As a clinical social worker, I can’t tell you how frightened I am for mentally ill and elderly people across the country. Because of the changes in Medicare effective January 1, 2006, many elderly and severely mentally ill people are not getting their medications due to confusion over their benefits or inability to pay the new co-pays. The New York Times described the dire situation in Florida, where the state has not stepped in to supply people with their medications, as some other states have. From the article:
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.
While Medicaid offers top-rate prescription coverage that includes virtually every kind of psychiatric medication, Medicare coverage is more limited, they say.
And although federal guidelines direct insurers administering Medicare benefits to cover most psychiatric drugs, many plans have restrictions that did not exist under Medicaid, such as limits on how much a patient can take or how drugs can be mixed.
While insurers are supposed to cover most drugs, an analysis by the psychiatric society’s Gross found some psychiatric medications aren’t covered by some plans.
Gross also found that some plans regularly change their approved drug list, causing problems for people who picked their plans based on their specific medication needs.Then there’s the confusion among patients and pharmacists.
Many patients don’t know about, or don’t understand, the changes in their coverage. They may show up at a pharmacy believing they still have Medicaid, when in fact they’re covered by Medicare.
When that happens, it’s up to the pharmacists to determine what coverage the patient has. While druggists have spent months trying to understand the plan, some still aren’t clear about the Medicaid/Medicare issue, mental health advocates say.
Even pharmacists have had problems accessing information over the phone and through the Internet site that allows them to enroll people in a Medicare prescription plan. “Instead of just having to deal with, understand, learn the ins-and-outs of Medicaid in Michigan, you’ve got to look at dozens of private plans and learn what’s available and how it’s available,” said Mark Reinstein, president of the Mental Health Association of Michigan. “It’s a very daunting task for anyone, let alone someone who might have a mental health issue.”
Elizabeth V. Earls, president of the Rhode Island Council of Community Mental Health Organizations, said that clients have been charged incorrect copayments, that pharmacists have been unable to access information about them, and that the federal government has deducted premiums from their Social Security checks, even though indigent people don’t have to pay premiums.
“In four to six weeks,” Earls predicted, “we’re going to see a huge surge in hospitalizations. . . . It is scary.”
At the South Shore Mental Health Center in Wakefield, Kathy Garlick, senior manager of the mobile treatment team, encountered a mentally ill man who just went two days without taking his heart medication.
“This is a man who had a heart attack a month ago,” Garlick said. “He went into the pharmacy on his own over the weekend.” Told he had to pay for the drugs, he replied that he didn’t have the money and walked out. The staff at the mental-health center learned about this yesterday. By the end of the day, they hadn’t figured out why he wasn’t in the system — but the pharmacy had agreed to provide a week’s worth of medication.
Garlick estimates that three-quarters of her clients have encountered difficulties getting their medications.
One was a woman who had received her Medicare drug card, and was actually in the system — but she needed preauthorization for her dosage of the antipsychotic drug Zyprexa. “I spent four hours on the phone,” Garlick said. “I kept track.” Eventually she obtained the necessary form, while the pharmacy gave the patient five days of drugs.
Luckily here in Rhode Island, the Governor did the prudent thing and reinstated the old Medicaid system for people until the new system appears to be able to function properly. Other states like Florida and Michigan have not done that, resulting in even bigger problems for their elderly and mentally ill residents.
Something needs to be done. The government that created this new system needs to step up to the plate and amend it so that it can function, before innocent people are made to suffer further disastrous consequences.