Use of wet nebulized inhaled respiratory medications under criteria-based reimbursement guidelines in a publicly funded Seniors' Pharmacare Program in Nova Scotia, Canada.

BACKGROUND: During the 1999/2000 fiscal year, approximately 19% of beneficiaries in the Nova Scotia Seniors' Pharmacare Program (NSSPP), a publicly funded drug insurance program in Nova Scotia, Canada, received inhaled respiratory medications by wet nebulization. The cost was estimated at more than Can $2 million annually. On August 1, 2000, the NSSPP initiated new criteria-based reimbursement guidelines for wet nebulized respiratory medications, requiring prior authorization.

OBJECTIVE: Within the NSSPP, we examined approved reimbursement requests to determine demographic characteristics of those who accessed wet nebulized therapy through exception criteria, compare these factors between those who accessed wet nebulized therapy within the exception criteria and those who fell outside the criteria, identify indications for use of wet nebulization, and determine patterns of wet nebulization use.

METHODS: Two hundred approved requests, received between August 1, 2000, and April 30, 2001, were randomly selected and reviewed for indications and patterns of use.

RESULTS: Of 200 requests reviewed, 28 were excluded due to coverage in another Pharmacare program (Community Services). Of the 172 requests reviewed, 27% were for nursing home or other residential care facility residents. Indications and patterns of use differed only by place of residence (P<0.001). The majority of indications (72%) fell within outlined reimbursement criteria, with the most frequently cited indication (56%) being inability to use portable inhalers due to cognitive or physical disability. Almost one third (28%) of exception requests were approved for other reasons (31% of these were for short-term use [ie, <3 months] secondary to an acute respiratory infection or for palliative care; 69% continued to access wet nebulization because of a preference or a perception of greater effectiveness). Examination of patterns of use demonstrated that 36% of beneficiaries, primarily community dwelling (P < 0.001), were using wet nebulized therapy and portable inhalers concurrently.

CONCLUSIONS: The majority of approved requests for wet nebulization criteria fell within the established reimbursement guidelines. Many approvals outside of guidelines were clinically valid. Approval of requests outside the criteria highlights the need for flexibility in the claims administrative and adjudication system to respond to unique circumstances not covered by established criteria. However, concurrent use of wet nebulization and portable inhalers by some beneficiaries suggests suboptimal use of portable inhalers, the need for portable inhalers for patients using wet nebulization when they leave their residence, and the need for more patient education.