Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

R S P
EVIEW OF  ERVICES  ROVIDED

I D
BY  NHALATION  RUG 

S
UPPLIERS

Daniel R. Levinson

Inspector General 

September 2005

OEI-01-05-00090
 Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts management and program 
evaluations (called inspections) that focus on issues of concern to HHS, Congress, and 
the public.  The findings and recommendations contained in the inspections generate 
rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 
effectiveness of departmental programs.  OEI also oversees State Medicaid Fraud 
Control units which investigate and prosecute fraud and patient abuse in the Medicaid 
program. 
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations. OCIG imposes program exclusions and civil 
monetary penalties on health care providers and litigates those actions within HHS. 
OCIG also represents OIG in the global settlement of cases arising under the Civil False 
Claims Act, develops and monitors corporate integrity agreements, develops compliance 
program guidances, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y  

OBJECTIVE 
To determine the nature and extent of dispensing services that 
Medicare beneficiaries receive from inhalation drug suppliers. 
BACKGROUND 
In 2003, about 1 million beneficiaries received Medicare-covered 
inhalation drugs.  Medicare paid suppliers about $1.4 billion for the 
drugs and an additional $35.5 million in dispensing fees.  In 2005, 
reductions in payments for inhalation drugs mandated by the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 took 
effect.  This resulted in up to a 90 percent drop in payment for some of 
these drugs from their 2003 level. To cover the cost of services 
necessary to dispense inhalation drugs, the Centers for Medicare & 
Medicaid Services (CMS) raised the dispensing fee from $5 to $57 for a 
30-day drug supply and offered $80 for a 90-day supply.  We estimate 
that payments for dispensing fees will total about $400 million in 2005. 
Yet, it is unclear what services suppliers provide and, therefore, how 
much Medicare should pay in its dispensing fee.  While the Medicare 
Program Integrity Manual requires suppliers to contact beneficiaries 
before providing drug refills, neither Congress nor CMS has stated what 
additional services the dispensing fee covers.  In its 2004 final rule 
setting the interim fee, CMS stated the need to learn more about the 
services inhalation drug suppliers provide to Medicare beneficiaries. 
We drew a stratified random sample of 480 beneficiaries who had 
Medicare claims for inhalation drugs in 2003.  We mailed surveys to the 
203 suppliers who provided these beneficiaries with their drugs and 
requested that the suppliers report and provide supporting 
documentation for all services they provided to the beneficiaries during 
2003. We received responses for 96 percent of the beneficiaries in our 
sample, yielding data on 11,777 services.  We excluded undocumented 
services and others outside of the scope of this inspection, such as drug 
deliveries and billing activities.  Our analysis considered 4,130 services. 
FINDINGS 
The most common service beneficiaries received in 2003 was 
contact for drug refills. Sixty percent of beneficiaries received this 
service at least once in 2003.  Thirty-one percent of beneficiaries who 
should have been contacted for a refill were not contacted by their 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  i  EEE XXX EEE CCC UUU TTT III VVV EEE     SSS UUU MMM MMM AAA RRR YYY
suppliers, contrary to the Medicare Program Integrity Manual. 
Suppliers contacted physicians offices for about half of beneficiaries to 
get physicians orders, consult on medication changes, and for other 
reasons. Less than a third of beneficiaries had their medication 
compliance reviewed by their suppliers. Few beneficiaries received 
more intensive services such as education, response to an inquiry, care 
plan revision, or respiratory assessment. Among beneficiaries who had 
2 months or more of drug claims, 16 percent received no services at all. 
Other services were less common. Contact for drug refills accounted 
for 56 percent of services. The next most common services, medication 
compliance reviews and contacting physicians offices, composed 
15 percent and 12 percent of services, respectively. 
The most common way beneficiaries received services was by 
telephone. Beneficiaries received 73 percent of services by telephone. 
Fourteen percent of services involved no supplier contact with 
beneficiaries. Home visits were rare; only about 1 in 10 beneficiaries 
received a home visit any time during 2003. 
Beneficiaries were three times more likely to receive a service 
beyond a refill contact if their supplier also provided their 
respiratory equipment. When beneficiaries inhalation drug suppliers 
also provided them with Medicare-covered respiratory equipment, those 
beneficiaries were far more likely to receive services beyond a refill 
contact. Those beneficiaries average monthly service level was higher 
than that of beneficiaries who only received inhalation drugs from their 
suppliers. 
Service levels dropped off after the first month suppliers billed for 
drugs. On average, services beneficiaries received fell from 
1.96 services in the first month suppliers billed for drugs to between 
1.01 and 1.18 services in the second through eighth months of service. 
CONCLUSION 
CMS set the interim dispensing fee for inhalation drugs based, in part, 
on an assumption that beneficiaries receive numerous, important 
services from their drug suppliers. This inspection shows that 
beneficiaries, on average, receive little service from their inhalation 
drug suppliers beyond contacting them to ask if they need a drug refill. 
We provide this information to CMS to assist it in setting a new 
dispensing fee for inhalation drugs. 
OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  ii  E X E C U T I V E   S U M M A R Y

AGENCY COMMENTS 
In its comments on the draft report, CMS expressed appreciation for the 
Office of Inspector Generals efforts to provide information on services 
that inhalation drug suppliers provide to Medicare beneficiaries. CMS 
stated that it will carefully consider this information as it develops a 
new dispensing fee policy. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
We appreciate CMSs comments and consideration of the information in 
the report. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  iii    T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY. .. ... . .. . .. . ... . .. . .. . ... . .. . .. . ...
  i 
I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Most services were drug refill contacts . . . . . . . . . . . . . . . . . . . . . .  5

Other services were far less common. . . . . . . . . . . . . . . . . . . . . . . .  6

Most services were provided by telephone. . . . . . . . . . . . . . . . . . . .  6

