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Switch to Medicare Drug Coverage
Poses Dire Risk for Nursing Home Residents, Experts Warn
Written By:
ElderLawAnswers.com
 April
13, 2005 - Thousands of nursing home residents are in grave danger of
losing coverage for life-sustaining drugs when the new Medicare drug law
takes effect on January 1, experts familiar with medication practices in
long-term care settings are warning. Any sudden loss of coverage will
likely result in illnesses or premature deaths, the experts say.
"We're very fearful," said Vicki
Gottlich, Senior Policy Attorney at the
Center for
Medicare Advocacy.
"The (Medicare prescription
drug) legislation was not very well thought out with regard to long-term
care," adds Thomas R. Clark, policy director for the
American Society of
Consultant Pharmacists, whose members specialize in the medication
needs of nursing home residents and the elderly. "We don't know exactly
how all of this is going to be implemented."
Abrupt Transition
Looms
Most nursing home residents are
on Medicaid and currently receive coverage of their prescription drugs
through that program. But as a result of the new Medicare law, nursing
home residents who are eligible for both Medicaid and Medicare
so-called "dual eligibles" -- are scheduled to lose their Medicaid drug
coverage in just eight and a half months, on January 1, 2006. From that
day forward, Medicare will cover their drugs through private drug plans
under "Medicare Part D".
The idea behind the change is
that Medicare beneficiaries will be able to carefully compare competing
prescription drug plans (PDPs) and enroll in the one that best meets
their needs. But more than a third of nursing home residents have
Alzheimer's disease or another form of dementia, and many more are in no
condition to weigh subtle differences between drug plans.
Anticipating this problem, the
federal Centers for Medicare and Medicaid Services (CMS), which is in
charge of implementing the new law, will randomly assign nursing home
residents and others covered under both Medicare and Medicaid to a PDP,
and these recipients will then have the option of changing plans.
But long-term care experts say
that as things stand now, nursing home residents are at risk of
experiencing lapses in coverage or a complete loss of coverage for
certain drugs. This could take place for any number of reasons:
Enrollment obstacles:
Different PDPs will use different pharmacies. Nursing home residents may
be arbitrarily enrolled in a PDP that does not use the long-term care
pharmacy that the nursing home uses. Switching PDPs is possible but will
take time and, in the case of incompetent residents, it raises the
question of who will select a PDP on the resident's behalf. Elderly or
disabled nursing home residents who are not on Medicaid but who still
need to choose a Medicare PDP also may not have anyone to make the
choice for them.
"Who will do this?" asks Janet
Wells, Director of Public Policy for the
National Citizens'
Coalition for Nursing Home Reform(NCCNHR). "The nursing homes are
concerned that their staff will not have the time to deal with that, and
many residents don't have family members or legal representatives who
can."
In addition, there are concerns
that many nursing home residents will not be identified by January 1 and
will simply lose their Medicaid drug coverage without ever having been
enrolled in a Medicare PDP.
"The states are supposed to
identify all their dual eligibles," Gottlich told ElderLawAnswers, "and
from what we're hearing from the states we're suspecting that there will
be people who won't be identified."
Drugs that nursing home
residents now take may no longer be covered: The new Medicare law
does not cover certain drugs that are currently widely used in nursing
homes, including barbiturates and benzodiazepines, which are prescribed
for many nursing home residents for seizure disorders, acute anxiety,
panic attacks, and muscle spasms. Since a states Medicaid program can
cover prescription drugs that are explicitly excluded under Medicare,
nursing home residents in these states will continue to have coverage
for these drugs. The trouble is that not all state Medicaid programs
cover all the drugs.
For example, the American
Society of Consultant Pharmacists' Thomas Clark says that a number of
states are planning to discontinue Medicaid coverage of benzodiazepines
in 2006.
"We're very concerned that some
states will drop their coverage and that could create serious problems
for nursing home residents and other frail elderly individuals," Clark
said in an interview with ElderLawAnswers. "These are not the kinds of
drugs you can just stop abruptly without serious adverse consequences.
You're looking at withdrawal symptoms, seizures, probably trips to
emergency rooms and hospitalizations to deal with the consequences of
abrupt cessation of these medications."
Even if a particular
prescription drug is covered by Medicare, it may not be included in the
list of drugs that a particular PDP will pay for, called a "formulary."
To obtain a non-formulary drug, the nursing home resident must get a
statement from her doctor that no formulary drug will work and then file
what amounts to an appeal. Gottlich calls this appeals process "pretty
burdensome," and in many cases the burden will fall on nursing home
staff, physicians or family members.
Nursing home staff will likely
bear the brunt. Rather than working with a single payer Medicaid --
they'll have to deal with many different PDPs, each of which will have
its own requirements about what kind of evidence will be required for an
appeal, Gottlich notes.
