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Facing the Consequences
May 10, 2007 • Volume 7, Issue 19A new study published in the American Journal of Psychiatry (AJP) details the often devastating consequences the transition from Medicaid to Medicare Part D drug coverage had for people with both Medicare and Medicaid (dual eligibles) receiving treatment for mental illness.
The study found that coverage restrictions imposed by Part D plans in violation of guidelines for patient protection issued by the Centers for Medicare & Medicaid Services (CMS) interrupted treatments for schizophrenia and severe depression, sending scores to the emergency room and triggering suicidal behavior.
Using a survey of 1,183 psychiatrists across the country with dual-eligible patients, the study found that, during the first four months of 2006, over half of the psychiatrists’ patients experienced at least one problem getting their medications and nearly one-third were cut off from access to required refills of medicines that had been covered under Medicaid.
The primary reason for access and continuity problems, the researchers report, is that needed medicines were not on a plan’s formulary, or list of covered drugs. Two-thirds of patients had trouble getting their prescriptions, because their plans did not cover those drugs. The drugs most subject to access barriers were antipsychotics and antidepressants, even though Part D plans were required to cover all drugs in these classes.
Researchers found that about one in five patients had been clinically stable on prescribed courses of treatment prior to the transition but were required to switch to a different medication by their Part D plan. Restrictions imposed by plans to control costs that have prevented patients from getting their medications include prior authorization requirements and “step therapy” requirements that force patients to try other medicines first. The private insurance companies offering Part D imposed these restrictions, even though they were required to lift any coverage restrictions that would interrupt treatment on patients already stabilized on these medicines.
Because of these sudden barriers, almost one-quarter of affected patients stopped taking prescribed medications.
Such restrictions put patients’ lives in danger: the report found that over a fifth of dual eligibles who had problems accessing psychiatric medicines experienced an increase in suicidal behaviors. Almost 20 percent ended up in the emergency room, and over 10 percent required hospitalization.
At the time of last year’s initial transition period, administration officials cavalierly dismissed reported problems experienced by dual eligibles as isolated cases. But the researchers who published the AJP study report that they have continued to collect data, and that the number of dual eligibles getting cut off from their medicines, and experiencing serious medical problems as a result, has remained unchanged.
The study’s findings do not illustrate isolated problems that have been resolved; they are indicative of a systemic failure of Part D plans to protect patients and cover vital medicines, as well as CMS’ failure to provide oversight and hold plans accountable.
Medical Record
“Last year, as I prepared to convert prescription drug coverage from Medicaid to Part D, I was told that Part D will cover mental health drugs. My Part D plan covered my generic Paxil [an antidepressant] all last year. This year my Part D plan notified me that it will no longer pay for that medicine. My doctor switched me to a different medicine that is on the formulary, but I just got a notification from the plan that it will not provide the full amount that was prescribed” (Story submitted to the Part D Monitoring Project, Medicare Rights Center, April 13, 2007).
“In an accompanying editorial, David Pollack, M.D., a professor of psychiatry, public health and preventive medicine, at the Oregon Health and Sciences University, describes the report as ‘an excellent article about a very critical issue,’ and notes that the study used ‘carefully designed survey method[s].’ Dr. Pollack writes, ‘Part D defenders may say that the problems cited in this study have all been addressed. If so, they should prove it’” (“New Study Shows More than Half of Medicare Part D Patients Delayed in Accessing Psychiatric Medications,” American Psychiatric Association, May 1, 2007).
The Centers for Medicare and Medicaid Services (CMS) responded to concerns about interruption and changes in psychotropics that could result from access restrictions under Part D. For most medication classes, original Part D legislation requires PDPs [prescription drug plans] to provide a minimum of only two drugs. Regulation amendments, however, stipulate that all antidepressants and antipsychotics be included in PDP formularies and that patients stabilized on these medications before switching to Part D should not be subject to utilization management (UM) strategies, such as prior authorization or requirements to first fail a preferred product (fail first), to continue therapy” (“Implications of Part D for Mentally Ill Dual Eligibles: A Challenge for Medicare,” Health Affairs, March/April 2006).
***** The Medicare Rights Center (MRC) needs to hear about all the problems with the Medicare Part D benefit, whether they happen to you or someone in your community. With this information, we will be armed with the needed evidence to push for a Medicare-administered drug benefit.
Fast Relief: Part D Monitoring Project
Submit your story at www.medicarerights.org/partdstories.html
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