Beneficiaries receivingequipment more likely toget services  . . . .  7

Service levels dropped off after the first month. . . . . . . . . . . . . . . .  7

CONC LUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

E N D NO T ES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13

A:  Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13

B:  Data Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  20

C:  Nonrespondent Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24

AGENCY COMMENT S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  26

A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  27
 I N T R O D U C T I O N
  I N T R O D U C T I O N  

OBJECTIVE 
To determine the nature and extent of dispensing services that 
Medicare beneficiaries receive from inhalation drug suppliers. 
BACKGROUND 
Medicare Coverage of Inhalation Drugs 
About 1 million beneficiaries received Medicare-covered inhalation 
drugs in 2003. These drugs, such as albuterol sulfate and ipratropium 
bromide, help beneficiaries to ease shortness of breath caused by 
emphysema, chronic bronchitis, and other ailments collectively known 
as chronic obstructive pulmonary disease.  Because this is an incurable, 
progressive disease, long term use of inhalation drugs is often required.1 
Until full implementation of Medicare Part D in 2006 as part of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (MMA), Medicare benefits typically do not cover outpatient 
prescription drugs.  However, Medicare does pay for drugs that are 
necessary for the effective use of covered durable medical equipment 
(DME). In this case, Medicare covers inhalation drugs because it covers 
a type of DME called a nebulizer, which beneficiaries use in home-care 
settings to administer the drugs.  Nebulizers aerosolize medications so 
that patients can inhale them into their lungs. 
Under the DME benefit, Medicare coverage of nebulizers includes the 
cost of renting/purchasing the equipment, delivering it to beneficiaries, 
and educating beneficiaries in its proper use and maintenance. 
Medicare regulations require that DME suppliers document proof of 
delivery and that they or another qualified party provide beneficiaries 
with the necessary information and instructions on how to use 
Medicare-covered items safely and effectively.2  Medicare pays suppliers 
separately for the inhalation drugs used with the nebulizer and a 
separate drug dispensing fee. 
Medicare Reimbursement for Inhalation Drugs 
In 2003, Medicare payments to suppliers totaled $1.4 billion for 
inhalation drugs and, under a fee structure of $5 per month per drug 
dispensed, $35.5 million in dispensing fees. 
About one-quarter of the suppliers that billed Medicare for inhalation 
drugs in 2003 also billed the program for nebulizers, oxygen equipment, 
and respiratory supplies.  These suppliers received several streams of 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  1  II NN TT RR OO DD UU CC TT II OO NN
Medicare payment for each beneficiary they serviced, enabling them to 
achieve economies of scale in their service delivery, for example, by 
attending to both equipment and drug issues during one service call. 
Reduction in Medicare Reimbursement for Inhalation Drugs 
In 2005, MMA-mandated reductions in reimbursement for inhalation 
drugs took full effect, resulting in cuts of up to 90 percent for some of 
these drugs from their 2003 payment level.3 This change followed 
numerous studies by the Office of Inspector General (OIG) and the 
Government Accountability Office (GAO) that found Medicares 
payment for inhalation drugs was up to five times suppliers acquisition 
cost, far exceeding the payment rate of Medicaid and others.4 In 2002 
alone, Medicare overpaid suppliers nearly $650 million for albuterol 
sulfate and ipratropium bromide, the two most commonly used 
inhalation drugs. Of this amount, about $130 million, or 20 percent, 
was paid by Medicare beneficiaries through copayments.5 
Suppliers contend that the difference between their acquisition costs 
and Medicare payment helps them provide important services to 
beneficiaries, in addition to providing their inhalation drugs. A 2004 
report written for the American Association for Homecare (AAH) stated 
that suppliers commit significant resources to compliance monitoring, 
beneficiary/caregiver education, care plan management, and other 
services. It also stated that suppliers spend 23 minutes on average per 
patient, per month conducting home visits. The report estimated that 
these services compose over 60 percent of the monthly cost of providing 
inhalation drugs.6 
Interim Dispensing Fee 
Because it was concerned that lower, MMA-mandated drug payments 
would not cover suppliers cost of furnishing inhalation drugs, CMS 
raised the dispensing fee on an interim basis for 2005.7 Under the 
interim fee, payment for providing a 30-day drug supply increased from 
$5 to $57. CMS also offered to pay suppliers $80 for providing a 90-day 
drug supply.8 Under these two fee structures, we estimate dispensing 
fees for inhalation drugs will total about $400 million in 2005.9 To 
calculate the interim dispensing fee, CMS relied largely on the services 
and costs described in the AAH report, but excluded sales and 
marketing expenses, bad debt, and an explicit profit margin.10, 11 
Uncertainty Over Services Provided 
Yet, it is unclear what services suppliers provide when furnishing 
inhalation drugs, and, therefore, how much Medicare should pay in its 
OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  2  I N T R O D U C T I O N  
dispensing fee. An October 2004 GAO report found that suppliers 
services varied widely and that their dispensing costs ranged from 
$7 to $204 per month.  GAO also found that some costs reported by 
suppliers might not be necessary to dispense drugs, such as overnight 
shipping costs.12 
CMS established the dispensing fee in January 1994.13  Since then, 
neither Congress nor CMS has provided guidance in either statute, 
regulation, or program memorandum concerning what services the 
dispensing fee should cover.  However, the Medicare Program Integrity 
Manual does require that suppliers contact beneficiaries prior to 
dispensing refills.14 
New Dispensing Fee for 2006 
In August 2005, CMS published a proposed rule stating its intention to 
set a new dispensing fee for 2006. Pursuant to the proposed rule, the 
fee should be . . . adequate to cover the costs of those services that 
appropriately fall within the scope of a dispensing fee . . . . To that end, 
CMS requested . . . data and information on the various services 
inhalation drug suppliers are currently providing to Medicare 
beneficiaries . . . .15 
METHODOLOGY 
We based this inspection on a review of services provided by inhalation 
drug suppliers to a stratified random sample of Medicare beneficiaries. 
Scope 
This inspection is national in scope and focuses on customer service 
activities that inhalation drug suppliers provide to Medicare 
beneficiaries.  This inquiry does not estimate the cost of providing these 
services, nor does it imply an appropriate level or composition of 
