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A troubled beginning for Part D

April 1, 2006
by MICHAEL LEVIN-EPSTEIN
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Behavioral health providers detail how they've been trying to help patients access the new drug benefit

Since Medicare Part D officially kicked in at the beginning of the year, the new program has given community mental health centers’ staff—and the people they serve—major headaches. Many behavioral health professionals remain skeptical that the federal government will make the regulatory and administrative changes needed to enable the more than 25 million participants to fully reap the intended benefit of the landmark program: access to prescriptions and reduced drug costs. The bottom line, say many behavioral health professionals, is that Part D has substantially increased their costs, taxed their resources, and frustrated their clients.

“From its inception, Part D has been an utter hassle for mental health service providers,” says Jim Van Norman, MD, medical director of the Austin Travis County MHMR Center in Texas. When the program first began, he notes, more than 6.2 million dually eligible Medicare and Medicaid recipients automatically were enrolled in Part D plans. Yet “it was difficult to figure out which plan the dual eligible was randomly enrolled in and whether that plan was the best option for the patient,” he explains. In addition, since many dually eligible beneficiaries have cognitive impairments, they were particularly vulnerable during the transition period because drug regimen consistency is paramount for patients with behavioral issues.

But for behavioral health agencies and their patients, the problems didn't end there. “Looking at the formulary choices available, it's clear that certain medications for patients with mental illness aren't covered,” Dr. Van Norman adds. Two classes of drugs prescribed by behavioral health providers—benzodiazepines and barbiturates—are excluded from coverage, but Part D plans are required to cover all antipsychotic, anticonvulsant, and antidepressant drugs, according to Andrew Sperling, legislative director of the National Alliance on Mental Illness (NAMI).

Under Part D, mental health treatment caregivers also are hindered because patients aren't always able to receive higher doses of medications than those specifically authorized under the program, according to Dr. Van Norman. “Sometimes,” he explains, “it's necessary to push doses higher than what's listed by the FDA to get a full response.” But the managed care companies that administer the plans aren't always flexible in approving higher doses, he adds.

In fact, Dr. Van Norman recently spent 40 minutes on the phone and three days completing paperwork to gain authorization to treat a patient with a higher dose than permitted by the plan administrator. “Meanwhile, the patient was getting frantic,” he says.

Another big Part D issue for behavioral health providers: Most states are not offering additional financial assistance or wraparound coverage to help dual eligibles with their copayments, according to a recent survey by the American Psychiatric Association. And when such coverage is available, it can be hindered by budgetary constraints. For example, in New York the proposal at press time limited wraparound help beginning July 1 to atypical antipsychotics, antidepressants, retroviral medications used in HIV/AIDS, and antirejection drugs used in organ and tissue transplants. Those with comorbidities may find that one or more of their non-mental health–related medications will not be covered by the supplemental wraparound program, explains Phillip Saperia, executive director of the Coalition of Voluntary Mental Health Agencies (CVMHA) in New York City.

In New York State, notes Karyn Krampitz, who operates a provider help line for the coalition, the legislature did approve an emergency Medicaid safety net program in February, which allows dual eligibles to get their medications paid by Medicaid if their first request for an exception is denied by the Medicare Part D drug plan. But that program will expire when the New York State health commissioner determines that the problems with Part D implementation are over. Krampitz is concerned that the safety net program is diverting attention from other troubling issues, such as drugs not being included in plan coverage and prior approval requirements. “Once the safety net is gone,” she explains, “we're afraid we'll be back to square one: beneficiaries without immediate access to their medications.”

For Linda Rosenberg, president and CEO of the National Council for Community Behavioral Healthcare, a critical component of the Part D problem is that Congress mandated a society-supported benefit for seniors while also trying to trumpet private business. “Promoting private business is certainly a good thing, but not necessarily when it comes at the expense of good public policy,” says Rosenberg. Therefore, the National Council would like to see the law changed to eliminate copayments for the poorest of the poor. “Two or three dollars doesn't sound like a lot of money, but for people on limited incomes, it can be,” she notes.

Medicare doesn't come close to paying for all drug expenses. Once a senior pays the deductible (in addition to a monthly premium), Medicare will cover only 75% of prescription drug costs until $2,250 in bills have been accumulated. At that point, beneficiaries are responsible for the entire costs of their medications until total drug expenses reach $5,100, when Medicare will cover 95% of the costs. That gap in coverage, called the “doughnut hole,” was implemented to save the government money, but the doughnut hole does not apply to dual eligibles.

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