By Christopher J. Gearon
Special to The Washington Post
Tuesday, December 20, 2005; Page HE01
Antionette Keys was relieved to discover that her new Medicare prescription drug plan covers the medications she takes for bipolar disorder. And when that plan takes effect on Jan. 1, she will be able to get her four medications at the same pharmacy she always uses. Keys, 40, will see her drug costs jump from $4 a month to $10, but she figures she can handle that.
To those administering Medicare's new Part D drug benefit, Keys is known as a "dual eligible." Her mental health condition is a substantial enough disability to make her eligible for Medicare. And because her income is too low to support herself and her teenage son, she qualifies for Medicaid, the program for the poor that now covers almost all of her drug expenses.
The nation's 6.4 million dual eligibles -- more than 200,000 of them live in the District, Maryland and Virginia -- present a big test for Part D, which goes live on Jan. 1. They are among Medicare's most vulnerable beneficiaries, and when the clock strikes midnight on New Year's Eve, the dependable and robust drug coverage they receive through Medicaid will disappear, replaced by more restrictive and complicated plans.
Dual eligibles include many frail elders, developmentally disabled individuals and nursing home residents. Most live in or near poverty, and they tend to be less educated than other Medicare beneficiaries. They also are more likely to suffer diabetes, Alzheimer's and stroke, and they take more prescription drugs than the typical retiree.
"They don't know what's going to hit them," said Jeanne Finberg, an attorney with the National Senior Citizens Law Center.
Under Part D, patient advocates say, dual eligibles will have fewer legal protections and could pay more for their drugs than before. Many may need quick help from their doctors to continue medications they have long taken, while others will be switched to different drugs.
"In most cases, this will not be a change for the better," said Thomas Clark, the director of policy and advocacy for the American Society of Consultant Pharmacists. "For some, this delay could be catastrophic," he said.
Asked what it is like when she misses her medications, Antionette Keys says, "Think of the most scary thing that has happened in your life. You don't want it to happen again."
Like most dual eligibles, Keys was assigned at random to one of the private insurance plans approved by Medicare. Her plan, SilverScript, is a subsidiary of Nashville-based Caremark Rx; its national network of pharmacies includes 107 in the District.
Clark's group is one of several plaintiffs in a lawsuit claiming that the federal government has done inadequate planning to protect dual eligibles. Bush administration officials, however, sound confident that beneficiaries will get assigned to a drug plan that meets their needs.
"There still may be a few people who fall through the cracks" and aren't enrolled in a plan on Jan. 1, said Mark McClellan, administrator of the Centers for Medicare and Medicaid Services (CMS), but there will be a process in place to ensure that all dual eligibles can get their drugs.
Still, many patient advocates, providers and Medicaid officials fear that frail seniors, the mentally ill and other seriously ill patients -- or their caregivers -- will show up at pharmacies early next month and be told that their Medicaid drug coverage has ended and the new drug plan that has been randomly assigned to them doesn't cover some of their medications or does not use their pharmacy.
"Many of these patients are unaware that they've been auto-assigned" into a Part D drug plan, said Wallene Bullard, a pharmacotherapy specialist at Howard University School of Pharmacy. As a result, she predicted, "pharmacies will face a chaotic time in the first two weeks of January."
"We are concerned," said Jeff Gruel, director of the Medicaid pharmacy program in Maryland. "I don't know the extent [to which] these plans have dealt with this population. It's a unique population."
Rob Maruca, director of the District's Medicaid program, said its dual-eligible clients concerned about confusion in the early days of Part D can double up on their medications this month to get them through January.
Dual eligibles are likely to go without their medications if they encounter sudden problems in obtaining their medications, said Patricia Nemore, an attorney at the Center for Medicare Advocacy. Doing so, even for a short time, can be dangerous, Clark said. People taking anti-seizure medications, for example, could collapse into life-threatening seizures, while people with diabetes could wind up in a coma if they stop taking insulin or other drugs for short periods.
