Respiratory med rollercoaster continues
WASHINGTON - CMS released the latest average sales price data for nebulizer meds last week, boosting reimbursement for albuterol so significantly that one industry watcher exclaimed: "It's the best thing to ever happen to the small provider." Others aren't so sure.
The single reimbursement amount for albuterol and Xopenex, now bundled under HCPCS code Q4094, will be $1.31 per unit dose beginning July 1. That's up from 20 cents per dose for albuterol and down from $3.84 for brand-name Xopenex.
"It's the best thing to ever happen to the small provider," said Mickey Letson, president of Decatur, Ala.-based Letco Companies. "We've had calls from 15 to 20 people that dropped out of the business wanting to get back in."
The new reimbursement is based on the weighted average sales price for both drugs, but with providers unable to dispense Xopenex at that price, some fear only a short-term bump in price for albuterol.
"My personal feeling is that as of July 1 nobody is going to be dispensing Xopenex anymore," said one California provider. "For the quarter beginning July 1, the price is ($1.31). Then, because you won't have any Xopenex, the price will drop and by the first quarter of 2008, you'll have no Xopenex in the running total so reimbursement will go back to 20 cents."
Letson confirmed that since the fee schedule was released, he has seen 50% of his sales of Xopenex "go out the window."
Estimates on Sepracor's sales of the drug to Medicare patients range from 20% to 30%, say industry insiders. Because ASP calculations are based on all sales of the drug, not just Medicare, any drop in reimbursement would be somewhat mitigated.
"The next two quarters you're likely to see an increase then I think it will level off mid next year," he said. "I don't think it will drop below a dollar."
Sepracor plans to offer a rebate to providers who use Xopenex, but Letson said with the cost of Xopenex so much higher than albuterol, it wouldn't be much of an incentive.
Other drug prices remained stable, with ipratropium up 2 cents to 19 cents per dose and DuoNeb dropping 4 cents to $1.11. Budesonide enjoyed an 18 cents increase to $4.74.