Millions of Americans who receive intravenous treatment for multiple sclerosis, blood diseases and rheumatologic conditions could soon lose access to those medicines — unless Congress intervenes.
Due to a drug-pricing provision in the 2022 Inflation Reduction Act, Medicare payments to infusion centers and clinics — the lowest-cost, highest-quality providers of these medications — will decline drastically starting in 2028.
Infusion centers provide dedicated access at a significantly lower cost than hospitals for patients requiring outpatient care. Hospitals charge three to four times what infusion centers do to ister the same medications. Hospitals also struggle to offer recurring access for these patients, as they understandably prioritize appointments for critical and urgent patients.
Without recurring care, many patients will experience harmful setbacks that could lead to hospitalization and irreversible damage that reduces their quality of life and life expectancy.
Care for patients with chronic diseases is personal for me. For the past 30 years, I have been living with and managing my Type 1 diabetes. I have lived a better and healthier life because I have been able to receive care outside the hospital. I have also witnessed firsthand how the lack of access to care negatively impacts patients’ lives.
These experiences are why I’ve spent the last two decades helping people who need infusion care. My company runs more than 50 infusion centers in the Western United States. They’re also why I am ionate about ensuring no patients lose access to life-saving treatment.
I’m sure Congress never intended to deprive patients of life-saving medicines. Without immediate action, that’s exactly what could happen.
I reining in health care spending, and Congress made a worthy attempt to rein in drug spending in Medicare by authorizing the federal government to negotiate drug prices for a growing number of medications each year as part of the Inflation Reduction Act.
In 2024, the Department of Health and Human Services set the “maximum fair price” that Medicare would pay for the first 10 drugs selected for negotiation. All 10 are covered under Medicare Part D — the benefit for pills and other drugs generally taken at home.
In 2026, the federal government will begin negotiations for Medicare Part B medications, which include infusion treatments istered in outpatient facilities for diseases like cancer, lupus, osteoporosis and Crohn’s disease.
Unfortunately, the new policy established by the IRA could cause infusion centers to lose massive amounts of revenue once the government-set prices go into effect in 2028. That, in turn, could cause sites to close even as patient demand for infusion drugs grows.
Currently, Medicare compensates infusion centers for purchasing, managing, and istering intravenous drugs to Medicare patients. Reimbursements are calculated based on a drug’s average sales price, or ASP, plus a 6% add-on payment to help cover things like shipping and storing medication.
Under the IRA, this calculation will be based on the new, lower “maximum fair price.” According to a recent study conducted by health care consulting firm Avalere, this change could lead to substantial payments cuts for infusion centers — between 42% and 61% for beneficiaries with Medicare.
The new maximum fair price mechanism will influence commercial and Medicare Advantage contracts as well. Reimbursement by private insurers could experience a decline of 12% to 18%.
Infusion centers already operate on razor-thin margins. The downstream impact of the maximum fair price will only compress them even further.
Infusion centers are small players in the massive medication supply chain. The new rules put companies like mine right in the middle of billion-dollar negotiations between drug manufacturers and the federal government.
In California alone, over 5.9 million patients are diagnosed with arthritis, which includes more than 100 rheumatic diseases that are often treated at infusion centers.
Without legislative protections, we’ll end up paying a steep price.
The good news is that lawmakers have crafted legislation to correct this unintended consequence of the IRA. The Protecting Patient Access to Cancer and Complex Therapies Act would direct Medicare to continue reimbursing infusion centers at current levels. After a provider is compensated, the drug manufacturer would pay a rebate directly to Medicare, covering the difference between what the infusion center paid and the maximum fair price.
The proposed legislation is estimated to save the federal government money over time and would ensure that infusion centers can continue to help patients. Moreover, Medicare beneficiaries would see lower out-of-pocket costs as a result of the negotiated prices, just as they were intended to under the IRA.
Congress has a lot on its plate this year. However, protecting infusion providers is a matter of urgency for the millions of patients with chronic conditions they serve. Congress should work to reintroduce this critical legislation and seek bipartisan opportunities to get it ed this year.
McCarty is a type 1 diabetic and CEO of Infusion for Health. He lives in Irvine.
