RespiteMatch.com Health Blog

By Laura Gilcrest
Feb 3, 2006, 19:00 GMT

WASHINGTON, DC, United States (UPI) — With Medicare`s Part D drug benefit one month out from a clumsy debut, some new problems are emerging beyond the fiasco of the automatically switched \’dual-eligibles\’ to include the dilemma of low-income seniors in assisted living having drug co-payments, while their counterparts in nursing homes do not, and complaints by cash-strapped pharmacies that the private health plans aren`t paying them on time.

At a hearing Thursday before the senate Special Committee on Aging, lawmakers grilled Mark McClellan, administrator of the Centers for Medicare and Medicaid Services (CMS) on how the center is handling the controversial program`s ongoing issues and how it`s tackling new ones.

\’We make no excuses for these problems,\’ McClellan told the committee.

The CMS chief told the lawmakers that his agency is moving to simplify the program, and make sure states and pharmacies that had to step in and pay drug costs for dual-eligibles are compensated.

He said CMS would make a reimbursement \’checklist\’ available Thursday to aid the process.

McClellan added that the agency is also closely monitoring the private health plans to ensure that they are living up to their end of the Part D bargain.

\’We`ll monitor and publish the plans` performance,\’ he told lawmakers.

The hearing was held the same day CMS announced it would extend by 60 days the rule ensuring an emergency supply of prescription drugs to Part D beneficiaries, including dual eligibles, seniors who hadn`t yet received a drug benefit card or who otherwise slipped through cracks in the new program.

But Senate committee members also pressed McClellan on new Part D issues that are emerging one month into the initiative, such as the discrepancy that exempts low-income seniors from co-payments if they live in nursing homes, but not if they reside in assisted living centers.

Sens. Hillary Rodham Clinton, D-N.Y., and Bill Nelson, D-Fla., said they were introducing a bill to fix the problem, but McClellan was noncommittal on whether the administration would support the measure. He said that CMS can help states \’fill in\’ those co-payments to assisted-living beneficiaries.

Senate lawmakers also asked McClellan about reimbursement for pharmacies that, unlike the states, can`t currently get direct help from CMS. \’I`d like to see pharmacies get reimbursed,\’ Clinton told the CMS administrator. \’They`ve been on the front lines.\’

McClellan said that pharmacies have to go through the health plans to seek drug reimbursements, but added, \’We`ll make sure these payments take place.\’

Committee members also asked McClellan about reports that some pharmacies aren`t getting paid on time for the Part D drugs they dispense. Noting that some plans pay drugstores every 10 to 15 days, McClellan told the panel, \’We want pharmacies to know that we`re monitoring the plans and we will help enforce those contracts.\’

He added that, under the Part D program, private plans have to first clear any formulary changes with CMS.

Clinton also blasted the health plans` laborious process requiring Part D beneficiaries to get pre-authorization from their doctors before getting certain drugs.

Clinton asked McClellan to \’require, not request that plans cease this practice,\’ noting that some plans require doctors to fill out a 14-page preauthorization form.

McClellan said CMS is working with the plans to devise a standardized form for the exceptions and appeals process.

Clinton further cited the problem of beneficiaries on essential drugs for mental illness having to switch to plans that cover their medications, or apply for exceptions to continue on an effective therapy not covered by a particular plan.

\’I predict, Dr. McClellan, that will be the next challenge,\’ she said. Clinton requested data on CMS`s appeals process related to drug exceptions and the timeliness with which those appeals are handled.

Sen. Mel Martinez, R-Fla., said he has filed an amendment to the tax reconciliation bill — which could be voted on Thursday — to delay for six months the time for signing up for Medicare`s Part D.

Despite the ongoing difficulties of seniors in negotiating the massive drug entitlement and the new problems emerging, McClellan defended the novel market-based effort, telling the committee that \’stronger than expected\’ competition among health plans has driven down Part D`s cost to one-third of anticipated levels.

The average Part D premium is $25, below the $37 premium level expected, and costs will continue to drop 25 percent over the next decade, he said. McClellan told the panel CMS is working with the health plans to improve the program and would keep a close eye on plans to ensure that they cover crucial drugs like therapies for HIV and are otherwise in compliance.

Meanwhile, McClellan said, the number of queries to CMS`s Part D help line is \’decreasing steadily.\’

During the hearing, the broader issue arose of whether the private sector should have been a player in Part D, with many pinning blame for Part`s D troubles on its market component.

Clinton called the program an \’absolute, embarrassing, heart-breaking disappointment.\’

\’Medicare in 1965 was (implemented) in 11 months, and we didn`t have computers,\’ she said.

However, Sen. Rick Santorum, R-Pa., noted that, \’No one who voted for (Part D) thought this was an optimal plan, but it was the best we could do in the deeply divided atmosphere we have in Washington.\’

\’The idea that we`re going to play politics with prescription drugs, rather than working together to fix the problems, is below this committee,\’ he said.

Noting that Medicare`s prescription-drug benefit was 20 years in the making, he urged committee members to stay the course. \’There are problems, but that doesn`t mean we need to throw (the program) out and start over,\’ Santorum told the committee.

Committee ranking member Sen. Herb Kohl, D-Wis., said a fundamental flaw in the program was the inability of the government to negotiate directly with pharmaceutical companies to get the best prices, but McClellan claimed that the private plans are coaxing from the drug makers prices 20 percent lower than the government is able to get in other federal programs. \’I don`t think any additional government negotiation would save money,\’ he told the panel. Plus, in other programs, the government has to narrow formularies to get low drug prices, but that strategy would limit Part D beneficiaries` access to drugs, he said.

Copyright 2006 by United Press International

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