services.  This inquiry does not address pharmacy, delivery, billing, and 
other activities that suppliers perform to provide drugs and that also 
drive their cost of doing business.  We excluded these activities because 
they must take place for suppliers to provide drugs and get reimbursed.  
We also excluded services related to equipment because Medicare pays 
suppliers separately for equipment and equipment-related services. 
Our analysis of services considered only those services that suppliers 
could support with documentation. 
Sample Selection 
We based our findings on a review of services provided by inhalation 
drug suppliers to a stratified random sample of 480 Medicare 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  3  I N T R O D U C T I O N  
beneficiaries who had paid claims for inhalation drugs in Medicares 
National Claims History File in calendar year 2003.  Our sample 
population comprises 966,966 beneficiaries.  We stratified our sample to 
enable us to test for differences related to longevity on the drugs and 
oxygen use.  This approach resulted in 4 strata of 120 beneficiaries 
each.  Our analysis showed that oxygen use does not affect service 
levels, and we do not report on it in our findings.  See Table 1 in 
Appendix A for the strata definitions and sample design. 
Data Collection 
To determine the services provided to beneficiaries in our sample, we 
surveyed the suppliers that provided them with inhalation drugs during 
2003. We requested that suppliers report all services they provided to 
the beneficiaries during 2003 and provide documentation supporting 
each service. We received responses from 186 of the 203 suppliers we 
surveyed. These suppliers provided data on 461 of the 480 beneficiaries 
in our sample, yielding a 96 percent response rate. 
Data Analysis 
We captured data on a total of 11,777 services, including 500 services 
that suppliers failed to report but were evident in supporting 
documentation.  Of these, we excluded 5,097 services related to drug 
delivery, billing, and pharmacy because they were outside of the scope 
of our inquiry and 441 equipment-related services.  We eliminated    
1,505 services that suppliers could not support with documentation.16 
We also excluded 181 unsuccessful service attempts because no service 
was provided, 344 duplicate reports of services, 68 services related to 
drugs not covered by Medicare, and 11 services for other reasons. After 
these exclusions, the total number of services in our analysis was 4,130. 
See Appendix A for a full discussion of our methodology. 
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on 
Integrity and Efficiency. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  4  FFF III NNN DDD III NNN GGG SSS    
  F I N D I N G S  
The most common service beneficiaries  Sixty percent of beneficiaries 
received in 2003 was contact for drug refills  received this service at least once in 
2003. This service involved 
salespeople, respiratory therapists, or other supplier staff contacting 
beneficiaries to ask if they need a new monthly supply of medication 
(beneficiaries sometimes initiate this contact as well).  Occasionally, 
beneficiaries would request refills by sending preprinted postcards to 
their suppliers. 
Among beneficiaries with 2 months or more of drug claims in 2003,     
31 percent had no refill contacts during the entire year. Pursuant to the 
Medicare Program Integrity Manual, these beneficiaries should have 
been contacted at least once by their suppliers that year. 
Suppliers contacted physicians offices for about half of beneficiaries 
Fifty-two percent of beneficiaries received this service in 2003.  
Suppliers contacted physicians offices to get physicians orders, to 
consult on medication changes, and for other reasons.  The Medicare 
Program Integrity Manual requires that suppliers get a physicians 
order before billing for inhalation drugs.17  Fifty percent of these 
contacts occurred in the first month that suppliers billed for drugs; the 
contacts dropped off significantly in subsequent months.18 
Less than a third of beneficiaries had their medication compliance reviewed 
by their suppliers 
Twenty-seven percent of beneficiaries received a compliance review 
from their supplier at least once in 2003.  Supplier staff conducted 
compliance reviews to determine whether beneficiaries were using their 
medication in accordance with the instructions of their physicians.  
Compliance reviews ranged from those using a telephone call script 
with questions on the beneficiarys drug use, side effects, and outcomes, 
to reviews that consisted of a note made in a refill call log stating how 
often the beneficiary used the drugs (e.g., using as needed).   
Eighty-nine percent of all compliance reviews occurred while supplier 
staff were calling beneficiaries to ask if they needed a drug refill. 
Few beneficiaries received more intensive services such as education, 
response to an inquiry, care plan revision, or respiratory assessment 
Sixteen percent of beneficiaries received an educational service from 
their supplier at least once in 2003. Educational services included 
printed fact sheets on the prescribed drugs, printed information about 
the supplier, and training on how to use the drugs.  Eight percent of 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  5  F I N D I N G S  
beneficiaries made an inquiry to their suppliers during the year, 
typically by telephone.  Inquiries included requests for emergency refills 
and reporting problems with medications.  Five percent of beneficiaries 
received care plan revisions and less than 3 percent received respiratory 
assessments.  Care plan revisions involved changing beneficiaries 
medication or frequency of use.  To conduct respiratory assessments, 
supplier staff visited beneficiaries in their homes to check clinical 
indicators of breathing functions.  See Table 6 in Appendix B for the 
percentage of beneficiaries who received different services. 
Sixteen percent of beneficiaries received no services at all 
Because some beneficiaries were beginning or ending their treatment 
regimens outside of 2003, we do not expect that all of them would have 
received a service during the year. However, among beneficiaries with 
2 months or more of drug claims in 2003, 16 percent received no services 
at all during the entire year. 
Other services were far less common  Of all services provided in 2003,    
56 percent were refill contacts. 
With 15 percent of services, medication compliance reviews were the 
second most common service beneficiaries received.  Contacting 
physicians offices composed 12 percent of services.  The next most 
common service was beneficiary/caregiver education at 7 percent of 
services, followed by clinical intake, which composed 4 percent of 
services.  Two percent of services were responding to beneficiary 
inquiries.  Other services, including respiratory assessments and care 
plan revisions, together composed about 5 percent of services.  See  
Table 7 in Appendix B for a list and frequency count of services. 
The most common way beneficiaries received 
 Beneficiaries received 73 percent of 

