Medicaid Patients Suffer Most From Part D Transition Problems

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:

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 [email protected] 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>.▪