Nursing home operators and pharmacies worry about how they are going to implement the new Medicare drug benefit in time
Larry Lane doesn’t mince words when it comes to assessing the federal government’s new Medicare prescription benefit.
“It’s a mess,” he says plainly. The declaration speaks volumes, for Lane has dealt with governmental relations at the highest level for decades.
“I can go through nightmare scenarios forever,” he continues. The vice president for governmental relations for nursing home giant Genesis Health Ventures, Lane and countless other stakeholders had anxiously awaited the government’s final rule for the Medicare Prescription Drug, Improvement and Modernization Act. The 1,500-page rule finally came out late Jan. 21, not leaving enough time for them to comment for this article.
They were desperately hoping for clues as to how drug administration is to be changed for more than 1 million nursing home residents by Jan. 1.
When Congress narrowly passed the controversial Medicare reform act in late 2003, it decreed drastic coverage changes. But it also neglected to give any details as to how nursing home residents — who have enormous drug needs and are served by specialty pharmacies — should be served.
About 11 months is all that regulators, providers and pharmacies have to get it right. That’s not a long time.
“It’s not difficult to write a terrible, meltdown scenario here,” said Paul Baldwin, executive director of the Long Term Care Pharmacy Alliance, an advocacy group for the four major U.S. nursing home pharmacy companies.
The reasons to worry about potential chaos are numerous.
Medicare-eligible seniors who currently receive drug coverage under Medicaid (so-called “dual eligibles”) will be switched into the new Medicare Part D program at the stroke of midnight Dec. 31. The new Medicare model, however, was designed with non-institutionalized beneficiaries in mind, experts point out. To get the new coverage, beneficiaries are theoretically supposed to compare prices from competing private plans. Then, they enroll with whom they wish.
How choices will be made for the more than 3 million people who spend time in a nursing home in a given year — yet alone the hundreds of thousands of them who have dementia disorders — was never addressed. About three-fourths of all nursing home residents fall under the “dual eligible” label.
“We can hand out brochures. We can invite speakers to come in. But we don’t have the competence to advise people on choosing an insurance plan. That’s not really our role,” said Barbara Manard, a vice president with the American Association of Homes and Services for the Aging.
Automatic conversion of the dual eligibles is supposed to take place by November or December, but that is cutting it close to the Jan. 1 switchover date.
Problem lists
Pharmacists and providers are also wringing their hands over formulary concerns.
“The thing that is most uncomfortable and difficult is if CMS leaves a lot of these issues up to each PDP (Prescription Drug Program) or decides on a case-by-case basis to set up things,” says Tom Clark, director of governmental affairs for the American Society of Consultant Pharmacists. “They have a huge amount of variety from one region to another and one plan to another. That would just be a nightmare for us.”
Currently, most nursing homes use a single pharmacy provider; that could change under the draft outline of the new law. If PDPs decide to limit medications’ use, residents could be put at risk, thus leaving facilities at risk for disciplinary action or worse. Congress, for example, excludes benzodiazepine medications from coverage under Medicare Part D.
“Without a legislative change, most nursing home residents will be denied access to medications commonly used to treat anxiety, insomnia, and seizure disorders. Hundreds of thousands of residents who have been taking these medications for years (or even decades) could be abruptly cut off, forcing hospitalizations, emergency room visits, and extra physician visits,” ASCP officials warn.
Final clearance reviews for the expansive rule were underway so a CMS spokesman sa
