Advocates Call for Medicare Prescription Fixes

Organizations representing people with physical and mental disabilities urged Medicare on Wednesday to significantly strengthen consumer protections under its new prescription drug benefit.

They called on the heathcare program for the elderly and disabled to guarantee prompt reimbursement for patients who had been overcharged and to require that all insurers follow simple, standard rules for appeals when they deny coverage of a particular medication.

“We are very unhappy with how things are turning out,” said Kirsten Beronio of the National Mental Health Assn. “In general, [Medicare] has been addressing problems on a case-by-case basis, instead of treating them as the systematic problems that they are.”

Groups that joined in the call for immediate changes included the Epilepsy Foundation, Paralyzed Veterans of America and United Cerebral Palsy.

The chief medical officer for the Medicare division that handles the drug benefit said the agency was responding to the concerns.

“We have made a lot of effort to work with the disability groups and the mental health groups, because they represent a very vulnerable and important population to bring into the benefit,” Dr. Jeff Kelman said.

But advocates for the disabled said Medicare’s directives to the private insurers that provide the drug coverage were sometimes being ignored, because they were issued only as guidelines and thus lacked the force of federal regulations.

Although millions of beneficiaries have obtained prescriptions with no trouble, the program got off to a stumbling start last month after several hundred thousand patients ran into billing problems at the pharmacy counter. In many cases, pharmacists could not determine whether a person was covered. In others, patients were charged too much.

Health and Human Services Secretary Mike Leavitt said this week that about 3% to 5% of beneficiaries were having such problems the first time they visited the pharmacy, compared with about 10% of beneficiaries last month. The lower figures still mean that tens of thousands of seniors and disabled people are having difficulty.

Although advocates agreed that the number of complaints had dropped significantly, they said some cases were more serious, involving frustrated patients who had gone without medications for several weeks.

In Wisconsin, a mentally ill man gave up trying to get his medications and had to be hospitalized, said Aimee McCutcheon, a lawyer for an advocacy group in the state. And she said a low-income woman was unable to afford a $70 co-payment for her heart medications and wound up in the emergency room with chest pain.

McCutcheon said calls to her office had dropped from about 200 a day in January to 40 a day now, but said her group was “seeing more hospitalizations than at the beginning of the year.”

Kelman said the next six weeks would be critical as doctors and patients adjusted to the coverage rules of individual insurers -- each with its own list of preferred drugs and procedures for obtaining exceptions.

“We are trying to get the plans to simplify,” Kelman said. “If we can get a more standardized and simplified process, it will be much easier. That is the direction we’re heading in.”

The advocacy groups urged Medicare to design model forms and procedures and then require all the plans to follow the same standard approach. They said that would make the adjustment easier for doctors.

The groups also called for prompt reimbursement for pharmacists who had absorbed the cost of some co-payments, and for stricter oversight of the drug plans. And they urged that Medicare guidelines requiring coverage of virtually all medications in certain critical classes -- such as drugs to treat cancer -- be given the full force of federal regulation.