WASHINGTON, July 11 (UPI) -- To ease the administrative burden of the Medicare Part D drug benefit on nursing homes and other long-term-care providers, long-term changes are needed, industry leaders told congressional staffers at a briefing Monday.
For nursing-home residents "Part D is like a square peg in a round hole," said Thomas Clark, director of policy and advocacy of the American Society of Consultant Pharmacists. "If some policy changes don't occur, its impact could get more severe down the road."
The program needs to be changed to allow facilities to advise patients on plan selection, allow patients to change plans with an immediate effective date and give pharmacists better information about which consumers are responsible for co-payments, said Paul Baldwin, executive director of the Long Term Care Pharmacy Alliance. Steps also need to be taken to ensure that nursing-home residents are not subject to undue restrictions when they do join plans.
Nearly 70 percent of nursing-home residents are dual eligibles, meaning they have low enough incomes to qualify for both Medicare and Medicaid and received drug coverage through Medicaid until they were automatically transferred to Part D on Jan. 1.
But unlike Medicaid, which offered essentially one benefits package for all beneficiaries, Part D is administered by private insurance companies that offer a variety of different plans.
An average nursing-home director might have "167 beneficiaries, 70 percent of whom were on one plan in December, versus Jan. 1 when they were auto-enrolled in as many as 16 different plans," Baldwin said. "Medicaid can be a challenging partner to work with, but one of the advantages of dealing with it is that it is the same program for every person in a state. That makes things easier ... you know who to call and what the scheme is."
Once beneficiaries were enrolled, they encountered many newfound obstacles to receiving the drugs they needed, he said. In the initial weeks after the rollout, information on what plan they had joined was not available for 40 percent of residents.
The people responsible for caring for them also found they had to negotiate a maze of new administrative requirements. Many Part D insurers require prior authorization for a variety of drugs -- a process that requires care providers to spend uncompensated time to complete paperwork justifying the prescription. Other plans use a technique called step therapy, whereby a patient must fail therapy with one drug before they can try another, usually more expensive, drug.
Many of the restrictions were especially problematic for the nursing-home population, Baldwin said. For example, several plans had placed such restrictions on all Alzheimer's medications, and others encouraged the use of medicines that are dangerous to seniors.
Also, dual-eligible beneficiaries, who are not supposed to have any cost-sharing requirements, found themselves being asked for co-payments, and since nursing homes cannot lawfully deny medication to residents, they were left covering that expense.
And while under Medicaid, there was only one phone number to call to straighten out difficulties, there were suddenly dozens.
Homes with relationships with one pharmacy also often found that it did not have a contract with the beneficiary's plan.
As a result of these problems, nursing homes also found themselves left responsible for charges, ASCP's Clark said. "If a doctor orders drug X for a resident, the facility is legally obligated to provide it to them in a timely manner. We've been asking Centers for Medicare and Medicaid Services from the beginning who pays for these denied payments," he said.
Nursing-home staff could avoid many of these problems by steering seniors into plans that already work with their pharmacy and cover necessary drugs. The catch: They are forbidden from discussing the issue with residents.
To address these problems, the program should be amended so that nursing-home staff can tell patients which plans will work best and then switch their enrollment effective immediately, Baldwin said. Currently, no matter when a senior enrolls, their coverage does not become effective until the first of the next month.
CMS also needs to take a tougher stance with plans to make sure they are not mistakenly asking for co-payments from low-income patients, he said.
If these changes are not made, it could begin to have an impact on the care seniors in nursing homes receive, Clark said.
"Quality of care and efficiency are achieved through consistency and uniformity. Facilities give better care when they work with a single pharmacy, and when residents are all on the same plan."
