Medicare Compliance & Reimbursement

Upside: New HEDIS standards say drugs shouldn't have been included in the first place

The Medicare prescription drug benefit may exclude several classes of Medicaid-covered drugs. That could create quality-of-care problems for nursing facilities.

States may decide to step in and cover excluded drugs with federal matching funds in 2006. If not, here's what an American Society of Consultant Pharmacists(ASCP) study predicts could happen:

Patient care: Enrollment in Part D will be mandatory for dual-eligible patients. But the frailest may not tolerate medication changes, the Feb. 18 study found. Among the drugs excluded are benzodiazepines for muscle spasms in cerebral palsy, and barbiturates, which treat seizures in elderly patients.

Costs: Some Part D-covered drugs can serve as alternatives to excluded ones - but they are mostly high-cost, brand-name drugs that dual eligibles cannot afford, the study found.

"That a resident is unable to pay for a medication is not an acceptable excuse for ... the facility not to administer it," the study says.

Counterpoint: Several of the excluded drugs - such as barbiturates - were never intended for elderly patients and are "potentially harmful," the National Committee for Quality Assurance said Feb. 22. The committee released proposed new quality measures regarding the drugs in its Health Plan Employer Data and Information Set (HEDIS).

To read the ASCP's "The Cost of Being Excluded," go to  www.ascp.com/medicarerx/docs/ascppaperexcludedmeds.pdf

Proposed HEDIS standards are at www.ncqa.org/Communications/News/hedis2006PubComment.htm.