肠外营养医保方案忽略了符合当前实践标准的部分家庭患者

　　家庭肠外营养（HPN）与住院PN支持相比，成本效益更优。因此HPN在美国应用非常普遍。接受HPN的患者如果满足联邦医疗保险（Medicare）方案可以大大减轻经济负担。然而，联邦医疗保险的覆盖范围不够精确，往往忽略掉一部分满足HPN适应症及营养不良的患者。

　　美国家庭输液服务机构（Option Care）回顾分析了2012年10月1日～2016年2月3日的成人HPN患者共142例，收集患者的年龄、性别、诊断等基本信息并判断是否符合“HPN联邦医疗保险方案”及“ASPEN的HPN推荐标准”。

　　结果发现，所有HPN患者中达到“HPN联邦医疗保险方案”的患者不足一半（34.5%），其中有55.4%的满足“ASPEN的HPN推荐标准”患者达不到“HPN联邦医疗保险方案”，并且67.5%的重度营养不良（ASPEN标准）患者也达不到“HPN联邦医疗保险方案”。

　　因此，建议HPN的联邦医疗保险覆盖范围应根据目前的HPN适应症及营养不良诊断做适当调整，以保证最大程度精准覆盖需要联邦医疗保险报销的HPN人群。

JPEN J Parenter Enteral Nutr. 2017;41(2):271.

Medicare parenteral nutrition criteria overlooks a segment of home patients that meet current practice standards.

Natalie S. Tu; Rene Korpolinski; Nicole B. Jacobson; Margaret Sloan; Noreen A. Luszcz.

Option Care, Farmington Hills, Michigan, USA; Option Care, Cape Coral, Florida, USA; Option Care, Panama City, Florida, USA; Option Care, Bannockburn, Illinois, USA.

Purpose: Provision of home parenteral nutrition (HPN) can be a cost-effective therapy when compared with inpatient parenteral nutrition (PN) and frequent readmissions due to malnutrition. With the intent to limit the financial burden on their patients, infusion companies ensure Medicare qualification criteria are met when a HPN patient is brought onto service. This provides infusion companies with a stronger appeals position if Medicare denies a claim. However, does Medicare's coverage criteria use antiquated malnutrition diagnostic tools and PN indications when compared with current recommendations? The objectives of this study are to determine the frequency of adult HPN patient referrals meeting Medicare's HPN qualification criteria, to determine the most frequently missed criteria, to evaluate if the patient would qualify under American Society for Parenteral and Enteral Nutrition (ASPEN) HPN recommendations, and for Situations E, F, and G/H evaluate if the patient would meet the ASPEN-Academy malnutrition criteria.

Methods: A retrospective review was completed on adult HPN patients referred from October 1, 2015, through February 3, 2016, and were reviewed to determine if they met Medicare's HPN qualification criteria. The following data were collected: patient age, sex, diagnosis, was Medicare qualification criteria met, which Medicare situation was being used, what documents were missing if not qualified, if the patient would qualify for HPN using ASPEN recommendations, and for those patients trying to be qualified under Situations E, F, or G/H whether the patients met the ASPEN-Academy malnutrition criteria.

Results: There were 142 patients included in the analysis. The mean age was 64.6 years and 61% of patients were female. Forty-nine patients met Medicare's HPN qualification criteria (34.5%), 56 patients (39.4%) did not, and 37 patients (26%) were categorized as a No-Go (defined as when the qualifying process was interrupted or incomplete). Of all patient referrals, 67.6% (96 of 142) met ASPEN's HPN recommendations. The percent of patients that qualified under Medicare criteria and also met ASPEN recommendations was 91.8% (45 of 49), and 55.4% (31 of 56) of the patients who did not qualify under Medicare did meet ASPEN recommendations. Of those patients trying to be qualified under Situation E, F, or G/H, 67.5% (56 of 83) had moderate-to-severe malnutrition using ASPEN-Academy criteria. Of those patients that did not qualify under Situation E, F, or G/H due in part to missing a low serum albumin level or 10% weight loss in past 3 months, 60.9% (14 of 23) met the ASPEN-Academy malnutrition criteria.

Conclusions: More referrals did not meet Medicare's criteria than those who did. More than half of the patients who did not meet Medicare's criteria met ASPEN's HPN guidelines, and more than half the patients who could not meet Medicare's malnutrition criteria were considered to have moderate-to-severe malnutrition using the ASPEN-Academy criteria. Medicare HPN coverage criteria do not appear to correlate with current nutrition support and malnutrition criteria in our patient sample. To promote overall patient care cost reductions, it may be beneficial for Medicare to consider a modification of current qualification criteria to concur with current practice standards for both HPN indications and malnutrition diagnosis. Additional research is necessary to validate these findings.

DOI: 10.1177/0148607116686023