CMS continues to monkey with med reimbursement

Thursday, January 31, 2008

WASHINGTON - Six months after bundling albuterol and Xopenex under the same reimbursement code, CMS is changing the rules again.
The recently signed SCHIP bill included a provision to revamp how the two drugs are paid for, splitting the reimbursement rate and revamping how the average sales price (ASP) is calculated.
Starting April 1, 2008, the ASP for albuterol will be calculated by itself, while the ASP for brand-name Xopenex will be calculated with albuterol. That change is expected to hold Xopenex rates steady and drop albuterol back down to around 20 cents per dose.
"The spirit here is to pull out the weighted push that Xopenex is providing for albuterol," said Wayne Vega, a consultant with Stat Vial in Acadiana, La.
The two drugs are expected to remain under the same code, J7603, probably with individual modifiers.
"Let's confuse everybody more," said Mickey Letson, president of Decatur, Ala.-based Letco Companies. "It's a blatant statement by the federal government to make up the rules as they go."
On July 1, Medicare started reimbursing generic albuterol and the more expensive brand-name Xopenex under the same code. As a result, albuterol surged from 20 cents to $1.31 per dose while Xopenex plunged from $3.84 (see HME News, August 2007). Providers began switching patients to albuterol, and Xopenex sales fell sharply.
The method was flawed from the start, said Sam Jarczynski, president of RxStat in St. Petersburg, Fla. ASP is based on manufacturers' overall sales data, including retail--which tends to boost sales costs--rather than just the homecare market, affecting what Medicare pays.
"When it's all billed under one code, (Medicare) doesn't know if the patient is getting albuterol or Xopenex," he said. "A lot of Xopenex is sold to non-Medicare patients."