Could a patient-centered change to Medicare's injectable drugs policy save billions?

Changing Medicare's policy to permit patients to self-administer injectable drugs in their homes could create "substantial savings" without inhibiting patient safety or treatment effectiveness, according to a recent NEJM editorial.

"Considerations of convenience, cost, and quality all argue for encouraging patients to participate in their own care by allowing self-administration of injectable drugs," the editorial's authors write. The authors, led by Jeffrey Faroni, PhD, JD, are from Houston's MD Anderson Cancer Center.

The Centers for Medicare and Medicaid Services' (CMS') current policy essentially pushes physicians and hospitals into in-office administration of injectables if they want to obtain reimbursement, the authors argue. To qualify for reimbursement, CMS requires that drugs that are "usually" administered in a doctor's office to be, in fact, administered in a doctor's office. In this case, "usually" is defined as more than 50% of the time for all Medicare beneficiaries who use the drug.

The circular and "self-fulfilling" nature of this policy basically ensures that physicians will frequently administer injectables in-office, even when they believe self-injection will reduce costs and increase treatment effectiveness, according to the editorial.

As an example, the doctors examine azacitidine, an injectable drug that is used to treat myelodysplastic syndrome-a group of conditions in which the bone marrow produces blood cells that are misshapen and does not produce enough healthy blood cells.

The drug can safely and easily be injected by the patient-and it was in the pivotal clinical trial that led to its regulatory approval. Medicare, however, effectively requires the drug to be administered in-office, which typically comes with a room charge of between $300 and $500 per patient. The authors do a little math and estimate annual Medicare costs for this at between $600 million and $2.4 billion.

And that's just one drug. Many other injectables, such as growth factors, anticoagulants, and antibiotics, are unnecessarily subjected to the same "mandate," according to the authors.

Admittedly, a home-injection program would need to be coupled with initial monitoring and supervision of patients, as well as additional patient education. But adding those safeguards to a home-injection program would still ultimately result in lower costs to the health system and better compliance from patients, according to the authors.

"Allowing self-administration (as we do routinely and safely at the MD Anderson Cancer Center when a patient is covered by insurance other than Medicare) will also free up hospital and clinic capacity for other patients," the authors write. "This step alone would save Medicare billions of dollars in reimbursement for hospital stays."

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