services was by telephone  services by telephone in 2003.  
Contacting beneficiaries for a refill 
and medication compliance reviews, the two most frequent services, 
were performed almost entirely by telephone.  Fourteen percent of 
services involved contacting physicians offices and other activities that 
required no beneficiary interaction. Service delivery methods also 
included U.S. mail, third-party delivery services such as FedEx, and   
in-person at retail locations.  See Table 8 in Appendix B for a list and 
frequency count of service delivery methods. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  6  FFF III NNN DDD III NNN GGG SSS  
Home visits were rare 
Only about 1 in 10 beneficiaries received a home visit from their 
suppliers at least once in 2003. These visits involved supplier delivery 
people or other staff visiting beneficiaries in their homes to perform 
services such as education and respiratory assessments. About 
2 percent of all services were provided by home visits. See Table 9 in 
Appendix B for the percentage of beneficiaries who received different 
service delivery methods. 
Beneficiaries were three times more likely to  When beneficaries inhalation drug 
receive a service beyond a refill contact if their  suppliers also provided them with 
supplier also provided their respiratory  their nebulizers, oxygen equipment, 
or other Medicare-covered 
equipment 
respiratory equipment, those 
beneficiaries were far more likely to receive services beyond a refill 
contact.19 Also, those beneficiaries average service level was higher 
than that of beneficiaries who only received inhalation drugs from their 
suppliers.20 Seventy-four percent of beneficiaries receiving inhalation 
drugs also got Medicare-covered respiratory equipment or supplies from 
their drug suppliers. 
Service levels dropped off after the first month  Services fell from 1.96 services in 
suppliers billed for drugs  the first month that suppliers billed 
for drugs to between 1.01 and
1.18 services in the second through eighth months of service.21 (See 
Chart 1 on page 8.) On average, beneficiaries received 1.2 services per 
month throughout 2003.22 Excluding contacts for drug refills, this 
service level fell to 0.71 services per month. 
OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  7  F I N D I N G S  

Chart 1: Average  2.5 
Number of 
Services per Month  es  2 
Received by  vic
Medicare  Ser 1.5 
Beneficiaries from  All 
Inhalation Drug  e  1 
g
Suppliers During  a
r
2003, by Month of  ve 0.5 
A
Service 
0 
1 2 3 4 5 6 7 8 
Claim Month 
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  8    C O N C L U S I O N  

For 2005, CMS set a revised, interim dispensing fee for inhalation drugs 
in response to significant cuts in drug payments mandated by the MMA. 
The fee is to remain in place while CMS gathers more information on 
the services that drug suppliers provide to Medicare beneficiaries. CMS 
plans to set a new dispensing fee for 2006. 
To set the interim fee, CMS relied primarily on a report commissioned 
by AAH, a trade group representing the respiratory therapy industry.  
The report stated that, in addition to providing drugs, inhalation drug 
suppliers provide numerous, important services to Medicare 
beneficiaries.  According to the report, services such as home visits, 
compliance monitoring, beneficiary/caregiver education, and care plan 
management compose 60 percent or more of the monthly cost of 
servicing each beneficiary. 
CMS set the interim dispensing fee for inhalation drugs based, in part, 
on an assumption that beneficiaries receive these services from their 
drug suppliers. However, this inspection shows that beneficiaries, on 
average, receive little service from their inhalation drug suppliers 
beyond contacting them to ask if they need a refill. 
We provide this information to CMS to assist it in setting a new 
dispensing fee for inhalation drugs. 
AGENCY COMMENTS 
In its comments on the draft report, CMS expressed appreciation for the 
OIGs efforts to provide information on services that inhalation drug 
suppliers provide to Medicare beneficiaries. CMS stated that it will 
carefully consider this information as it develops a new dispensing fee 
policy.  For CMSs complete comments, see page 26 of this report. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
We appreciate CMSs comments and consideration of the information in 
the report. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  9    E N D N O T E S  

