APA Applauds Senate Legislation Improving Medicare Part D, Securing Access To Essential Psychiatric Medications, USA

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Psychology / Psychiatry;  Pharmacy / Pharmacist
Article Date: 05 Aug 2007 - 1:00 PDT

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The American Psychiatric Association (APA) applauded the introduction of the Medicare Access to Critical Medications Act introduced by Sens. Gordon Smith (R-Ore.) and John Kerry (D-Mass.). The act would improve Medicare Part D - the prescription drug benefit that launched in January 2006 - by ensuring that patients will have access to six life-saving classes of medications, including essential psychiatric medications, anticancer drugs, HIV/AIDS medications, and drugs needed to sustain organ transplants. Current law does not guarantee patients' access to these medications, but guidelines issued by the Centers for Medicare & Medicaid Services (CMS) do. Nonetheless, the administrative burdens of some Medicare prescription drug plans (PDPs) have resulted in patients being denied their prescribed medication, which has sometimes led to real harm, including hospitalizations and an increase in suicidal thinking and behavior.

The APA, joined by a diverse group of national and community-based patient, provider and advocacy organizations, has led the effort to codify reliable access to critically needed medications in the Medicare Part D program.

If enacted, the Medicare Access to Critical Medications Act would:

-- Codify protections for vital medications, such as antipsychotics, antidepressants, anticonvulsants, and antiretrovirals, in the Medicare Part D program. These protections would require PDPs to include "all or substantially all" drugs in these classes on their formularies and include important managed care limitations;

-- Require that the medication be covered until the appeals process can be completed when a PDP and a patient's physician disagree about whether a critical medication is needed; and

-- Require that CMS report on the number of coverage determination appeals for these important classes of medications. "Senator Smith has been a longstanding ally, and the APA appreciates his leadership and commends him for his continued outstanding advocacy on behalf of patients," said APA President Carolyn Robinowitz,

M.D. "Plans have not been compliant with CMS's guidelines about mediation access. Codifying these guidelines will give CMS new leverage in enforcing its appropriate and patient-centered policy. In the end, patients will receive better care, and the Medicare program as a whole will save money by avoiding the bad outcomes associated with reduced access to needed medications. The APA urges the full Senate to pass this bill in order to strengthen existing protections for patients who rely on these classes of medications."

In 2006, an American Psychiatric Institute for Research and Education (APIRE) study tracked 1,193 dually-eligible Medicare/Medicaid psychiatric patients and found serious access problems for these vulnerable patients. Among the findings:

-- Approximately 43 percent of patients could not access medication refills or new prescriptions in 2006.

-- Approximately 29 percent of patients had medications discontinued or temporarily stopped in 2006 due to administrative, benefit management or coverage issues.

-- 69 percent of patients with medication access problems experienced a significant adverse clinical event, such as an ER visit, hospitalization, homelessness, or detained/incarcerated in a jail or prison, compared to 40 percent among patients with no medication access problems.

-- 41 percent of patients with medication access or continuity problems had an ER visit compared to 26 percent for those with no access problems.

-- Medication access problems were highest for patients with step therapy (83 percent), limits on medication number/dosing (81 percent), generic requirements (80 percent) and prior authorization (79 percent).

-- 36 percent of patients studied in the September to December data collection cycle had prescription drug exceptions requests or appeals initiated on their behalf during this time.

-- And, for every hour of direct patient care, psychiatrists and their staff spent 40 minutes on PDP administration.

One stark example of current barriers encountered under Medicare Part D involves a patient in Prineville, Ore., who was repeatedly denied coverage of her prescribed medication. Despite her depression, inability to gain relief by taking other medications, and appeals by her psychiatrist, her PDP denied her prescription for ten days. Her psychiatrist was finally able to move beyond frontline staff to talk to the PDP's pharmacist, who, upon hearing the physician's explanation, agreed the plan was wrong to deny coverage. Her medication was approved.

About the American Psychiatric Association

The American Psychiatric Association is the nation's leading medical specialty society whose more than 38,000 physician members specialize in diagnosis, treatment, prevention and research of mental illnesses including substance use disorders. Visit the APA at http://www.psych.org and http://www.HealthyMinds.org.