Psychiatr News March 3, 2006
Volume 41, Number 5, page 1
© 2006 American Psychiatric Association
Medicaid Patients Suffer Most From Part D Transition Problems
Mark Moran
Many problems encountered in the first days of the new Medicare program
are likely to recur when patients who had enough medication on on January 1
enter the system when those prescriptions run out.
Enormous problems continue to plague the new Medicare Part D prescription
drug program, despite temporary relief provided by states that have intervened
to pay the costs for dual eligibles and other beneficiaries moving into the
program.
Irvin (Sam) Muszynski, J.D., director of APA's Office of Healthcare Systems
and Financing, said that his office is continuing to receive reports through
the Part D monitoring system it established regarding serious problems with
enrollment of patients in the program, including inappropriate copayment
requirements, failure to ensure continuity of care for dual-eligible
beneficiaries transitioning from drug coverage under state Medicaid plans, and
inappropriate utilization review requirements.
Moreover, Muszynski and clinicians who spoke with Psychiatric News
said that many problems encountered in the first days of the new program are
likely to reappear when countless patients who had received refill medications
prior to December 31, 2005, enter the system when those prescriptions run
out.
In a statement submitted to the Senate Finance Committee last month, APA
said that widespread problems persist as the new Part D program is being
implemented.
"Many of these problems concern the transition of Medicaid/Medicare
dual eligibles to Part D plans, and states have spent millions of dollars
covering the medication costs of these beneficiaries on an emergency basis.
Common problems include inaccurate enrollment data, excessive charges for
deductibles and copayments, drug plans failing to provide a temporary
transition supply to beneficiaries stabilized on drugs, and ineffective use of
the fallback drug plan [by which the government had assured beneficiaries that
they would receive necessary medications if they showed up at the pharmacy
with identification of their dual eligibility in Medicaid/Medicare].
"As a result, thousands of Part D beneficiaries are unable to access
their medications," APA informed the committee.
APA also submitted the following recommendations:
- Require the Centers for Medicare and Medicaid Services (CMS) to report on
drug plan progress in implementing effective transition policies.
- Request that CMS restate its guidance to drug plans, directing them to have
formularies that allow access to important classes of drugs (including
antipsychotics and antidepressants) beyond the initial transition period.
- Ask CMS to monitor drug plans' exceptions and appeals process.
- Pass legislation requiring coverage of drugs for substance abuse and of
benzodiazepines and barbiturates.
- Establish a CMS advisory board to identify persistent short-term problems
and long-term correctives.
Meanwhile, the pervasive problems with the Part D rollout have been the
subject of reports in the popular press, but there are no formal data on how
the program is actually affecting patients and clinicians. For that reason,
the American Psychiatric Institute for Research and Education (APIRE) is
undertaking a large, national study to assess issues around continuity of care
for individuals with mental illness receiving medications under the new
program (see article below).
"Medicare Part D is the single most significant mental health policy
initiative to have been undertaken in the last decade," said Darrel
Regier, M.D., M.P.H., director of APIRE and APA's Division of Research.
"We think it would be extremely helpful to have a sense of how this is
actually impacting our patients and practitioners. The only way of
systematically assessing the strengths and weaknesses of the new program is a
survey that would get a representative sample of the experiences our patients
are having."
Utilization Review Causing Problems
Clinically inappropriate utilization review (UR) requirements by
prescription drug plans (PDPs) appear to be the most pervasive—but by no
means the only—complaint. In some cases, it appears that UR requirements
have been backed up by CMS in defiance of the agency's stated transition
policies requiring continuity of medications for people moving from Medicaid
into the new program.
Muszynski described the case of one clinician seeking prior authorization
to prescribe Zyprexa for a patient previously stabilized on that drug. The
clinician was told by a physician reviewer to treat the patient with
Clozaril—despite the potential problems associated with that drug and
the requirements for regular blood testing.
"In some cases it appears that CMS is just not serious about its own
transition policies," Muszynski said. "Another serious concern we
are having is that the exceptions and appeals process is one sided and in
disarray."
In many parts of the country, states have stepped in to assume the costs of
prescription drugs for dual eligibles who have not been able to receive
necessary medications in a timely fashion (Psychiatric News, February
3).
That appears to have provided at least temporary relief for what
Massachusetts psychiatrist Andrea Stone, M.D., had described as
"pandemonium" in the first weeks of January. But she told
Psychiatric News that problems persist, and some are likely to recur
since states are providing only temporary coverage.