1 Global Strategy for Diagnosis, Management, and Prevention of 
Chronic Obstructive Pulmonary Disease, Executive Summary based on 
April 1998 National Heart, Lung, and Blood Institute/World Health 
Organization workshop.  Global Initiative for Chronic Obstructive 
Pulmonary Disease, updated 2004. 
2 42 C.F.R.  424.57(c)(12) (2003). 
3 Medicare now pays for inhalation drugs at 106 percent of the average 
sales price. The average sales price reflects the actual average price at 
which manufacturers sell inhalation drugs. 
4 See:
  Department of Health and Human Services, Office of Inspector 
General, Update: Excessive Medicare Reimbursement for Albuterol, 
OEI-03-03-00510, January 2004. 
  Department of Health and Human Services, Office of Inspector 
General, Update: Excessive Medicare Reimbursement for Ipratropium 
Bromide, OEI-03-03-00520, January 2004. 
  Government Accountability Office, Payments for Covered Outpatient 
Drugs Exceed Providers Cost, GAO-01-1118, September 2001. 
5 Department of Health and Human Services, Office of Inspector 
General, Update: Excessive Medicare Reimbursement for Albuterol, 
OEI-03-03-00510, January 2004. 
  Department of Health and Human Services, Office of Inspector 
General, Update: Excessive Medicare Reimbursement for Ipratropium 
Bromide, OEI-03-03-00520, January 2004. 
6 Muse & Associates, The Costs of Delivering Inhalation Drug Services 
to Medicare Beneficiaries, August 2004. 
7 69 Fed. Reg. 47,549 (August 5, 2004). 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  10  8 69 Fed. Reg. 66,338 (November 15, 2004). 
9 We base this estimate on about 7,100,00 dispensing fees paid in 2003 
at a blend of the 2005 interim amounts of $57 and $80.  
10 70 Fed. Reg. 45,848 (August 8, 2005). 
11 69 Fed. Reg. 66,338 (November 15, 2004). 
12 Government Accountability Office, Appropriate Dispensing Fee 
Needed for Suppliers of Inhalation Therapy Drugs, GAO-05-72, 
October 2004. 
13 Authority for a dispensing fee for inhalation drugs is based on 
 1842(o)(2) of the Social Security Act which reads, If payment for a drug 
or biological is made to a licensed pharmacy approved to dispense drugs 
or biologics under this part, the Secretary may pay a dispensing fee (less 
the applicable deductible and coinsurance amounts) to the pharmacy.  
14 Medicare Program Integrity Manual Rev. 71, 04-09-04  4.26.1. 
15 70 Fed. Reg. 45,848 (August 8, 2005). 
16 Of these, about half were medication compliance reviews and about a 
third were contacts for drug refills. 
17 Medicare Program Integrity Manual Rev. 100, 01-21-05  5.1.1. 
18 The average decrease in physician contacts from month 1 to 
months 2 through 8 was 0.61, with p<.01.   
19 We performed logistic regression to determine the relationship 
between beneficiaries receiving respiratory equipment from their 
inhalation drug suppliers and receiving a service beyond a refill contact.  
The regression determined that, compared to beneficiaries receiving only 
drugs from their suppliers, beneficiaries receiving equipment were 
3.14 times more likely to receive a service beyond a refill contact.  This 
effect is statistically significant at p<.05; the upper and lower   
95 percent confidence intervals are 1.73 and 5.70, respectively. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  11  20 Beneficiaries who also received Medicare-covered respiratory 
equipment and supplies received 1.31 services per month on average. 
Beneficiaries who only received inhalation drugs from their supplier 
received 0.83 services per month, on average.  A statistical test of 
differences shows that the difference between these means is statistically 
significant with t=3.25 and p<.01. 
21 The average decrease in services from month 1 to months 2 through 
8 was 0.93, with p<.01.   
22 Including undocumented services reported by suppliers, this service 
level is 1.59 services per month. 
  OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  12  A P P E N D I X   ~   A  

