What is at stake ?

Issue Fact Sheet

 The Situation

Federal health care policy allows one MS injected therapy, Avonexâ, to be covered by Medicare in a physician office setting, but denies coverage to three other FDA-approved therapies, Betaseronâ, Copaxoneâ and Rebifâ.

The Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) sought to clarify Medicare’s coverage of “drugs and biologicals which are not usually self-administered by the patient” and are administered “incident to a physician’s service.”  The result, however, is that today only one of the four FDA-approved treatments for MS qualifies for coverage when administered by a physician.

Coverage for one of the therapies benefits thousands of MS patients who qualify for Medicare. But thousands more MS patients on the other therapies are without coverage.  MS patients who take one of the uncovered injected MS therapies simply cannot understand how federal policy can deny them access.

The Solution

The Coalition, along with Representatives Jim Greenwood (R-PA) and Henry Waxman (D-CA), is calling upon Congress to enact bipartisan legislation that would grant equitable Medicare coverage for all four MS therapies.

The proposed legislation, H.R. 1956, would improve Medicare coverage of treatments for MS and correct the inequities created by BIPA.

The language accomplishes the two goals:

1.  Ensure that Medicare beneficiaries have access to all four FDA-approved injected products found to slow the progression of MS or reduce the relapse rate among patients.

2. Provide coverage to all Medicare beneficiaries who have MS, regardless of the setting in which their treatments are administered.

Access & Choice

MS patients need and deserve the full range of treatment choices currently available.  Any one of the four FDA-approved treatments for relapsing, remitting multiple sclerosis may prove to be the “optimal” treatment for a patient throughout the course of his or her disease.  The current policy poses an access barrier for those patients who do not respond well to, or cannot tolerate, the covered MS therapy.

In addition, patients react differently to different medications, which is why patients must have access to the treatment that is therapeutically best for them. The current situation has the potential of encouraging physicians and patients to choose the treatment that is covered, rather than the treatment that is best for the patient.  Fairness and equity for MS patients on Medicare dictate that they should have access to the full range of treatment options currently available. 

Last, MS patients who are disabled would bear an additional hardship and expense in getting to a doctor’s office for an injection when many can just as easily get the injection at home.  Given the dosage schedule of the MS therapies, it is reasonable to allow self-administration in any setting.  Such an option could also save the Medicare program some costs by not incurring expenses associated with a physician’s office visit.

 The Cost of the Proposal

The net cost to the government of enacting this proposal will be relatively low, about $882 million over the period from 2004 to 2013. Furthermore, the benefit will far exceed the cost as people with MS will have access to all disease modifying therapies that often slow the debilitating course of the disease. 

 Call to Action

The current MS Medicare coverage policy is inequitable. Passage of H.R. 1956 to ensure equitable Medicare coverage for MS therapies is a top priority of MS patients and their families, the National Multiple Sclerosis Society and the other Coalition members, including patient groups, providers and manufacturers of MS therapies.