Patricia Han is a retired nurse with very serious health challenges who struggles with chronic wounds. She’s written articles about Medicare Advantage vs. regular Medicare for patients with wounds, as well as what she wishes every wound care practitioner knew (see links at the end of this article).
This article is about the difficulty of getting outpatient IV antibiotics – and healthcare provider ignorance of avoidable costs. It’s a must read for every wound care practitioner.
–Caroline
Dr. Fife,
I know some physicians read your blog, so I’d like to tell you a story about getting intravenous (IV) antibiotics for an infection as an outpatient– in hopes that doctors will become aware of the issues. My wound care doctor had no idea what his patients had to go through to get care until I told him.
I was diagnosed with a serious wound infection as an outpatient, so my practitioner referred me to an Infectious Disease (ID) doctor. However, even though I am an RN who worked in a hospital, I didn’t know that ID doctors have different approaches to delivering IV antibiotics, and that these differences can mean huge, unnecessary charges for patients. I have Medicare Fee for Service (MFFS)- which is traditional Medicare — plus a supplement for the 20% of charges not covered by Medicare, and Medicare part D for drugs. It seems like anyone with that kind of “full coverage” should be OK when they need intravenous antibiotics, right? Well, read on . . . .
First, let’s talk about PICC Lines
PICC stands for Peripherally Inserted Central Catheter. This is an intravenous line that is usually inserted into a vein on the inside of the upper arm and goes into a larger vein near the heart. PICC lines can stay in safely for several days and there’s usually less irritation when medications are infused. However, they require skill to insert, and the correct placement has to be confirmed before medication can be infused through the line.
The ID doctor’s office referred me to a free-standing facility to have the PICC line placed. I did not ask whether they could handle patients with limited mobility. I have muscular dystrophy and need a Hoyer lift to get out of my wheelchair. It never occurred to me to ask if they would be able to manage patients with serious mobility issues since I thought this was required at healthcare facilities. Well, they did not have a lift to get me onto the surgical table, so the doctor tried to do the procedure in my chair since my wheelchair is able to recline into a bed. However, the whole thing was a debacle, and the line caused so much pain that it had to be removed.
So, I asked to be referred to the Interventional Radiology Department of the hospital for another the PICC line placement. The procedure in the hospital was done by a vascular trained nurse, and he was great! Not only was he able to do the procedure in my chair, but he had the equipment needed to do a beside fluoroscopy. I was able to view the line as it was placed! He was also able to get a portable chest x-ray to confirm placement. Best of all, there was no discomfort! I wonder what would have happened if I hadn’t known to ask to be referred to the hospital interventional radiology department? Neither the ID doctor nor the doctor in the free-standing facility suggested this as a solution. Thank goodness I am a nurse! However, figuring this out should not be the job of the patient.
The Hidden Costs of Specialty Pharmacies
The ID doctor to whom I was initially referred was a “hospital-based” doctor, which means he primarily sees hospital inpatients. When an outpatient with an infection is referred to him, he often evaluates them via a “telehealth” visit – which is what he did for me. So far, so good.
The ID doctor then referred me to an outpatient “Specialty Pharmacy” that provides the intravenous (IV) medications, as well as the supplies required to administer the medication. The specialty pharmacy then assigns a Home Health Agency to come to the house to perform the infusions and draw any necessary blood for laboratory testing.
The Specialty Pharmacy told me that they would file my Medicare Part D, but that I would still have to pay $720 every 2 weeks for the medication! They told me that insurance did not cover the IV supplies at all, so in addition to the drug costs, I would need to pay $800 every two weeks for supplies. And they informed me that before I could start getting the IV antibiotics, I’d need to pay $1,520! What a SHOCK!
I asked why these charges were not covered by Medicare since Medicare covers home IV supplies. They told me that they could only file Medicare Part D because they were a pharmacy! That seemed like a stupid excuse.
So, I contacted Medicare. The Medicare representative I spoke to told me that the additional charges were because the pharmacy uses an elastomeric pump and Medicare doesn’t cover those. I am a former hospital nurse, and we didn’t use those in the hospital (at least in my day), so I had to Google to find out what that was. Here’s what Google told me those things are:
“Elastomeric pumps, also known as balloon or ball pumps, are medical devices that use a stretchable balloon filled with fluid to deliver medication. When the pump is filled, the balloon’s elastic walls stretch and then contract back to their original size, creating pressure that pushes the fluid through tubing and into a patient. The pumps don’t require external power sources like batteries or electricity.”
