Medicare Woes Take High Toll on Mentally Ill



Oscar Sosa for The New York TimesStephen Starnes, 49, has paranoid schizophrenia and is a resident at Dayspring Village, a Florida assisted living center for the mentally ill.



By ROBERT PEAR
Published: January 21, 2006
HILLIARD, Fla., Jan. 16 - 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 Belshé, 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."

Medicare drug snag hard on mentally ill

By Olga Pierce Jan 19, 2006, 1:30 GMT

WASHINGTON, DC, United States (UPI) -- The transition from Medicaid to the new Medicare Part D prescription-drug benefit has been especially hard on the one-third of low-income seniors who are also seriously mentally ill, psychiatric groups said this week.

Not only have mentally ill seniors faced the general problems of being turned away and overcharged for prescriptions during the rocky transition period since the plan`s Jan. 1 launch, but they also often find themselves forced to navigate a maze of bureaucracy to justify prescriptions that have been working for them for years, Sam Muszynsky, director of the office of healthcare systems and financing at the American Psychiatric Association, told United Press International.

'We have received many reports of plans not giving people their emergency one-month supply with no strings attached, as they are contractually required to do,' Muszynsky said.

According the contracts Medicare has with prescription-plan providers, every patient is entitled to one refill of any medication they were taking while on Medicaid.

But patients who arrive at pharmacies have been turned away, and that has dangerous consequences, Muszynsky said.

'You can generally go without allergy medication for a few days and be alright. But if you go without (anti-psychotic) Clozanil for a few days, you`ve got a serious problem,' he said, with the medication gap possibly resulting in a trip to the emergency room or even being committed to an institution.

Even patients who have avoided many of the transition pitfalls and are correctly entered in computer systems have difficulty because they find themselves subject to two common restrictions that are actually allowed in the drug plans.

The first, called prior authorization, means that the patient must contact their health plan and specifically request permission to purchase a particular medication under the plan. The second, called step therapy, is a system in which the insurance company will not cover a medication until the patient has unsuccessfully tried all the cheaper alternatives in its drug class.

If pharmacies followed the automatic 30-day supply guideline, patients and their doctors would have time to appeal the policies without disruption in treatment. Instead, some plans and pharmacies have declined to issue the supplies, which means that mentally ill seniors must scramble to maintain essential treatment.

In addition to being harmful to patients, the complicated process puts additional strain on mental-health caregivers.

'It takes a lot of time to go through prior authorization and appeals, and it`s not compensated,' he said. 'Most doctors really care about these people and are willing to do what it takes. They`re certainly not going to abandon them, but it is a burden.'

Step therapy and prior authorization can be very harmful to the mental health of patients, Andrew Sperling, director of legislative advocacy at the National Alliance on Mental Illness, agreed.

'Abruptly switching medications is extremely dangerous,' he told UPI. 'These medications are not interchangeable.'

Some health plans, he said, have imposed prior authorizations across the board on important medications.

Others have tried to require patients to substitute one psychiatric medication for another, such as the cheaper Clozanil for the anti-psychotic medication Zyprexa, he said.

'Our organization is completely opposed to that sort of substitution. We believe there is significant clinical research backing up the assertion that these drugs cannot be interchanged. They have different properties and interact with different neural receptors,' Sperling said.

NAMI supported the creation of Medicare Part D, Sperling said, because the law creating it includes protections for the mentally ill. In three important classes of drugs, anti-psychotics, anti-depressants and anti-convulsants, health plans were required to cover 'all or substantially all' of the available medications.

What is needed now is enforcement of those rules, he said.

'We believe the problems are largely the result of drug plans not following requirements set down by Medicare,' he said. 'In design, the plan should`ve worked better -- they took every step.'

When medications for mentally ill seniors fall through and they end up hospitalized or in the judicial system, taxpayers and not insurance companies end up bearing the cost, Sperling added.

For low-income mentally ill seniors, Medicare spokesman Peter Ashkenaz told UPI, protections are in place.

'There is a requirement that plans cover the drugs they`re on for at least 30 days,' he said. 'The plan has to cover any drug for that long.'

The Bush administration sent a letter to plan providers over the weekend reminding them of their obligation to provide a 30-day supply of medications.

The Centers for Medicare and Medicaid Services also sent a letter Jan. 6 to all Part D plans advising them that 'delaying or denying the filling of initial prescriptions for new enrollees at point-of-sale because of prior authorization/step edit requirements is not consistent with the intent of CMS` transition policy.'

Low-income seniors transferred from Medicaid are also the only group who are allowed to change plans from month to month, he said.

In the long run, step therapy and prior authorization are allowed under Part D contracts, but patients and their doctors can appeal any plan decision.

And when properly used, these mechanisms can help hold costs down, he said. 'There may be alternative drugs that cover the same conditions.'

But the volume of complaints to the APA and NAMI has not slowed down since the launch of the plan.

'Anyone walking away from a pharmacy without their medication is a bad, bad problem,' Sperling said, 'and we`ve got a long way to go to fix that.'

Copyright 2006 by United Press International