On April 1, 2006 insurers will be able to deny requests for necessary rx’s and demand that a beneficiary go through “step therapy” before granting an authorization for a refill of a potentially life-saving rx.  For the first three months of Medicare D(isaster), insurers had to pay for an rx, even if it was an uncovered drug.

Acording to Tom Clark, policy director at the American Society of Consultant Pharmacists,

“I think that, after April 1st, you’re going to see huge problems with access. It’s going to be January 1st all over again.”

This has further been “clarified” by Mark McClellan,

“What we’re requiring is that the formularies all must be broad, all must meet our stricter-than-usual requirements, plus there must be a timely way for beneficiaries to get an exception.”

This includes monitoring of the Medicare D(isaster) plans to act within a day for those who need their rx’s “urgently”.  However, there are hidden restrictions on Medicare D(isaster) Plans, according to a report released by Henry Waxman.

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Step therapy is a requirement that beneficiaries receive less costly rx’s, that in some instances, do not work, before an insurer will pay for the prescription written by his/her doctor.  

The following recommendations by the Medicare Rights Organization were issued.

  •  CMS should issue stiff financial penalties–including debarment from the Medicare program–to drug plans that do not comply with required appeal standards.  Plans that do not deal expeditiously with appeals should lift formulary “restrictions” in order to triage the appeals.
  •  For drugs in the six protected classes–immunosuppressants, antidepressants, antiretrovirals, antipsychotics, antineoplastics, and anticonvulsants –CMS should require that drug plans lift all quantity limits, prior authorization and step therapy requirements.
  •  CMS should immediately implement its strengthened transition protections proposed for 2007.

Another restiction to receiving rx’s is the “five levels of hell” appeal process.  It appears that the appeal process could have been designed for the benefit of the insurance companies in controlling costs by restricting/denying access to costly rx’s.

The last statement is made after a careful reading of this WaPo article which states,

“The evidence indicates that QIOs (Quality Improvement Organizations) have not publicized beneficiary rights effectively and have issued fewer provider sanctions in recent years…This may be the result of inherent conflicts of interest: QIOs consider providers, not beneficiaries, to be their primary clients, and a QIO may not want to antagonize the providers.”

Translated, there is possibly an apparent conflict of interest within the non-profit organizations monitor compliance with the regulations that have been established.  Suggestions for remedying this are

  •  increased oversight and more competition,
  •  less secrecy in the QIO operations,
  •  major revision of the governance of the physician-dominated groups,
  •  putting more consumers on their boards,
  •  making public the compensation paid to directors.

To further clarify, QIO’s are organizations of professionals that are possibly affiliated with one (or more) of the following sectors: Medical, Insurance, Hospital, Pharmacy and other related professional organziations/fields.  So, there are professionals overseeing organizing, quantifying, and interpeting data that is meant to be presented objectively to demonstrate the success/failure of a program/necessary corrections.  As a result, the potential for abuse/misinterpetation is inherent.

Consider the following:

The Post documented lavish salaries and perks paid to some QIO executives and board members, including a nonprofit contractor in New Jersey that paid its trustees more than $500,000 in 2003.

Criticisms of the procedure that places the providers ahead of those who are Medicare D(isaster) beneficiaries will become more common, unless there is drastic reform taken to the health care system immediately.  More bandaid fixes will be encouraged that will have absolutely no benefit.  Disputes will not be resolved, but more rules and regulations will have to be successfully followed for any person to be able to navigate the health care system.

According to Robert M. Hayes, president of the Medicare Rights Center,  

“Until these for-profit drug plans are mandated by the Administration to operate a meaningful appeals process, come April, even more older and disabled Americans will face the fiasco they experienced when the drug benefit first took effect. If the Bush Administration and Congressional leadership want to lower the price of the Medicare drug benefit, they should permit the Medicare program to use its bulk purchasing power and negotiate good prices with the drug companies.   Instead, they allow federally subsidized, for-profit drug plans to deny older and disabled Americans the critical medications their doctors’ prescribed.”