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Medicare Woes Take High Toll on Mentally Ill    [

    The Medicare Drug Mess
    The New York Times | Editorial

    Sunday 22 January 2006

    After getting off to a promising start last fall, the new Medicare prescription drug program has stumbled badly in recent weeks, leaving tens of thousands of patients unable to obtain essential medicines. We can only hope that Medicare officials fix the glitches quickly before public disenchantment undermines prospects for enrolling enough people to give the new program real prospects for success. When the dust settles, it will be imperative to pinpoint how the problems arose, how much they reflect government ineptitude or malfeasance by private companies, and how further fiascos can be avoided.

    The immediate problems have little to do with the most common complaint against the program, namely that many people find it dreadfully confusing to choose a good drug plan from a bewildering array of options offered by private insurers. Instead, most of the snags occurred in the part that should have been the easiest to execute smoothly - the automatic switchover of more than six million poor people from the Medicaid programs in their home states to the new Medicare drug program.

    The Medicaid recipients were randomly assigned to a private drug plan, with the option to switch to another if they were dissatisfied. Along the way, as data bounced from one bureaucracy and set of computers to the next, some people's names dropped out of the system. Others, though listed as enrolled, were not earmarked as they should have been for the lowest level of co-payments. Thus many poor people found that when they showed up at the pharmacy they either were denied coverage or were asked to pay hundreds of dollars in deductibles or co-payments. Pharmacists who tried to call the private drug plans could seldom get through. And some plans improperly refused to approve drugs during the transition as they were required to.

    Nobody knows how many people were affected, but officials acknowledge it may be in the tens of thousands. California alone says that some 200,000 of its one million Medicaid patients had trouble getting medications during the switchover, an astonishing error rate. More than 20 states stepped in to guarantee drug coverage until the glitches are resolved. They had little choice, given the potentially catastrophic consequences for people who depend on their medicines to keep mental illness at bay, pain at tolerable levels and diabetes or other ailments under control.

    This is a disheartening setback for a critical program and we can only hope that Michael Leavitt, the secretary of health and human services, is right that after everyone has used the new drug card at least once, the system will run more smoothly.

    If not, any further snags are apt to throw a cloud over the whole program just when it desperately needs to attract more participants. Officials have been trying to deflect the recent bad news with exaggerated claims of success. Mr. Leavitt announced with great pride that some 24 million of the elderly had drug coverage. But 20 million of those 24 million already had drug coverage, through retiree plans, Medicaid or other programs.

    The real measure of success will be how many people sign up who previously had little or no drug coverage - a pool estimated at 12 million to 14 million, or possibly more. Only about 3.6 million signed up voluntarily for Medicare's new stand-alone drug plans in the first 60 days of the enrollment period - a modest figure undoubtedly due at least in part to the complexity of the system. Worse yet, those who would benefit the most from the new drug coverage, namely low-income people entitled to special subsidies, have been disproportionately slow to sign up.

    Federal officials and private health plans will have to reach out more vigorously to raise the numbers before the enrollment period ends on May 15. They have a long way to go to prove their argument that their approach was better than that of a classic federal program like the original Medicare. Their efforts will not be helped if further glitches continue to tar the program's image.

 

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    Medicare Woes Take High Toll on Mentally Ill
    By Robert Pear
    The New York Times

    Saturday 21 January 2006

    Hilliard, Florida - On the seventh day of the new Medicare drug benefit, Stephen Starnes began hearing voices again, ominous voices, and he started to beg for the medications he had been taking for 10 years. But his pharmacy could not get approval from his Medicare drug plan, so Mr. Starnes was admitted to a hospital here for treatment of paranoid schizophrenia.

    Mr. Starnes, 49, lives in Dayspring Village, a former motel that is licensed by the State of Florida as an assisted living center for people with mental illness. When he gets his medications, he is stable.

    "Without them," he said, "I get aggravated at myself, I have terrible pain in my gut, I feel as if I am freezing one moment and burning up the next moment. I go haywire, and I want to hurt myself."

    Mix-ups in the first weeks of the Medicare drug benefit have vexed many beneficiaries and pharmacists. Dr. Steven S. Sharfstein, president of the American Psychiatric Association, said the transition from Medicaid to Medicare had had a particularly severe impact on low-income patients with serious, persistent mental illnesses.

    "Relapse, rehospitalization and disruption of essential treatment are some of the consequences," Dr. Sharfstein said.

    Dr. Jacqueline M. Feldman, a professor of psychiatry at the University of Alabama at Birmingham, said that two of her patients with schizophrenia had gone to a hospital emergency room because they could not get their medications. Dr. Feldman, who is also the director of a community mental health center, said "relapse is becoming more frequent" among her low-income Medicare patients.

    Emma L. Hayes, director of emergency services at Ten Broeck Hospital, a psychiatric center in Jacksonville, said, "We have seen some increase in admissions, and anticipate a lot more," as people wrestle with the new drug benefit.

