Medication Access and Continuity Under Medicare Part D

“Medication Access and Continuity: The Experiences of Dual-Eligible Psychiatric Patients the First Four Months of the Medicare Prescription Drug Benefit” by West et al. is an excellent article about a very critical issue. The passage of the Medicare Modernization Act, with the specific provision for Medicare Part D, the first broad pharmaceutical benefit for Medicare beneficiaries in its history, was met with great fanfare, friction, and fear.

Many people were concerned that the pharmaceutical industry and certain health plans, the chief proponents of the Medicare Modernization Act, would reap huge profits while limiting access to critical medications for some of the most ill and at-risk members of the Medicare constituency, especially persons with disabilities who had previously been provided medication coverage through state-run Medicaid programs, the so-called “dual eligibles.”

Clearly, there would be some benefit to a large portion of Medicare recipients, mainly older persons who depended on small to moderate amounts of medications for maintenance of their chronic and episodic—but not so disabling—illnesses, especially those who had never had pharmacy benefits before. But the dual eligibles, as well as their providers and advocates, were fearful that the fragmentation and privatization of the pharmacy benefit would lead to initial chaos. This would be followed by dramatic reductions in access to critical treatment for those with the most serious and chronic illnesses, many of them persons with psychiatric conditions. These are the same people who are generally the least capable of managing or advocating for their own care.

The study authors, mainly from APA, were part of a dedicated group of mental health advocates who tried to mitigate some of the perceived early problems of Part D by educating providers and patients about the Part D process both before and during its implementation, especially to facilitate improving access to appropriate medications. These same advocates have worked tirelessly consulting and lobbying with policy makers at the federal level to make the new benefit as minimally harmful to persons with psychiatric illness as possible. They contributed to the policy that required the pharmacy plans to preserve formulary access to “all or substantially all” of the medications in the major classes of psychiatric medications. Their work on this study is a reflection of that dedication to their patients.

The study reported in this issue uses a carefully designed survey method to obtain information from psychiatrists throughout the country with regard to their patients’ ability to access psychiatric and other medications as they transitioned into Part D during the first 4 months of 2006. It describes the various points in the treatment process that Part D policies affect, especially how pharmacy plans are organized, what formulary limits exist, and how the utilization management process affects patients’ and providers’ ability to successfully obtain medications. It identifies and estimates rates of a number of problems with obtaining medications and the consequences of delays in or denial of access to preferred medications.

The results demonstrate that the initial experience with Medicare Part D was indeed a very challenging one for many patients and providers, even hazardous for some. For the patients, one in five discontinued or temporarily stopped taking the medication, and one in five who were previously stable switched medications. Among these two groups, one in four had a significant adverse clinical effect, and one in five had an emergency room visit. Only one in 10 reported improved access to medications. Physicians filed exception requests or appeals for one in four of their patients, and for one in five, they changed the patients’ medication rather than pursuing appeals or exceptions. Part D defenders may say that the problems cited in this study have all been addressed. If so, they should prove it. Anecdotal reports continue to indicate that access to appropriate medications is compromised.

At the same time, the article whets our desire to have more contemporaneous follow-up studies of what has happened since that first period of implementation. It would have been nice to include findings from complementary analyses derived from state Medicaid/mental health data analyses.

We are left wondering about some of the larger policy issues that the Medicare Modernization Act affected. Specifically, what about the overarching policy preventing the federal government from negotiating prices with the pharmaceutical industry, as the Veterans Administration currently does. This is clearly an important issue, which is finally getting serious consideration in Congress. Another concern is the overwhelmingly complex array of for-profit and other prescription drug plans associated with the original legislation’s intent to privatize the management of this Medicare benefit. This is a condition that seems to guarantee a very chaotic and unregulatable system of access and utilization management, leading inevitably to decreased overall access and quality of care.

Additionally, there is no mention of the problems associated with tracking the data associated with Part D recipients, especially dual eligibles, whose care is still partially managed by state Medicaid programs. The states are now cut off from most, if not all, pharmacy claims data that would allow them to more effectively manage the overall health services for such patients. Although state Medicaid programs may have provided better access arrangements than Part D, we should not fall into a nostalgic longing for the “good old days” when, in fact, 19 states had some form of restrictive access by means of prior authorization or other formulary limitations. The need for a more consistent approach to ensuring access may require a national system, but not the one that the current Medicare Part D policies have created. We need to carefully reprioritize our health system values to provide for patients’ needs, especially those with the greatest level of severity and acuity, rather than assuring windfall revenues to large corporations.