METHODOLOGY 
We based this inspection on a review of services provided by inhalation 
drug suppliers to a stratified random sample of Medicare beneficiaries. 
Scope 
This inspection is national in scope and focuses on customer service 
activities that inhalation drug suppliers provide to Medicare 
beneficiaries.  This inquiry does not estimate the cost of providing these 
services, nor does it imply an appropriate level or composition of 
services.  This inquiry does not address pharmacy, delivery, billing, and 
other activities that suppliers perform to provide drugs and that also 
drive their cost of doing business.  We excluded these activities because 
they must take place for suppliers to provide drugs and get reimbursed.  
We also excluded services related to equipment because Medicare pays 
suppliers separately for equipment and equipment-related services. 
Our analysis considered only those services that suppliers could support 
with documentation from patient records and other sources. See   
Table 6 in Appendix B for the list of services we included in our 
analysis. 
Sample Selection 
We based our findings on a review of services provided by inhalation 
drug suppliers to a stratified random sample of 480 Medicare 
beneficiaries who had Medicare-paid claims for inhalation drugs in 
calendar year 2003. We chose 2003 as our reference year because it was 
the latest year with complete and available Medicare claims data when 
we drew our sample.  We excluded Medicare beneficiaries from Puerto 
Rico and U.S. territories. We used CMSs year 2003 100 percent 
National Claims History file to identify beneficiaries who had paid 
Medicare claims for 1 of 32 inhalation drugs covered for use in a 
nebulizer. Our sample population comprises 966,966 beneficiaries. 
We stratified our sample to determine if beneficiaries beginning 
inhalation drug use and those who use oxygen receive different amounts 
or types of services.  
o Stratum 1: Beneficiaries who began using inhalation drugs in 2003 
and had 8 or more months of drug claims during the year from the 
same supplier and were not using oxygen.  
o Stratum 2: All other beneficiaries who had a claim for inhalation 
drugs in 2003 and were not using oxygen. 
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o Stratum 3: Beneficiaries who began using inhalation drugs in 2003 
and had 8 or more months of drug claims during the year from the 
same supplier and were using oxygen. 
o Stratum 4: All other beneficiaries who had a claim for inhalation 
drugs in 2003 and were using oxygen. 
Our analysis showed that oxygen use does not affect service levels, and 
we do not report on it in our findings. 
To identify which stratum members of our sample population belonged 
to, we used CMSs Enrollment Data Base and 2002 - 2003 100 percent 
National Claims History files. See Table 1 for more information on the 
strata populations. 
Table 1: Population and Response Rate for OIG Survey of Inhalation 
Drug Suppliers, by Strata 
Number of  Percent of 
Strata  N (Population)  n (Sample) 
Cases Received Cases Received 
Stratum 1 13,827  120  118  98 
Stratum 2  473,867  120  119  99 
Stratum 3 13,918  120  113  94 
Stratum 4  465,354  120  111  93 
Overall Total  966,966  480  461  96 
Data Collection Instrument 
Drawing on work by GAO, private researchers, CMS staff, and other 
research, we developed a list of possible services that suppliers might 
provide to beneficiaries and the ways they might interact with 
beneficiaries in doing so. (See Table 2 on page 15.) 
Next, we incorporated our lists of service types and interaction types 
into a 1-page data collection form. We designed the form to be 
photocopied and completed by suppliers for each service they provided 
to beneficiaries in our sample during 2003. The form captured the date 
suppliers provided the service, the type of service provided, how 
suppliers interacted with the beneficiary to provide the service, and 
whether documentation to support the service was attached. We vetted 
the form within OIG and with staff at CMS. 
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Table 2: Service and Interaction Types 
Service Types  Interaction Types 
Delivered Supply of Drugs  By U.S. Postal Service 
Responded to Patient Inquiry About Drugs  By a Delivery Service (e.g., FedEx) 
Responded to Patient Inquiry About Equipment  By Company Delivery Person 
Performed Equipment Maintenance  By Telephone 
Performed Patient Education  By Company Staff Visiting in Patient's Home 
Performed Clinical Intake  In Person at Retail Location 
Reviewed Medication Compliance  No Interaction 
Contacted Patient for a Refill  Other Interaction 
Contacted Patient's Physician 
Revised Plan of Care 
Compounded Drugs 
Other Service 
Data Collection 
To determine the services suppliers provided to beneficiaries in our 
sample, we contacted the suppliers that provided them with inhalation 
drugs in 2003. For beneficiaries in Strata 2 and 4, we contacted every 
supplier the beneficiaries had during the year. For each beneficiary in 
Strata 1 and 3, we only contacted the supplier that provided that 
beneficiary with 8 or more months of inhalation drugs. Using this 
approach, we identified 203 suppliers that were associated with the 
beneficiaries in our sample. 
To conduct our survey, we sent each supplier via express delivery a 
packet with a cover letter, a supplier information form, a beneficiary 
roster, instructions, and at least one copy of the data collection 
instrument. Our instructions asked that suppliers report and document 
all services they provided during 2003 to the beneficiaries on the roster. 
We attempted to contact suppliers three times in writing over 8 weeks. 
We also attempted to contact unresponsive suppliers by telephone. We 
received responses from 186 suppliers. These suppliers provided data 
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on 461 out of the 480 beneficiaries in our sample, yielding a 96 percent 
response rate. (See Table 1 on page 14.) See Appendix C for a 
nonrespondent analysis. 
Data Analysis 
We reviewed each completed form and the corresponding supporting 
documentation suppliers submitted to attempt to verify the service the 
supplier provided and how the supplier interacted with the beneficiary. 
We captured data on 11,777 services, including 500 services that 
suppliers failed to report to us but were evident in the supporting 
documentation for other services. During data entry, we added 