Then I asked “AI” on my computer, “Does Medicare cover elastomeric pumps?” Answer: “No”
“Medicare does not cover elastomeric infusion pumps because they are considered disposable drug delivery systems and don’t meet Medicare’s definition of durable medical equipment (DME). However, Medicare does cover some other infusion pumps and supplies under the DME benefit, including: Infusion pumps, IV poles, Tubing, Catheters, and Infusion drugs. Medicare may also cover services like nurse visits, training for patients or caregivers, and monitoring. Depending on the equipment, Medicare may require you to rent or buy it, or you may be able to choose between the two.”
Thank you, computer AI! Too bad my doctor did not know this. I called several different ID doctors to inquire about their services. It turns out that, just like the ID doctor who saw me, most hospital-based ID doctors refer patients to an outside pharmacy that can only bill Medicare Part D for the drugs. Depending on what cost “tier” the drug is in, and where the patient is in terms of the “Gap”, the patient responsible portion might be only 25% of the cost. I am going to let readers Google what the “Gap” is. Let’s just say that if a patient’s medications are prescribed before the gap starts, they could end up paying twice that, or 50% of the costs, PLUS supplies.
I want to raise awareness of the huge problem with some of these specialty pharmacies. My sister-in-law got an infection in her mitral valve and before she could be discharged, she needed home IV antibiotics set up. The hospital Case Manager referred us to a free-standing pharmacy, and she was told that while the medication was covered by insurance, the supplies were not and she would have to pay $231 for supplies that day or she could not be discharged. She paid the money and eventually got 3 weeks of IV antibiotics at home. But then the bills starting coming in! Bills for additional supplies and copays for the medication – hundreds of dollars! We called to get an itemized list of the charges the pharmacy was billing on the insurance. I researched her Medicare Advantage plan benefits, which clearly stated that the plan DID cover IV supplies and medication costs. I called her insurance company, and the company called the pharmacy. The insurance company told the pharmacy to file the supplies with the correct Medicare codes, and they would be paid. This took severe months with the insurance company having to call the pharmacy multiple times to do the job correctly. The Medicare Advantage plan paid 100 % of the supplies, although she had copays for the medication. My point is that patients are often paying hundreds of dollars for services and/or supplies that are actually covered by insurance. This is a travesty on the part of the pharmacies – and doctors should know about this issue!
At last, I found the right ID Doctor!
I finally found an ID doctor who could provide antibiotic infusions in his office. I was informed that my Medicare B and AARP Medicare Supplement would cover this at 100%. In other words, I’d have zero out of pocket costs.
I go to the ID doctor’s office three days a week to get my portable medication pump refilled. This type of pump is battery operated. Some people wear it around their waist, but I hang mine over the headrest of my wheelchair. The ID doctor’s office has a pharmacist that mixes medication into a small IV bag that lasts for 2 days on Mondays and Wednesdays. On Fridays I get a bigger bag that covers 3 days (Friday, Saturday and Sunday). However, I noted when I was at the ID doctor’s office that there were patients coming daily for antibiotics that have to be administered that way. His office is open Monday through Friday 8 am to 5pm, and as needed on Saturday and Sunday. My IV dressings are changed there, too. There is a 24-hour number to call for any questions or problems with the pump, etc. Each patient with a pump is given a list of instructions on how to handle the typical issues they may have with the pump. The pumps do have an ear-splitting alarm if there’s a problem!
My point is writing you this long letter is that if I had not been able to advocate for myself, I probably would not have gotten a PICC line at all, and if I had, I would have been unable to afford the out-of-pocket charges that turned out to be unnecessary anyway! I know wound care practitioners are busy with many things, but home IV antibiotics are a relatively common need. I hope doctors will take the time to understand how the ID doctors and pharmacies to whom they refer patients handle their referrals.
–Pat Han RN
Read Patricia’s other articles:
- The Patient’s Perspective: Things I Wish Wound Care Doctors Would Consider When They See a Patient – Caroline Fife M.D. (carolinefifemd.com)
- The Patient’s Perspective: What Wound Care Clinicians Need to Know About Documentation – Caroline Fife M.D. (carolinefifemd.com)
- A Patient’s Perspective on Choosing a Medicare Prescription Drug Plan – Caroline Fife M.D. (carolinefifemd.com)
- Tales of the Medicare Disadvantaged #1 – Caroline Fife M.D. (carolinefifemd.com)
- Tales of the Medicare Disadvantaged #2 – Caroline Fife M.D. (carolinefifemd.com)
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
