Health Care Experts Raise Concerns About Problems for Nursing Home Residents Under New Medicare Law

Pharmacists, health experts and federal and state health officials are expressing "serious concern" about how nursing home residents will receive prescription drugs under the new Medicare law, the New York Times reports.

The approximately 1.5 million people who are in nursing homes receive their medications through specialized long-term care pharmacies. Nursing home residents take an average of eight different prescriptions per day, and some residents take as many as 20 to 30 pills daily, according to the Times.

Long-term care pharmacies, which often charge more than traditional pharmacies, provide extra services to help facilities manage residents' complicated medication schedules. Long-term care pharmacies are on call 24 hours per day, make deliveries as many as five times per day and review residents' medication records to ensure they are receiving the right drugs in the proper doses.

The role of long-term care pharmacies under the new Medicare law remains "unclear," and experts on long-term care "foresee a number of problems," according to the Times. One potential problem is that traditional pharmacies and pharmacy benefit managers have little experience providing long-term care pharmacy services, the Times reports.

Spokespersons for PBMs Medco and Express Scripts said the companies do not provide services to nursing homes, and a spokesperson for Walgreen said the pharmacy has no program to supply drugs to nursing homes. In addition, CVS spokesperson Todd Andrews said CVS provides drugs to "only a handful of very small nursing homes."

Nursing home officials say that without the additional services and specialized care provided by long-term care pharmacies, it would be more difficult to meet federal health and safety standards, and more patients might have to be transferred to hospitals for treatment, the Times reports.

Health experts also worry about how nursing home residents will respond to choosing a private health plan that would provide the drug benefit.

Joan DaVanzo, vice president of the Lewin Group, said that the new Medicare law "presumes that Medicare beneficiaries are sophisticated elderly people living in the community and using retail drugstores." However, more than 33% of nursing home residents have Alzheimer's disease or another form of dementia, so they will not easily be able to "compare the costs and benefits of different plans," according to the Times.

While nursing homes can offer residents information on the new benefit, they say they will not counsel residents on which plan they should choose, because they feel they "don't have the competence to advise people on choosing an insurance plan," Barbara Manard, vice president of the American Association of Homes and Services for the Aging, said, adding, "That's not really [their] role."

Pharmacists also "express dismay" that there will be several private drug plans with various coverage and out-of-pocket costs under the drug benefit, the Times reports.

"If nursing homes have to deal with multiple formularies from multiple prescription drugs plans, that will result in chaos and an increased potential for medication errors," Thomas Clark, policy director for the American Society of Consultant Pharmacists, said. He added that additional confusion could result for the estimated two-thirds of nursing home residents who receive drug coverage through Medicaid and will be switched to Medicare once the drug benefit takes effect.

The range of drugs covered by Medicare is expected to be more limited than under Medicaid in most states, and the kinds of drugs covered will change for many nursing home residents, experts said, the Times reports.

As a result, doctors might have to write new prescriptions to switch many nursing home residents to medications covered under Medicare, Stanton Ades, senior vice president of Maryland-based long-term care pharmacy NeighborCare, said. He added that major changes in prescription drug regimens could be dangerous for frail nursing home residents.

Richard Stefanacci, executive director of the Health Policy Institute at the University of the Sciences, added, "If nursing home residents are faced with restrictive formularies, the outcomes could be devastating for their health."

Claudia Schlosberg, a health care lawyer, said, "The vast majority of nursing home residents do not have the resources to pay" for medications not covered by Medicare. She added, "An entire industry has developed expertise to meet the pharmaceutical needs of nursing home residents. We have to find some way to ensure that it has a role in the new program."

According to the Times, Bush administration officials have said they recognize "the value of long-term care pharmacies," and they are working to meet the needs of nursing home residents. CMS Administrator Mark McClellan said the Bush administration would ensure that beneficiaries had access to "all medically necessary drugs," adding that drug plans cannot "discriminate against any particular type of beneficiaries."

The Times reports that in a preamble to the proposed Medicare rules, the administration said that access to long-term care pharmacies "should be preserved." However, the rules did not specify how the Bush administration would ensure preservation, according to the Times (Pear, New York Times, 12/5).

Health plans participating in the new drug benefit will have to submit their proposed drug formularies to a committee for approval, CMS announced Friday, CongressDaily reports.

CMS said it will compare the proposed formularies to industry standard lists to ensure that the proposals are in line with existing drug formularies offered by traditional health plans. CMS also said it will review the drug classifications and individual medications covered to ensure there is no discrimination against beneficiaries with conditions that require specific medications. CMS also said it will allow plans some "flexibility" in designing their formularies.

The agency will issue final guidelines for the drug lists early next year (CongressDaily, 12/3).