News Analysis: More needed on Medicare drug benefit

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As time runs shorter, providers say the final CMS rule leaves a lot to the imagination. With all the day-to-day hassles of running a nursing home, most operators don't have the opportunity to worry about problems that will first hit their doorstep in 10 months.

Then again, there's never been a Medicare prescription drug benefit to implement before. And there's never been the occasion when approximately 70% of U.S. nursing home residents will have at least part of their drug regimens changed, all on the same day.
But that's all coming, and even though its stormy effects are not supposed to hit land until Jan. 1, 2006, there is more than enough angst to be found. Still.
Issuance of the federal government's final rule for the Medicare drug benefit Jan. 21 soothed some worries. But it also kept anxiety at a high pitch.
"It's just a mess right now. We have to get some sort of clarity," said Thomas Clark, director of governmental affairs for the American Society of Consultant Pharmacists, Alexandria, VA.
Clark was referring to regulatory decisions that hadn't been determined yet – for drug distribution entities that hadn't come into being yet.
Whether or not a person was satisfied with what came out in the final rule, there was universal agreement with Clark: Clarity and more details are needed.
Even federal regulators, who are under the gun to roll this out on time, acknowledge this is playing out almost like a soap opera, with some of the script being written as events unfold.
A key report from Lewin Associates clarifying long-term care pharmacy matters for regulators was expected to bring clarity. That report was due to be finished around the last week of March. Many thought the Centers for Medicare & Medicaid Services would use it to help issue a much-anticipated "sub-regulatory" guidance on policy points not yet addressed.
Nursing home administrators, pharmacists and others say that government officials have been open to their concerns and sympathetic to many problems. But providers remain concerned that the regulators either will run out of time or have their hands tied by lawmakers so problems won't get fixed.
Further complicating matters was the unveiling of President Bush's budget, which called for Medicare and Medicaid cuts in fiscal 2006. The idea of getting paid less while dealing with even more regulatory burdens brought by the new drug benefit  deeply frustrates providers.
Why they're pleased
Sitting firmly in the "satisfied" camp for the final rule were leaders at the American Association of Homes and Services for the Aging, which represents non-profit nursing homes.
"We were enormously pleased," said Barbara Manard, vice president for long-term care health strategies. "Our major concerns were thoughtfully addressed."
Most observers were very pleased in fact, when CMS announced that "dual eligibles" -- people covered under both Medicare and Medicaid -- would be automatically enrolled in coverage programs by the end of the year. About 70% of U.S. nursing home residents fall into this category.
But because CMS has not devised plans, yet alone chosen them, operators naurally are still concerned how residents will pass through the system. And facility-level personnel are adamant about not having to act as insurance counselors to help residents choose specific Prescription Drug Plans (PDPs).
The second point AAHSA officials were happy about was that regulators changed a provision that could have led to private-pay residents paying more for prescriptions.
Manard was one of numerous people who expressed satisfaction with CMS officials' willingness to deal with problems, particularly after the Medicare prescription drug-card system largely bypassed long-term care providers.
"Our word is, 'Let's all dig in and make it work,'" said Manard, acknowledging that many gaps in procedural information exist. "We are looking at it optimistically with the thought we have a good partner in CMS."
Unresolved as of press time, however, was what would define "institutional." Seniors in "institutional" settings will have their prescription co-pays paid by CMS.
Funding picture upsetting
Laurence Lane, a 40-year veteran of long-term care policy and management, was both heartened and skeptical about recent events.
He said h