    Medicare's free-standing prescription drug plans are not responsible for the costs of hospital care or doctors' services. "They have no business incentive to worry about those costs," said Dr. Joseph J. Parks, medical director of the Missouri Department of Mental Health, who reported that many of his Medicare patients had been unable to get medicines or had experienced delays.

    At least 24 states have taken emergency action to pay for prescription drugs if people cannot obtain them by using the new Medicare drug benefit. Florida is not among those states.

    In an interview, Alan M. Levine, secretary of the Florida Agency for Health Care Administration, said: "We've set up a phone line and an e-mail address for pharmacists. We try to solve these problems on a case-by-case basis. We have stepped in to get drug plans to pay for prescriptions, so people don't leave the pharmacy without their medications."

    Federal officials said they were moving aggressively to fix problems with the drug benefit. About 250 federal employees have been enlisted as caseworkers to help individual patients. The government has told insurers to provide a temporary supply - typically 30 days - of any prescription that a person was previously taking. And Medicare has sent data files to insurers, supposedly listing all low-income people entitled to extra help with premiums and co-payments.

    But in many cases, pharmacists say, they still cannot get the information needed to submit claims, to verify eligibility or to calculate the correct co-payments for low-income people. And often, they say, they must wait for hours when they try to reach insurers by telephone.

    S. Kimberly Belsh , secretary of the California Health and Human Services Agency, said the actions taken by the federal government "have not been sufficient to address the problems that California residents continue to experience."

    At Dayspring Village, in the northeast corner of Florida near Jacksonville, the 80 residents depend heavily on medications. They line up for their medicines three times a day. Members of the staff, standing at a counter, dispense the pills through a window that looks like the ticket booth at a movie theater.

    Most of the residents are on Medicare, because they have disabilities, and Medicaid, because they have low incomes. Before Jan. 1, the state's Medicaid program covered their drugs at no charge. Since then, the residents have been covered by a private insurance company under contract to Medicare.

    For the first time, residents of Dayspring Village found this month that they were being charged co-payments for their drugs, typically $3 for each prescription. The residents take an average of eight or nine drugs, so the co-payments can take a large share of their cash allowance, which is $54 a month.

    Even after the insurer agreed to relax "prior authorization" requirements for a month, it was charging high co-payments for some drugs - $52 apiece for Abilify, an anti-psychotic medicine, and Depakote, a mood stabilizer used in treating bipolar disorder.

    The patients take antipsychotic drugs for schizophrenia; more drugs to treat side effects of those drugs, like tremors and insomnia; and still other drugs to treat chronic conditions like diabetes and high blood pressure.

    "If I didn't have any of those medications, I would probably be institutionalized for the rest of my life," said Deborah Ann Katz, a 36-year-old Medicare beneficiary at Dayspring. "I'd be hallucinating, hearing voices."

    Michael D. Ranne, president of the Jacksonville chapter of the National Alliance on Mental Illness, said the use of powerful psychiatric medications "virtually emptied out state mental hospitals" in the 1970's and early 80's. Ms. Katz said she had been "in and out of hospitals" since she was 13.

    Sponsors of the 2003 Medicare law wanted to drive down costs by creating a competitive market for drug insurance. They focused on older Americans, not the disabled. They assumed that beneficiaries would sort through various drug plans to find the one that best met their needs. But that assumption appears unrealistic for people at Dayspring Village.

    Heidi L. Fretheim, a case manager for Dayspring residents, said: "If I take them shopping at Wal-Mart, the experience is overwhelming for them. They get nervous. They think the clerks are plotting against them, or out to hurt them."

    Residents of Dayspring Village see worms in their food. Some neglect personal hygiene because they hear voices in the shower. When nurses draw blood, some patients want the laboratory to return it so the blood can be put back in their veins.

    Under the 2003 Medicare law, low-income people entitled to both Medicare and Medicaid are exempted from all co-payments if they live in a nursing home. But the exemption does not apply to people in assisted living centers like Dayspring Village.

    Douglas D. Adkins, executive director of Dayspring Village, said: "Some of the pharmacists have been saying, 'No pills unless we get a co-payment.' Well, how are these people going to get the money for a co-payment? They don't have it."

    Eunice Medina, a policy analyst at the Florida Department of Elder Affairs, said the state was trying to "find a solution" for people in assisted living centers.

    "We are all aware that the next couple of months will be difficult for these clients, and that the possibility of a transition to a nursing home is their only option if prescriptions are not covered in assisted living facilities," Ms. Medina said in a memorandum to local social service agencies.

    Luis E. Collazo, administrator of Palm Breeze, an assisted living center for the mentally ill in Hialeah, Fla., said many of his residents were forgoing their medications on account of the new co-payments.

    "Because of their mental illness," Mr. Collazo said, "they don't have the insight to realize the consequences of not taking their medications. Without their medicines, they will definitely go into the hospital."