Advocates call Medicare benefit too problematic

01:34 PM CST on Thursday, February 23, 2006

By BOB MOOS / The Dallas Morning News

Medicare's new drug benefit has made life even more vexing for people with mental illnesses.

MIKE STONE / Special Contributor

Hal Whitfield and his son Dan Whitfield shown with Dan's prescriptions.

The mentally ill face the same problems other Medicare beneficiaries have encountered since Jan. 1 – plus their own unique frustrations.

Some have fallen through the cracks and waited two or three days for prescriptions. A few of the more seriously ill have suffered relapses and gone to emergency rooms for treatment.

"It's almost cruel to expect them to deal with something as arcane as this," said Dallas mental health advocate Sharon DeBlanc, who's spent the last three months explaining the benefit to people.

Mental health experts fear that the complexity of Medicare's new coverage will overwhelm people who have enough difficulty coping with the anxiety and confusion of everyday life.

Under the worst-case scenario, some people with mental illnesses could miss their medications, lose their jobs, end up on the street and get into trouble.

Social workers say their worst fears haven't been realized, but they don't rule out the possibility.

"We have yet to see many people hospitalized for lack of drugs, but we're headed that way," said Sam Muszynski, director of health care systems and financing for the American Psychiatric Association.

That would be a setback not only for the individuals but also for the nation's 40-year-old effort to empty state hospitals and help the mentally ill lead productive lives in their communities, he said.

"We will have failed to live up to the promise of deinstitutionalization," Mr. Muszynski said.

People with mental illness are likely to be among the heaviest users of Medicare's new benefit, since their conditions are chronic and the severely ill may be on six to 12 prescriptions.

No one knows how many people will use Medicare to cover psychiatric medications, but the number will include at least the 2.5 million Americans – and 128,000 Texans – who are both mentally ill and poor.

These people are called "dual eligibles," since they qualify for both Medicare, because of their disabilities, and Medicaid, because of their limited incomes.

Before Jan. 1, they got their medications free through state Medicaid programs. At the first of the year, that drug help was replaced by Medicare's drug benefit.

They're now covered by one of the private insurers participating in the new program.

Greg Shannon, 43, of San Angelo is typical of this group. He had been on Medicaid but now belongs to a United Healthcare plan.

Mr. Shannon takes Clozaril to treat his schizophrenia. Because of his low income, his only expense is a $3 co-payment for each prescription; he pays no premiums or deductible.

All dual eligibles were randomly assigned to a drug plan, but the switch from Medicaid to Medicare hasn't always gone smoothly. Medications once covered by Medicaid aren't in some of the new drug plans.

"Just because you were automatically enrolled in a plan doesn't mean all of your prescriptions are covered," said Laura Galbreath, director of health care reform for the National Mental Health Association.

People with mental illnesses have more trouble dealing with gaps in coverage, mostly because they can't just ask doctors to prescribe another drug that's covered by their plan.

"Many medications that treat mental illness can't be used interchangeably," Ms. Galbreath said. "Each medication affects each person's brain in a different way."

Switching psychiatric drugs also carries health risks. It may take six to 12 weeks to determine if a new medication works, and each failed trial may worsen a person's condition and cause suffering, she said.

Ms. Galbreath said taking a wrong drug can have side effects such as blurred vision, muscle spasms or severe insomnia.

Dan Whitfield, 52, of Rowlett, who has had schizophrenia since college, enrolled in an Aetna drug plan only to discover that it didn't cover one of his prescriptions at the dosage his psychiatrist prescribed.

At the wrong strength, the medication won't help Mr. Whitfield. So his father and doctor are asking Aetna to make an exception to its list of covered drugs.

"We've spent 12 hours sorting out his Medicare coverage," said his father, Hal.

Medicare's new benefit also poses a problem for people whose incomes are too high for Medicaid but who still qualify for free medications from their community mental health system – typically, incomes between $14,700 and $19,600 a year.

If they join a Medicare drug plan, they won't be eligible for free psychiatric medications, even though they'll save money on nonpsychiatric prescriptions.

"This will be a dilemma for them," said Patty Anderson, executive director of the Planned Living Assistance Network of North Texas, a mental health counseling agency.

Jeanine Hayes, 57, of Dallas, who has schizoaffective disorder, faces that choice.

She hasn't decided whether to give up her four free prescriptions in return for insurance protection against other high drug costs.

"I'm waiting to hear from my counselor about what to do," she said. "It's so confusing."

Mental health experts say Dan Whitfield and Ms. Hayes are fortunate to have a relative or counselor to rely on for advice.

Many people with mental illness live on their own and may not know they have a problem with their new drug plans until they try to refill a prescription and find out from their druggist that the drug isn't covered.

Medicare has told insurers to provide dual eligibles with up to 90 days of any drug they had been taking before Jan. 1, even if the medication isn't in their drug plan.

The 90-day transition, which ends March 31, is supposed to give low-income beneficiaries time to switch to a plan that covers their drugs.

Still, mental health experts fear that insurers are undercutting Medicare's good intentions.

"Medicare may have written some good rules, but something's being lost in their translation," Mr. Muszynski said.

Psychiatrists are discovering that some drugs covered by the new benefit aren't easily available, said Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness.

Some drug plans are requiring "prior authorizations" for certain drugs, he said. A doctor must provide laboratory test results, office notes and other data showing why the prescriptions should be filled.

"We're also seeing 'step therapy' – that's where you have to demonstrate failure with a cheaper drug before you get a higher-priced one," Ms. Galbreath said.

Insurers say they're trying to hold down costs and make sure medications are properly used. But mental health advocates worry that an overuse of the "benefit management tools" will prove penny-wise and pound-foolish if patients have relapses and land in the hospital or jail.

"Patients may be forced to switch to drugs that don't work as well," Mr. Sperling said.

The American Psychiatric Association says the insurers' restrictions are widespread and are likely to become even more common when the 90-day transition period ends.

Medicare administrator Mark McClellan says that most drug plans are complying with Medicare's requirements and that the agency is working with other insurers during the transition to make sure beneficiaries get all of the prescriptions they had received from Medicaid.

Mr. Muszynski acknowledges that Medicare is "trying to work through the problems," but he urges the agency to get tougher with drug plans he believes are bending the rules.

"You can't mess around with these drugs – people are going to get hurt," he said.

E-mail bmoos@dallasnews.com