13 additional service types and 2 additional interaction types to 
categorize information suppliers reported to us. About 1,800 services 
fell into these additional categories. See Table 3 below for detail on how 
we defined service delivery methods and Table 4 on page 17 for how we 
defined services. 
Table 3: Definitions of Service Delivery Methods 
Service Delivery Methods  Definition 
By U.S. Postal Service  U.S. mail 
By a Delivery Service  Third-party delivery service (e.g., FedEx, United Parcel Service) 
By Company Delivery Person  Driver/delivery person employed by drug supplier 
By Telephone Contact  Supplier spoke with beneficiary or caregiver by telephone 
By Company Staff Visiting in Patient's Home  Supplier staff travel to and work inside beneficiary's home 
In Person at Retail Location  Beneficiary or caregiver went to retail pharmacy 
No Interaction  Supplier did not interact with beneficiary or caregiver 
Left Message/Voicemail*  Supplier telephoned beneficiary and left a message 
Telephone/No Answer*  Supplier telephoned beneficiary and received no answer or voicemail 
Other  Supplier reported a service delivery type that does not fit in these categories 
* Service delivery methods excluded from our analysis. 
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Table 4: Definitions of Services 
Service  Definition 
Delivered Supply of Drugs*  Supplier provided the beneficiary with nebulizer drugs 
Responded to Patient Inquiry About  Beneficiary or caregiver contacted the supplier with a drug-related question and the supplier 
Drugs  answered it 
Responded to Patient Inquiry About  Beneficiary or caregiver contacted the supplier with an equipment-related question and the 
Equipment*  supplier answered it 
The supplier performed maintenance on or replaced the beneficiary's nebulizer, oxygen 
Performed Equipment Maintenance* 
concentrator, or other respiratory equipment 
Performed Patient Education  Supplier educated beneficiary or caregiver about drugs 
Clinical Intake  Supplier captured beneficiary's demographic and/or clinical information 
Supplier asked beneficiary or caregiver how often beneficiary is using drugs and/or about 
Reviewed Medication Compliance 
effectiveness, side effects 
Supplier corresponded with beneficiary or caregiver to determine if beneficiary needed a refill 
Contacted Patient for a Refill 
shipment of drugs 
Contacted Physician's Office  Supplier contacted physician's office for prescription, doctor's order, etc. 
Revised Plan of Care  Changed beneficiary's medication or frequency of use 
Compounded Drugs*  Pharmacist mixed two or more drugs together into single vial, or mixed drug from powder 
Billing Activity*  Medicare billing activity (e.g., verified insurance, mailed assignment of benefits form) 
Patient Education about Equipment*  Supplier educated beneficiary or caregiver about nebulizer or oxygen equipment 
Delivered Equipment*  Supplier delivered nebulizer, oxygen, or respiratory equipment to beneficiary 
Respiratory Assessment  Supplier performed clinical assessment of beneficiary's respiratory functions 
Quality Control/Quality Assurance*  Supplier staff verified drug order, tested drug batch, etc. 
Notified Patient of Impending Delivery  Supplier contacted beneficiary or caregiver to confirm delivery date 
Supplier changed beneficiary mailing address due to vacation, beneficiary moving; supplier 
Patient Tracking 
terminated service 
Internal Order Processing*  Supplier processed drug order (e.g., sent order from call center to pharmacy) 
Pharmacist Filled/Dispensed*  Pharmacy-related work needed to fill order 
Stat Dose  Supplier arranged for initial drug supply to be picked up at local retail pharmacy 
Other Service  Service that does not fit into these categories 
* Services excluded from our analysis. 
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We excluded services outside of our scope from our analysis. We also 
excluded undocumented services, duplicate reporting of services, and 
unsuccessful service attempts, such as attempted phone calls with no 
answer. After all exclusions, the total number of services in our 
analysis was 4,130. See Table 5 for a breakdown of the services we 
excluded from our analysis. 
Table 5: Services Excluded From Analysis, by Category 
Number of Services 
Service Category 
Excluded 
Equipment-related  441 
Drug delivery  3,520 
Billing activity 61 
Pharmacy activity  1,516 
Duplicate service 344 
Undocumented service  1,505 
Unsuccessful service attempt 181 
Related to non-Medicare drug 68 
Other reason 11 
Total services outside the scope of analysis  7,647 
Source: Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
We based our analysis of average services per month on the count of 
documented services each beneficiary received in each month. We 
included a month in our analysis if the supplier reported any 
documented drug-related service, including delivery, during that month. 
This approach allowed us to include months with services even if there 
was no Medicare claim billed in those months. For example, when a 
beneficiary begins using inhalation drugs, his or her supplier could 
provide services such as clinical intake and contacting the beneficiarys 
physicians office before billing Medicare for drugs. Our approach 
enabled us to include these services in our analysis. 
Our analysis of the percentage of beneficiaries who got a particular 
service is based on a count of those that received the service at least 
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once during 2003 divided by the total number of beneficiaries for whom 
we received a survey response. 
The numbers of beneficiaries in our analysis changed depending on 
whether we were analyzing our data at the beneficiary level or at the 
service level and whether or not we were focusing on subgroups of 
beneficiaries or services.  We excluded beneficiaries whose suppliers 
reported no documented services, including delivery, from all analysis 
except that projecting the overall percentages of beneficiaries that 
received services.  We excluded beneficiaries whose suppliers only 
reported documented drug deliveries from all analysis except our 
calculations of average services per month and our projections of the 
overall percentages of beneficiaries that received services. 
We weighted the results of our analysis to account for our sample 
design. 
Confidence intervals and point estimates are provided in Table 10 in 
Appendix B. 
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DATA TABLES 

