Medicare D

Centers for Medicare & Medicaid Services (CMS)

Warning, this could turn into a long and very boring post.

I went to a presentation on Medicare D today. After the presentation the only thought I had was that the Medicare benefit “D” for “drug” is nothing short of a disaster. Anyone who can say with a straight face that the government in concert with private corporations can provide effective medical services should have their head crushed with a 20 pound hammer.

The Centers for Medicare & Medicaid Services (CMS) which used to be the Health Care Finance Administration (HCFA) took over the effort to implement the Medicare D benefit mandated by the brain dead congress critters December 8, 2003. Congress believes that private companies can implement the drug benefit of Medicare D and can better serve the beneficiaries than a government bureaucracy. I think the actual name of the bill was the “Medicare Prescription Improvement, and Modernization Act of 2003.” The other thought expressed by congress is that the free market through competition will drive down the costs of the medications. I don’t believe this will happen.

This new welfare entitlement benefit is supposed to shift the responsibility of medications for Medicaid and Medicare patients from the states to the Prescription Drug Plans (PDP’s). There will be PDP regions and a Medicare Advantage plan similar to what is currently in use. It is projected that there will be 34 PDP and 25 Medicare Advantage Regions. The numbers are constantly changing as the final determination has not been made. There should be a minimum of two choices per region. Here in Arizona we are expected to have our own region and two PDP’s servicing the region. So far there have been about 150 PDP applications submitted and at least four companies have announced their intent to create a national PDP.

Most of the current 300 Medicare Advantage plans are expected to add the drug benefit with region wide coverage.

CMS released operational guidance in March of 2005. Part D and MA-PD final bids were due June 6^th, 2005. Completion of Long Term Care pharmacy network contracting by PDP’s is supposed to be completed by July 15, 2005 and finalized by August 1^st, 2005. The implementation of the Medicare D benefit is supposed to take place January 1^st, 2006.

Enrollees will have until May 15, 2005 before they will be penalized for late enrollment.  They may begin signing up November 15, 2005. Marketing for enrollment is expected to start October 1, 2005.

Enrollment in the program will be mandatory for those receiving both Medicare and Medicaid benefits and optional for those receiving just Medicare benefits. There are proposed stiff penalties for those who enroll late. This is to encourage participation in the program. Those who have both Medicare and Medicaid are called duel enrollees and comprise about 6.5 million people.

CMS will auto enroll all duel eligibles in the September-October timeframe using a random assignment to available PDP’s. The duel eligibles will have the option of changing their PDP on a monthly basis. If one makes less than 100% of the federal poverty level there will be no deductibles and generic meds will be $1 dollar with brand name meds a $3 dollar copay.

If you are between 100-135% of the federal poverty level there will be no deductibles and the copays will be $2 and $5 dollars.

If you make between 135-150% of the federal poverty level there will be a $50 dollar deductible, a 15% cost share, and a $2 and $5 dollar copay. Long term care (Nursing Home) residents will have no copay.

There may be a monthly premium that could range from $37 dollars to over $100 dollars depending on the state. All these numbers are just being bantered about and may change between now and August or January.

One of the scary things about these PDP’s is that they are going to decide what is medically necessary. I went to a talk on Medicare D last week and the Psychiatrist who gave the talk said that the proposed two antipsychotics proposed for most PDP’s are Haldol and Thorazine. He was livid and was actually talking about leaving medical practice should this come about. It would be a great loss to his patients to have a psychiatrist with 37 years experience leave his practice.

Tiered formularies are still being developed by the PDP’s and CMS and will be different for each PDP. We are all waiting for the formularies to be published. LTC (nursing home patients) will have equal access to tiered medications and there will be no copays.

If an enrollee has better private drug coverage than the Medicare D benefit they will be allowed to keep that benefit. It was not discussed whether they will have to surrender to the Medicare D monster if they enter a nursing home and are subsequently placed on Medicaid.

Non-Coverage

There will be services and medications not covered by Medicare D. Insulin supplies and infusion therapies will not be covered as well as spacers for inhalation devices. Heparin and saline for IV flushes are also not covered. There are normally part B Medicare items and it is not clear if it is going to remain so.

Excluded Medications

Benzodiazepines

Barbiturates

OTC medications

Drugs to treat weight loss or gain.

This is one of the areas I am most concerned about. I can get around not prescribing benzo’s for anxiety as I don’t do that already. Of 88 patients only eight are on ativan for anxiety and none of those orders were written by me. But I do have 18 to 20 patients on ativen for muscle spasms and pain control. There is nothing that works as well for some of my patients and congress in their infinite wisdom has doomed them to a life of pain for no other reason than some CMS bureaucrat thinks it’s a bad idea to allow nursing home residents to have benzos. I pray these arses have an accident causing quadriplegia with severe muscle spasms and no ativan available.

One of the big problems with this restriction is the CMS is focusing on patient pain control. How the hell can I control my patient’s pain if they refuse to allow me to prescribe mediations designed to control their pain. I can be fined for not controlling a patient’s pain but they can’t be sued for denying the various medications I could use to control their pain. This is criminal as well as one of the dumbest ideas I have heard.

Moving on. CMS has determined that state Medicaid must pay for drugs not covered by Medicare D if Medicaid covers these drugs for Non-Medicare D persons. This is a mandate without funding and could cost the states hundreds of millions. It is being appealed and may foster federal lawsuits.

And as usual there will be an appeals process for drugs which are denied. This process has yet to be worked out but will most likely involve the provider filling out even more paperwork which some bureaucrat can deny and then have some physician who has sold his soul to the devil sign off on. Keep in mind there is always a physician’s name on the bottom of those denial letters. They are paid by the insurance company to deny medically needed treatments. They are even lower than lawyers in my way of thinking.

What this means is that the PDP’s have the option of creating an entirely new level of obstruction to getting medications my patients need. No, I don’t believe in prescribing fosamax for my 96 year old osteoporosis patient. But pain medications should not be denied because some ass downtown thinks my patient is not in “enough pain.” Which is what happened today.

In conclusion I think the entire scam as presented should be tested on members of congress first. If it works for them then we institute it in the rest of the population.

Additional information.

http://www.medicare.gov

http://www.cms.hhs.gov/medlearn/drugcoverage.asp

http://cms.hhs.gov/partnerships

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