Clinical Geriatrics

The Centers for Medicare & Medicaid Services (CMS) has the difficult, if not impossible, task of implementing the laws governing Medicare. CMS’s philosophy in developing the regulations has been to look at the overall well-being of the program. Unfortunately, in doing so, individual patients who exist at the extremes often suffer. Medicare Part D and the effect of this program on nursing home residents is a clear example of this problem.

As is often the case, the needs of long-term care (LTC) residents were not considered in the drafting of Medicare Part D legislation. States had viewed the ability to move their dually eligible individuals from Medicaid coverage of prescription drugs to Medicare as a way to relieve them of this heavy financial burden. Of course, to the surprise of most states, this was not entirely the case as they were stuck with the “clawback provision,” a monthly bill from CMS based on a percentage of the cost of caring for the dually eligible. In addition, states are finding that the benefit coverage available under Medicare Part D plans is less than had been offered under their Medicaid program in most situations. On top of that, states are fearful that prescription plans will restrict access to important medications, such as the antidementia agents, potentially resulting in premature nursing home placement—which will end up costing the states millions of dollars.

CMS felt that it was important to move all of the dually eligible from Medicaid to the Medicare Part D program to assure that prescription plans would have enough membership from the start to cover their high fixed operating expenses. It made it much easier to get plans to participate knowing that there were 6.5 million members guaranteed to enroll.

THE LTC DIFFERENCE
Of course, LTC residents are very different from community-based seniors, not only because of their unique demographics, but also because of the process that governs the distribution of medications within LTC facilities. The 1.6 million dually eligible nursing home residents have the highest acuity of any subset of Medicare beneficiaries, with 60-80% suffering from mental impairment.1 The intensity of services required for LTC residents is significantly greater than that of community seniors, with twice the number of prescriptions being utilized and four times the total overall health care spending being allocated.2

Because of the significant needs of the LTC resident, state and federal regulations have been developed to ensure that these needs are appropriately covered. In the area of prescription drug coverage, this is reflected in the Federal Regulations requirements for States and Long Term Care Facilities, section 483.60, Pharmacy Services.3 This section states that the facility must provide routine and emergency drugs and biologicals to its residents. The interpretive guideline states that a drug must be provided in a timely manner. If failure to provide a prescribed drug in a timely manner causes the resident discomfort or endangers his/her health and safety, then this requirement is not met. Unfortunately, Medicare Part D with its prescription plans provides incentives to restrict utilization of medications, placing LTC residents and facilities in a dangerous situation.

BARRIERS TO CMS RECOGNIZING THE LTC DIFFERENCE
Having had the opportunity to spend a year at CMS as a Health Policy Scholar, I witnessed first-hand the deficiencies that have led to CMS’s inability to recognize the LTC difference. To start, CMS has written almost every Medicare Part D document with the objective that the prescription plan was the most vital component of this program. Prescription plans must be encouraged to participate in this new program so that CMS would not have to participate as its own plan under the fallback plan provision.