"This is going to be very hard
to track from a billing perspective and for the social workers and
nurses when they order the meds," says Diane Libby-Gilbert, director of
social services at Maine General Rehabilitation and Nursing Care in
Augusta, in an article in the April issue of
Briefings on Long-Term Care Regulations. "We know for sure that
there are going to be many more limitations on what medications
residents can get," Libby-Gilbert adds.
Clark fears that the added
administrative load could deter physicians from working in nursing
homes. "We don't want physicians to be discouraged from serving nursing
home residents by having to spend several times a day jumping through
hoops, calling 800 numbers, sending faxes and so forth to try to get
permission to use drugs that are really needed for their residents," he
says. "If physicians get discouraged by all of the administrative work
and start walking away from nursing home residents, that could create a
real serious access to care problem, especially in rural areas where
there are not that many physicians to begin with."
Many nursing home residents take
as many as eight or ten drugs at once. There is no guarantee that any
one PDP will cover all of them, or that an appeal will be granted when
needed. Trying out substitute drugs is a possible health risk to
patients, especially those sensitive to different medications and who
have achieved the right balance of medications only after much trial and
error. "You can't change three or four different medications
simultaneously without risking destabilization and creating serious
clinical problems," says Clark.
Lost in transition: Given
all this, it seems inevitable that some nursing home residents will at
least experience gaps in drug coverage. CMS has urged Medicare drug
plans to allow nursing home residents a 90-day supply of drugs to see
them through any coverage lapse during the appeals process or in the
switch from a non-formulary to a formulary medication. But this is not
mandatory. Plans can adopt this safeguard at their discretion.
This non-directive stance has
been typical of CMS's overall approach to implementing the new drug
benefit in long-term care settings. The agency is clearly trying to walk
a fine line between meeting the needs of nursing homes and their
residents without discouraging private PDPs from participating as
Medicare drug providers.
Although the American Society's
Clark notes that "CMS has been very responsive to the concerns that we
have expressed," he also says that "they seem to be leaving a lot up to
the PDPs."
Congressional Response
Sen. Charles E. Grassley
(R-Iowa), the lead Senate negotiator on the Medicare drug bill and
chairman of the Senate Finance Committee, continues to monitor CMS's
implementation of the legislation, according to spokeswoman Jill Gerber.
"The [legislation] called for
CMS to conduct a study on current standards of practice for pharmacy
services provided to patients in nursing facilities," Gerber said. "The
study was intended to help CMS formulate recommendations to ensure the
provision of a prescription drugs benefit that reflected nursing home
residents' special needs."
Unfortunately, the study Gerber
refers to was only recently begun and has not yet been completed. In the
meantime, all of CMS's final regulations and operational documents to
guide PDPs in providing coverage to nursing home residents have already
been issued.
"It's too early to say whether
we'll pursue follow-up legislation the program isn't up and running
yet," says Gerber.
Some are not waiting.
Sen. Jay
Rockefeller (D-W.Va.) has introduced legislation that would put
nursing home residents and other dual eligibles on the same footing as
regular Medicare beneficiaries, who will be given six months to
transition to the new Medicare drug benefit.
Clark says the American Society
supports this bill. "The dual eligibles are the sickest and most
vulnerable of all the Medicare beneficiaries," Clark notes. "Everybody
agrees on that. It would seem to make sense to get the infrastructure
for the program put in place first and then allow a longer period of
transition for the dual eligibles to begin gradually signing up instead
of having all of them signing up on day one."
"It's a brand new program,"
Clark adds. "Many of the PDPs that are going to be responsible for
implementing the drug benefit have very little expertise in long-term
care. So they're feeling their way along."
As the crucial deadline looms,
there is much concern for the fate of the nation's 1.6 million nursing
home residents, 1 million of whom receive help from Medicaid.
"I'm having a hard time
picturing how all of this going to come into place on January 1," says
NCCNHR's Wells. "It's hard to see what's going to happen when you have
this massive overnight shift from people who are currently getting drugs
through Medicaid and can get pretty much what they want and need. . . .
It's almost inevitable that there are going to be big problems. You have
a potentially life-threatening situation."
Resources:
CMS guidance on Medicare Part D
plans and long-term care facilities:
http://www.cms.hhs.gov/pdps/LTC_guidance.pdf
CMS guidance on the transition
process (including in LTC facilities):
http://www.cms.hhs.gov/pdps/transition_process.pdf
Two-hour audio conference on
implementation of the Medicare drug law in long-term care settings:
http://www.scoup.net
Timeline on implementation of
the Medicare drug benefit:
http://www.medicareadvocacy.org/PrescDrugs_PartDTimeline.htm.
"Advocacy needed to assure
prescription drug coverage for nursing home residents," Center for
Medicare Advocacy:
http://www.medicareadvocacy.org/SNF_PrescDrugCov.htm
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