Medicare Compliance & Reimbursement

Problems persist, researchers say.

The verdict is in: Medicare Part D is bad news for patients with psychiatric diagnoses.

That's the take of researchers at the American Psychiatric Institute for Research & Education in Arlington, VA. Their survey of nearly 1,200 physicians is hailed as the first systematic, nationally representative survey of dual eligible patients.

More than half (53.4) percent of the dual eligible patients reported on by the physicians had at least one problem accessing their medications during the first months of the Part D benefit. About one-third (30.6 percent) could not get required refills of drugs that were covered under their old Medicaid drug benefit.

The report was published in the May 2007 issue of the American Journal of Psychiatry, the journal of the American Psychiatric Association.

Problem #1: Not On Formulary

Medicare Part D's obstacles to coverage left patients in precarious situations, researchers say: Nearly one fourth (22.3 percent) stopped taking the prescription drug because of the Part D coverage problems. The physicians reported that 18.3 percent of the patients who had been clinically stable on their prescribed drugs before transitioning to Part D were required to switch to a new medication by their Part D prescription drug plan (PDP).

No go: Medicare Part D often denied access to atypical antipyschotics and SSRI antidepressants. Two of every three patients (67.6 percent) who experienced problems getting their medications under Part D did so because the drugs were not on a PDP's formulary. Other common barriers to access were the PDP's prior authorization requirements and limits on the number of pills dispensed or the dosage prescribed. The researchers also noted problems with PDPs' policies related to step therapy or "fail-first" protocols.

Problem #2: Exorbitant Co-Pays

Co-pays introduced under Part D were also problematic. About one fourth (24 percent) of patients reported not being able to afford the co-payment their PDP required.

Alert: Though the period studied was early in the Medicare Part D program, the study is an important look at the problems experienced by many beneficiaries.

"Part D defenders may say that the problems cited in this study have all been addressed. If so, they should prove it," says David Pollack, professor of psychiatry, public health and preventive medicine at the Oregon Health and Science University.

Resource: For "free, full-text" access to the article, go to www.ajp.psychiatryonline.org.