"When Mass Health stepped in [to assume costs of medications for
beneficiaries unable to receive them] there was an immediate improvement in
the overall situation," she said. "At this point most people are
getting their medications through their Medicare plans, but sporadic problems
exist. A patient was told by her insurer that all of her medications would
require prior authorization. In fact, none did. Another patient cannot get her
ID number, which means she can't get her meds. She was on the telephone for
three hours one Friday without resolution of the problem, Stone noted.
Some of the actions taken by PDPs have bordered on the bizarre. Stone
reported a denial for medication in which the patient was asked to provide two
unique peer-reviewed journal articles to support the request.
"This is a patient who has been taking the refused medication for at
least eight years and is in the best psychiatric shape of her life,"
Stone said. "The letter said that she or her representative could
appeal, but did not provide information on how to do that except to say that
it had to be done within 60 days."
Some PDPs Ignore Rules
Jeffrey Geller, M.D., director of public psychiatry at the University of
Massachusetts Medical School and a treating clinician at the Carson Center,
pointed out that the CMS transition policy, designed to ensure that patients
who are stabilized on a particular medication prior to January 1 continue to
receive those meds without interruption, has not been adhered to by PDPs.
"This has not been the case even for oral medications, much less
depot medications, including antipsychotic and antidepressant
medications," Geller reported.
Moreover, every company has a different form for prior authorization,
requiring significant paperwork from clinicians, yet none appears to allow for
the override of a denial on the basis of prior stabilization. "Not one
of the forms indicates prior stabilization on the medication will justify an
override," he said.
In Pennsylvania, problems of enrollment in the new program, stemming from
inadequate communication, continue to plague continuity of care.
"We weren't clear what PDPs were going to be operating in
Pennsylvania until very late in the game," psychiatrist Mary Diamond,
M.D., medical director for the state's Office of Mental Health and Substance
Abuse, told Psychiatric News. "When we did finally get the PDPs
arranged it was a great challenge to get our state-hospital population
enrolled. Medicare didn't realize that our seriously mentally ill patients
couldn't enroll themselves and didn't have the ability to get the right
plans.
"My greatest disappointment has been that many people in the
community didn't know about these systems," she said. "Medicare
chose to notify pharmacies through their national organizations, but we have a
substantial number of independent pharmacies."
In Washington, D.C., leaders in both parties have acknowledged serious
problems with the new Medicare program's roll out. But Democratic leaders are
calling for legislative fixes to the problems, while Republicans argue that
most of the problems can be fixed administratively.
The Hill, a Capitol Hill newspaper, published a number of opinion
pieces by leaders in both parties addressing the problems in the Medicare
prescription drug program.
"There were some unacceptable problems, but as the problems are
resolved I'm confident beneficiaries will agree the new benefit will bring
them better health security in the long run," wrote Charles Grassley
(R-Iowa), chair of the Senate Finance Committee, who helped champion passage
of the program.
But Grassley took a swipe at Democrats calling for new legislation to fix
problems with the program. "Some senators who aren't on the [finance]
committee—mostly those with partisan political motives—are pushing
for legislation to change the benefit in the name of fixing the problems. But
the problems so far don't lend themselves to a legislative fix. The issues
with computer systems and long wait times on phone lines are better addressed
administratively."
Sen. John Kerry (D-Mass.) was one of those calling for new legislation in
his column in The Hill.
"In some states, as many as 20 percent of elderly Medicaid recipients
have seen their coverage denied," he wrote. "Already overburdened
states are being forced to pick up the tab for the White House's incompetence,
to the tune of hundreds of millions of dollars. Insurance and pharmaceutical
companies are no doubt thrilled with their profits, but this latest Bush
boondoggle is a real-life nightmare for state budgets and, worse, for millions
of seniors just looking to fill a needed prescription."
APA members can contact the Part D monitoring system by e-mail at
partd{at}psych.org
or by phone at (866) 882-6227. APA is continuing to post information about the
program at
<www.mentalhealthpartd.org>.
APA's testimony to the Senate Committee on Finance on implementation of the
new Medicare drug benefit is posted at
<www.psych.org/members/download.cfm?file=1013>.
Get information about faster international access.
Privacy Policy
Copyright © 2006
American Psychiatric Association.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
| 
