Medicare Drug Plan Leaves Out Supplies

The new Medicare drug program is denying supplies that seriously ill patients need to administer intravenous antibiotics and other medications at home. As a result, some patients are being referred to nursing homes, and others have had to go into hospitals.

Although no national estimates are available, the number of patients affected -- including some with life-threatening diseases such as cancer and multiple sclerosis -- could run into the thousands. One Anaheim pharmacy says 200 of its patients are having trouble.

Medicare officials say they are aggressively addressing the problem, which they attribute to restrictions in the law that created the prescription benefit and to difficulty communicating with states, pharmacies and medical providers.

Essentially, the prescription program allows coverage of the drugs but does not pay for the medical supplies and nursing help needed for the home infusion treatments to be safe and effective -- a policy that effectively shuts down such treatment for some patients, even though it is substantially cheaper than the alternatives. Two GOP senators warned the Medicare agency last fall that the gap in coverage “may limit access to home infusion therapy.”

Home infusion pharmacies say they are overwhelmed trying to help patients deal with the problem. “It’s like I’m doing triage in a MASH unit,” said pharmacist Michael Rigas, vice president for clinical affairs with Crescent Healthcare in Anaheim.

For Kathleen Senna, 68, a retired cannery worker living in West Sacramento, the policy has meant she can’t get intravenous medications at home to fight a lung infection. Instead, Senna said, she is taking Cipro, an oral antibiotic that was ineffective for her in the past. Hospital doctors recommended she go into a nursing home for treatment, but Senna said she was afraid.

“You feel like they are putting you in there because they expect you to die,” she said. “Me going to a convalescent hospital is going to cost a lot more than bringing antibiotics to my house.”

Paulette Bryson of Escondido said she had to take her daughter, Kimberly Tyler, back to the hospital after Tyler was unable to get intravenous medications to treat a blood and spinal infection.

Disabled with severe osteoporosis, Tyler, 32, had been released from the hospital last week after extensive back surgery. Her mother said she returned to the hospital after two days because she could not get the IV medications, which are considered more effective than pills.

“I truly feel that if the president, the governor and all the legislators had to stand in line and wait for their prescriptions and find out they weren’t covered, they would make some major changes,” Bryson said. “Unfortunately, it’s the small person who does not have pull, and they have to beg for their medicine.”

Senna and Tyler previously were covered for intravenous medications at home under Medi-Cal, the California healthcare program for low-income seniors and disabled people. But despite emergency help ordered by Gov. Arnold Schwarzenegger for Medi-Cal patients whose prescription coverage was switched to Medicare on Jan. 1, Senna and Tyler were not able to get their medications.

The problem mainly appears to be affecting the poor. But pharmacists say many middle-class Medicare beneficiaries also could run into trouble, because they would have to pay to cover support services for their medications or find other insurance. On average, the medicines represent a little less than half the cost of treatment, which can run thousands of dollars a month, according to a pharmacy industry group.

Republican Sens. Arlen Specter and Rick Santorum, both of Pennsylvania, wrote to the Medicare agency in October, saying it “has opted to define the coverage of home infusion therapy in a manner that does not include financial coverage for ... professional services, supplies and equipment that are required for the safe and effective provision of therapy.”

In a response dated Dec. 27, Mark McClellan, administrator for the Centers for Medicare and Medicaid Services, said the agency lacked specific legal authority to broaden the coverage policy, in effect, handing the problem back to Congress.

“If we could pay for it, we would,” said Dr. Jeff Kelman, chief medical officer for the division of Medicare that handles the drug benefit. “Read the act yourself .... It’s a drug benefit, not a medical benefit.”

Kelman suggested that states could pay for the support services for low-income seniors and disabled people. However, it is unclear how many states would do that.

Pharmacists say other seniors may be able to get coverage by joining a managed care plan, such as a health maintenance organization. Additionally, a small number of IV medications are covered through Medicare’s Part B benefit.

Most private insurers take a comprehensive approach to covering home infusion drugs, so Medicare’s policy is hard to fathom, said Dr. Edward Ratner, a professor at the University of Minnesota medical school.

“The proof that it isn’t sensible is that commercial insurance companies and health maintenance organizations don’t do it this way,” said Ratner, who is also the medical director for a private company that provides support services for patients receiving intravenous treatments at home.

Until the mid-1980s, intravenous medications normally were given only in hospitals and nursing homes. But technological advances enabled the treatments to be administered safely at home, albeit with some supervision. Concern over rising healthcare costs accelerated the trend.

Most at-home patients are being treated with antibiotics for serious infections, according to industry statistics. Others are receiving painkillers, and some are undergoing chemotherapy for cancer.

Saving money by making hospitalization unnecessary was part of the rationale for creating the Medicare prescription benefit, which has an estimated price tag of $700 billion over 10 years. But the most far-reaching Medicare change in a generation failed to adequately provide for this kind of at-home drug therapy, critics say.

Specialized pharmacies that handle home infusion will not provide the service unless they are paid.

Some patients discovered their Medicare drug plans did not cover the specific medications they were getting and had to switch insurers. But even when the drugs were covered, things didn’t always go smoothly.

Rigas, the Anaheim pharmacist, said one patient called and told him a substance had been delivered to the patient’s house. “I’ve got the powder on my doorstep, now what do I do with it?” Rigas recalled the patient asking.

“They had no bags, no tubing ... but this is what they’ve been stuck with,” Rigas said. “It’s really bothersome to me, what patients are suffering. The carpet that they were standing on has been ripped out from under them.”

Some say an obvious solution would be for Congress to step in and craft a comprehensive benefit.

But congressional leaders are loath to make any legislative changes to the drug benefit, fearing that political support for the plan could unravel.

That leaves patients in limbo.

“I’m worried about it,” said Senna, the West Sacramento patient with chronic lung disease, saying that an oral antibiotic may not be effective in treating her periodic infections.

“I’m not going to let them put me in a convalescent hospital as long as I can take care of it at home,” she said. “If I start running a temperature, they can take me back to the regular hospital, although that’s not great.”