Table 6:  Number of Medicare Beneficiaries Receiving Different Services 
from Inhalation Drug Suppliers in 2003* 
Estimated  Percent of 
Frequency of 
Service  Population of  Beneficiaries Who 
Beneficiaries 
Beneficiaries  Received Service 
Contacted for a Refill  303  555,357  59.9 
Contacted Physician's Office  268  486,361  52.5 
Reviewed Drug Compliance  140  251928  27.2 
Clinical Intake  170  228,350  24.6 
Performed Education  103  152,321  16.4 
Responded to Inquiry 48  73,838   8.0 
Revised Plan of Care  38  45,991   5.0 
Patient Tracking  21  40,547  4.4 
Delivery Followup  18  32,463  3.5 
Delivery Notification  26  29,696  3.2 
Other Service  13  24,290  2.6 
Stat Dose  13  24,218  2.6 
Respiratory Assessment  12  24,174  2.6 
Delivery Confirmation  8    4,757  0.5 
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
* Beneficiaries may receive more than one service. 
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Table 7:  Frequency and Percent of Services Provided to Medicare 
Beneficiaries by Inhalation Drug Suppliers in 2003 
Estimated 
Sample Frequency  Percent of All 
Service  Population of 
of Services  Services 
Services 
Contacted for a Refill  2,316  3,675,554  55.9 
Reviewed Drug Compliance 570   952,208  14.5 
Contacted Physician's Office  500   801,099  12.2 
Performed Education  289   485,108  7.4 
Clinical Intake  183   245,114  3.7 
Responded to Inquiry  76   115,126  1.8 
Delivery Followup, Patient 
Tracking, Revised Plan of Care, 
Respiratory Asessment, Delivery   196   299,578  4.6 
Notification, Other Service, Stat 
Dose, Delivery Confirmation
Overall Total  4,130  6,573,787  100 
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
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Table 8:  Number of Services Delivered by Inhalation Drug Suppliers in 2003 
by Method of Service Delivery 
Estimated 
Frequency of  Percent of All 
Service Delivery Method  Population of 
Services  Services 
Services 
By Telephone Contact with 
3,044  4,809,297  73.2 
Beneficiary 
No Interaction 614   943,125  14.4 
By a Delivery Service  197   361,033  5.5 
By U.S. Postal Service  129   154,883  2.4 
By Company Staff Visiting in 
 71   144,862  2.2 
Beneficiary Home
In Person at Retail Location, By 
Company Delivery Person, Other 
 75   160,586  2.4 
Service Delivery Type, Could Not 
Verify Service Delivery Type
Overall Total  4,130  6,573,786  100 
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
Table 9:  Number of Medicare Beneficiaries Receiving Services from 
Inhalation Drug Suppliers in 2003 by Method of Service Delivery* 
Percent of 
Estimated 
Frequency of  Beneficiaries Who 
Service Delivery Method  Population of 
Beneficiaries  Received Service 
Beneficiaries 
Delivery Method 
By Telephone Contact with 
313  590,517  63.7 
Beneficiary 
No Interaction  280  514,298  55.5 
By a Delivery Service 34  80,100  8.6 
By U.S. Postal Service  47  73,647  7.9 
By Company Staff Visiting in 
 44  69,405  7.5 
Beneficiary Home
In Person at Retail Location, By 
Company Delivery Person, Other   14  28,239  3.1 
Service Delivery Type
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
* Beneficiaries may receive multiple services through multiple methods. 
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Table 10: Confidence Intervals 
95 Percent Confidence 
Statistic  Point Estimate  n 
Interval 
Percent of beneficiaries who received a refill contact  59.9%  461  54%  - 66% 
Percent of beneficiaries with 2 months or more of drug claims who did 
30.8%  377  24%  - 37% 
not get a refill contact during the year 
Percent of beneficiaries whose doctors were contacted by their supplier  52.4%  461  46%  - 59% 
Percent of physician contacts that occur in the first month suppliers bill 
49.8%  146  44%  - 56% 
for drugs 
Drop in doctor contacts from month 1 to subsequent months  0.61  212  0.51 - 0.72 
Percent of beneficiaries who received a compliance review  27.2%  461  22%  - 33% 
Percent of compliance reviews done over the telephone during a refill call  89.1%  142  84%  - 95% 
Percent of beneficiaries who got education  16.4%  461  12%  - 21% 
Percent of beneficiaries who had an inquiry answered by their supplier  8.0%  461  5%  - 11% 
Percent of beneficiaries who had their care plan revised  5.0%  461  2%  - 8% 
Percent of beneficiaries who got a respiratory assessment  2.6%  461  1%  - 5% 
Percent of beneficiaries who got no services  16.3%  409  12%  - 21% 
Percent of all services that were refill contacts  55.9%  377  52%  - 59% 
Percent of services that were medication compliance reviews  14.5%  377  11%  - 18% 
Percent of services that were contacting physician offices  12.2%  377  10%  - 14% 
Percent of services that were beneficiary/caregiver education  7.4%  377  4%  - 10% 
Percent of services that were clinical intake  3.7%  377  3%  - 5% 
Percent of services that were responding to beneficiary inquiries  1.8%  377  1%  - 3% 
Percent of services that were other services including respiratory 
4.6%  377  3%  - 6% 
assessments and care plan revisions 
Percent of services provided by telephone  73.2%  377  69%  - 77% 
Percent of refill contacts done by telephone  93.5%  303  90%  - 97% 
Percent of compliance reviews done by telephone  96.0%  142  92%  - 100% 
Percent of services with no beneficiary interaction  14.4%  377  12%  - 17% 
Percent of beneficiaries who got a home visit  8.8%  461  5%  - 12% 
Percent of services provided by home visit  2.4%  377  1%  - 4% 
Percent of beneficiaries who got drugs and respiratory equipment from 
74.1%  461  69%  - 80% 
their inhalation drug supplier 
Number of services in first month  1.96  215  1.75 - 2.18 
Low number of services received in months 2 -8  1.01  203  0.87 - 1.16 
High number of services received in months 2 -8  1.17  192  1.01 - 1.35 
Average number of services beneficiaries received in 2003  1.20  444  1.08 - 1.32 
Excluding refill contacts, average number of services beneficiaries 
0.71  444  0.60 - 0.82 
received in 2003 
Source: Office of Inspector General Survey of Inhalation Drug Suppliers, 2005 
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NONRESPONDENT ANALYSIS 
A consideration in surveys or data collection efforts of this type is 
whether the results may be biased by significant differences between 
respondents and nonrespondents.  To determine whether significant 
differences exist in this data collection effort, we compared respondents 
and nonrespondents by whether or not beneficiaries got respiratory 
equipment from their inhalation drug suppliers and by the average 
months of inhalation drug claims beneficiaries had in Medicares 
National Claims History file. 
We achieved a 96 percent response rate with respect to the beneficiaries 
sampled. As a result, we had 461 responses and 19 nonresponses to use 
for this analysis. 
Our analysis suggests that our survey results were not biased with 
regard to these variables.  
Analysis by Whether the Beneficiary Also Received Equipment 
A chi-square test showed no relationship between respondents and 
nonrespondents with respect to beneficiaries receiving respiratory 
equipment from their inhalation drug suppliers.  (See Table 11.) 
Table 11:  Analysis by Whether the Beneficiary Also Received Equipment 
Received  Received  Did Not Receive Did Not Receive 
Equipment  Equipment  Equipment  Equipment 
(Number)  (Percent*)  (Number)  (Percent*) 
Sample (n=480)  369  73.1  111  26.9 
Respondents (n=461)  359  73.3  102  26.7 
Nonrespondents (n=19) 10  69.1 9  30.9 
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
* Percents were weighted based on the sample design. 
Chi-square=0.08 (not significant) 
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Analysis by Average Months of Claims 
We performed a t-test to compare the average months of inhalation drug 
claims between respondents and nonrespondents.  The difference was 
not statistically significant. (See Table 12.) 
Table 12:  Analysis by Average Months of Claims 
Sample (n=480)  Average Months of Claims* 
Respondents (n=461)  4.97 
Nonrespondents (n=19)  6.10 
Source:  Office of Inspector General Survey of Inhalation Drug Suppliers, 2005. 
* Average claims were weighted based on the sample design. 
t=1.09 (not significant) 
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OEI-01-05-00090  REVIEW OF SERVICES PROVIDED BY INHALATION DRUG SUPPLIERS  26 
   A C K N O W L E D G M E N T S  

This report was prepared under the direction of Joyce M. Greenleaf, 
Regional Inspector General for Evaluation and Inspections in the 
Boston regional office, and Russell W. Hereford, Assistant Regional 
Inspector General.  Other principal Office of Evaluation and Inspections 
staff who contributed include: 
Kenneth R. Price, Team Leader 
Ivan E. Troy, Program Analyst 
Benjamin T. Mahdi, Intern 
Linda B. Abbott, Program Specialist 
Technical Assistance  
Barbara Tedesco, Mathematical Statistician 
David Graf, Program Analyst 
Rob Gibbons, Program Analyst 
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