital, one of which lasted two weeks and racked up a staggering $60,634 bill - far exceeding the cost of home care.

“This does not surprise me at all,” said Joan Cross, president of the Florida Association of Medical Equipment Services. “These are the rules, but they don’t see how much they have to pay to have this person in the hospital versus treating them at home where it is less expensive. It makes no logical sense.”

According to Cross, Florida Medicaid’s move to cut costs by reducing DME reimbursement has lead to other reimbursement conundrums. For example, Medicaid will pay for CPAP rental, but it won’t pay for supplies.

While it remains undocumented how much money has been wasted by such regulations, it is clear that treating DME reimbursement as a line item is not the most efficient way to cut costs, said Cross.

“Cutting reimbursement is the easiest way to save money, but it is not necessarily the most cost effective method or the best move for the patient,” said Cross.

The lack of home infusion benefits under Medicaid is problematic nationwide, according to Lorrie Kline Kaplan, executive director of the National Home Infusion Association.

“Very few state Medicaids have home infusion benefits,” she said. “Many cover it under their retail benefit, which is not set up properly for these types of therapy.”

Kline Kaplan has tried to fix gaps in the benefit structure, but has come up against what she described as a “silo mentality” within Medicaid.

“They have people in charge of the pharmacy budget who don’t want to pay any more even if it reduces the inpatient budget,” Kline Kaplan said. “Medicaid programs are behind the times in terms of being able to move the patient to the most cost effective treatment. Managed care has generally mastered this concept.”

With DME reimbursement cuts looming year after year, Florida infusion providers are left wondering how to fix the problem.

“Medicaid reimbursement is a big issue,” said Kathy Baptreall, vice president of Coral Medical Equipment in Tavernier, Fla. “Sometimes it barely covers the cost to provide the service.”

To cover the costs of providing home infusion to its poor customers in the Florida Keys, Baptreall said, her firm often turns to a local nursing agency’s indigent fund.

“We need to have a study that shows Medicaid how much money they would save if they covered it in the home,” said Baptreall.

Cross agreed that a study would be the best way to solve the problem, but said that gathering the information would be difficult for the industry to do alone.

“It is a lot of work to give to an already overburdened industry,” she said. “Medicaid ought to do it to save their own money.”