Transcript Slide 1

Economic Considerations
Lynn Webster M.D.
Lifetree Clinical Research and Pain Clinic
Salt Lake City, Utah
Economic Factors
• Site of Service
– Hospital Inpatient, Hospital Outpatient, ASC,
Office
• Management Cost
– Cost of drugs, refill kits and office overhead
• Management Reimbursement
– Drugs
– Cognitive skills
Payment by Site of Service: Trial
Outpatient Hospital Trial
Code
Description
Facility Pymt
MD Pymt
w/Fix
MD Pymt
w/o Fix
62319
Injection, including
catheter placement,
cont infusion
$485
$92
$71
$485
$92
$71
Total
Inpatient Hospital Trial
Description
DRG
Facility Pymt
MD Pymt
w/Fix
MD Pymt
w/o Fix
Medical back
problems
w/MCC
552
$4487
$92
$71
$4487
$92
$71
Total
CPT Copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Changes to the Hospital Outpatient Prospective Payment System and FY 2010 Payment Rates. Federal Register Display Date: October 30, 2009
Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010. Federal Register Display Date: October 30, 2009
The drug used for the
trial is included in the
DRG for Inpatient Trials.
For outpatient hospital
trials, Lioresal and Prialt
are reimbursed
separately, Infumorph is
packaged in the APC
payment.
Payment by Site of Service: Implant
Outpatient Hospital Implant
Code
Description
Facility Pymt
MD Pymt
w/Fix
MD Pymt
w/o Fix
62350
Catheter Implant
*multiple surg
$1443
$184
$146
$13305
$385
$306
$14748
$569
$452
reduction is reflected
62362
Programmable
Pump Implant
Total
Inpatient Hospital Implant
Description
DRG
Facility Pymt
MD Pymt
w/Fix
MD Pymt
w/o Fix
Peripheral/Cranial
and Other Nervous
System W/CC or
Peripheral
Neurostimulator
41
$11967
$184
$385
$146
$306
$11967
$569
$452
Total
CPT Copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Changes to the Hospital Outpatient Prospective Payment System and FY 2010 Payment Rates. Federal Register Display Date: October 30, 2009
Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010. Federal Register Display Date: October 30, 2009
The DRG assignment
varies depending on
diagnoses and
severity of illness
(MCC or CC). For
illustration above a
pain disorder
diagnoses was used.
Payment by Site of Service
Refill Programming and Analysis
Outpatient Hospital Refill
Code
Description
62368
95990
95991
J2275
Total
Facility
Pymt
Pump
Programming and
Analysis
$171
Refill – NonPhys
NA
Refill –
Physician
$127
Morphine, 10
mg
N/A
Physician Office Refill
MD
Pymt
w/Fix
MD
Pymt
w/o Fix
$37
$28
$64
$37
$56
Code
Description
MD Pymt
w/Fix
MD Pymt
w/o Fix
62368
Pump Programming
and Analysis
$54
$43
95990*
Refill – Non-Phys
$75
$56
95991
Refill – Physician
$93
$79
J2275
Morphine, 10 mg
$14
$28
Total
$298
$74
$161
$56
•Fee not established for 95990 in facility
Totals calcuated using MD Refill
For illustration, Infumorph 50 mg used for calculating payment
http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a1_2009aspfiles.asp
Refill kits are used in both sites of services and are included in the payment reflected above
CPT Copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Changes to the Hospital Outpatient Prospective Payment System and FY 2010 Payment Rates. Federal Register Display Date: October 30, 2009
$136
Drug Reimbursement Methods
•
•
•
•
AWP
ASP
Fee Schedules
Rebate Programs
Medicare Administrative Contractor
(MAC) Drug Reimbursement
• All contractors instructed to utilize ASP pricing for
commercially prepared drugs used in infusion pumps
– http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a19_2010aspfiles.asp
• Because of some confusion, a couple MACs still
paying at 95% of Average Wholesale Price (AWP)
• Compounded Drugs are Paid at MAC discretion
– Payment Varies
– Coding/reporting requirements vary
Current ASP* Payment Amounts
Facility
Reimbursement
= ASP + 5%
10/1/2010
10/1/2010
Difference
HCPCs
Code
Drug
Dosage
J0475
Baclofen 10 MG
injection
10 MG
$203.93
$200.08
$3.85
J0476
Baclofen intrathecal
trial
50 MCG
$73.15
$71.77
$1.37
J2275
Morphine sulfate
injection
10 MG
$2.42
$2.37
$0.05
J2278
Ziconotide injection
1 MCG
$6.61
$6.48
0.3
*Average Sales Price
Cost
Physician Office
Reimbursement
= ASP + 6%
Current AWP* Amounts
•
•
•
•
Baclofen 10 mg
$215.18
Baclofen 50 mcg
$ 79.80
Morphine Sulfate 10mg $4.39 approx
Ziconitide only priced at ASP
*Average Wholesale Price
IT Reimbursement
• Industrial Claims
– Each state’s Industrial Commission sets the fee
schedule
• Some states pay at invoice plus ~15%
• Private Payers
– Most use the Medicare ASP + 6% fee schedule
• Noridian Medicare
– J3490 code
– Pay from invoice with no additional payment
allowed
IT Therapy Costs
LOW
$
$ $
HIGH
$ $
IT Morphine
•Average dose 6 mcg/day
in 20-mL Medtronic pump
•ASP + 6% = $2.83/10 mg
$ $
$ $
IT Prialt
•Average dose 4 mcg/day
in 20-mL Medtronic pump
•ASP + 6% = $6.51/mcg
Oral Therapy Costs
LOW
$
$ $
HIGH
$ $
Methadone® 10 mg QID
Oxycodone® 15mg QID
Gabapentin® 400 mg QID
Desipramine® 10mg TID
Trazodone® 50mg QHS
$ $
$ $
Oxycontin® 80 mg TID
Percocet® 10/325 mg 8x day
Lyrica® 150 mg BID
Cymbalta® 60 mg QD
Klonopin® 1 mg BID
Ambien® CR 12.5 mg QHS
Cost Comparison of 2 Intrathecal Medications to an
Oral Brand Name Medication Regimen and an Oral
Generic Medication Regimen
$36,000.00
$33,000.00
$30,000.00
Cost ( in Dollars )
$27,000.00
$24,000.00
$21,000.00
$18,000.00
$15,000.00
$12,000.00
$9,000.00
$6,000.00
$3,000.00
$0.00
0
1
2
3
4
5
6
7
8
9
10
11
Time ( in Months / 30 Days )
Intrathecal Prialt
Intrathecal Morphine
Deer and Smith, et al. Manuscript in Progress
Oral Brand Name Regimen
Oral Generic Regimen
12
Economic Considerations
• IT therapy can be less expensive than using
oral medications
• Reimbursement depends on payer and site of
service
• Drug invoice pricing may not provide payment
for handling and acquisition
Economic Considerations
• The Neuromodulation Therapy Access
Foundation (NTAC) is working with multiple
organizations to provide appropriate payment
for all aspects of pump therapy
– Palmetto GBA recently implemented fee schedule
that replaces invoice only methodology
(California, Nevada, Hawaii)
– Allows for fee schedule to cover drug and separate
compounding fee
• Thanks to Drs Schwachmann, Helm and
William Stuart PharmD