If she misses her medication, Keys said, "I don't function at all." She gets paranoid, weepy and puts herself into dangerous situations. "My family members can't deal with me, so it's better to stay in the street. I sometimes even get in trouble with the law."
An Inferior Benefit?
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"My biggest concern with the duals is we aren't hearing about this from our clients," said Sarah Lichtman Spector, an attorney with Legal Aid Society of D.C. "These are the poorest and most disabled" citizens, with many facing literacy and language barriers. "I'm terrified [these] people aren't walking through my door every day. Come January 1, I think we'll be in crisis."
For those who have sought help, one complication is a lawsuit that has blocked use of a computer tool for matching a person's drug needs with the available Part D plans.
"Without this Web tool we will be, as a practical matter, unable to provide meaningful assistance to the approximately 600 Medicaid dual-eligible people who have asked us for help to make sure their assigned drug plan covers their medicines," said Suzanne Jackson, director of the Health Insurance Counseling Project at George Washington University School of Law. It was unclear last week when this legal action would be resolved.
Dual-eligible beneficiaries get the most financial assistance under the Medicare's new drug benefit, having their monthly fees waived if they join a plan with below-average premiums and paying $1 to $3 per prescription. They can also switch drug plans monthly, while other beneficiaries can only switch at the end of each year.
Still, some experts believe Part D is an inferior benefit.
For example, Medicaid recipients can get their prescriptions for free if they can't afford the co-payment; under Part D, a pharmacist can refuse to dispense a drug for lack of a co-payment.
About 20 percent of dual eligibles live in nursing homes, where rules differ a bit. These people don't have co-payments and their non-formulary drugs may be covered temporarily. But these individuals have no guarantee that the plan to which they are auto-assigned will include the long-term care pharmacy used by their facility. Meanwhile, many of the protections extended to nursing home residents do not apply to those in assisted living or other settings.
McClellan said duals will not be left out in the cold. If a beneficiary shows up at a pharmacy in January, he will be given his drugs, most likely a 30- to 45-day supply. This, McClellan said, should happen even at a pharmacy outside the network of the drug plan to which the person has been assigned and even if the drugs are not covered by that plan.
In addition, any dual eligible who has not been auto-assigned to a plan can be enrolled on the spot into a plan that covers his drugs. "That will all happen right there at the pharmacy encounter," McClellan said.
(Another set of dual eligibles -- those who have partial Medicaid benefits and whose income is higher than the group being moved into Part D on Jan. 1 -- will be assigned to a drug plan by June 1. They will pay $2 to $5 per prescription.)
Relying on Goodwill
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Patient advocates say federal authorities have not done enough to guarantee a smooth transition. "The cutoff is very dramatic," Nemore said. "Suddenly as of Jan. 1, there is no safety net to pick up all the mistakes that are bound to happen."
Clark said key aspects of the computer system that will allow pharmacists to check the formularies and beneficiary eligibility and enrollment were not operational as of last week.
"Physicians will be inundated" with requests from patients to switch drugs and to explain the plans to which they have been assigned, Clark predicted.
"The contingency plan seems . . . dependent on the goodwill of pharmacists and physicians" to assist beneficiaries voluntarily, Nemore said, and on smooth operation of the computer systems linking the government, the private firms operating Part D plans and the nation's pharmacies, .
The medical establishment also has qualms about the transition -- which begins on the same day that Part D starts serving millions of other Medicare beneficiaries who have voluntarily enrolled in the drug plans.
"We have been especially concerned that pharmacists and physicians could be overwhelmed in January," the American Medical Association said in a statement posted on its Web site. "The potential exists for confusion because, even though the Centers for Medicare and Medicaid Services has provided assurances that plans' formularies will be adequate to meet patients' needs, plans will undoubtedly have policies in place that will differ from patients' current drug plans in some respects."
Christopher J. Gearon has written several articles for the Health section on the Medicare drug program. Comments: health@washpost.com.
http://www.washingtonpost.com/wp-dyn/conte...5121700889.html
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