http://www.nytimes.com/2004/12/05/health/05nursing.html?hp&ex=1102222800&en=1db401a693f76ceb&ei=5094&partner=homepage 2004 Medicare Law Said to Trouble Nursing Homes By ROBERT PEAR                                     HOME
	WASHINGTON, Dec. 4 - A wide range of experts on long-term care express serious concern that the new Medicare law will be unworkable for most of the 1.5 million Americans who live in nursing homes. Nursing home residents take large numbers of prescription drugs, an average of eight a day. But many have physical disabilities and brain disorders that impair their memory and judgment. So they cannot easily shop around for insurance plans to find the best bargains on their drugs, as other Medicare beneficiaries are supposed to do. Federal and state officials, pharmacists and nursing home directors said they had no idea how these patients would obtain their medicines under the new program, which begins in January 2006. "Nobody knows where they're going to get their drugs from," said Stanton G. Ades, senior vice president of NeighborCare, a company in Baltimore that supplies drugs to more than 1,500 nursing homes and assisted living centers in 32 states. The role of such long-term care pharmacies under the new law is unclear. One of the homes served by NeighborCare is at Asbury Methodist Village in Gaithersburg, Md. NeighborCare delivers drugs to the home two to five times a day. The drugs for 20 patients are kept in a medication cart with six drawers. A month's supply of each drug prescribed for each patient is kept in a separate little box labeled with the patient's name. The cart has 165 boxes, indicating an average of about eight prescriptions for each resident. Since each prescription may call for 2 or 3 pills a day, a patient may be taking 20 to 30 pills a day. The nurses keep detailed logs that show every pill given to every patient. NeighborCare, which supplies drugs for all 250 patients in the home, continually reviews those records to ensure that patients are taking the right drugs in the proper doses.
	By contrast, the new law relies on private health plans to provide drug benefits to the elderly. Each Medicare beneficiary will have a choice of two or more government-subsidized plans. Each plan can establish its own list of approved drugs, known as a formulary, and its own network of retail pharmacies. Premiums, generally expected to average $35 a month, can vary from plan to plan. The premise of the law is that Medicare beneficiaries will carefully compare these plans and enroll in the ones that best meet their needs. Aetna, for example, might offer a Medicare drug plan, dispensing medications at discounted prices through retail pharmacies around the country. But the network would not necessarily include NeighborCare, the supplier at Asbury Village. Bush administration officials said they were seeking ways to meet the special needs of nursing home residents and recognized the value of long-term care pharmacies. Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services, said the administration would ensure that beneficiaries had access to "all medically necessary drugs." Moreover, he said drug plans cannot "discriminate against any particular type of beneficiaries." In a preamble to the proposed Medicare rules, the government said access to such pharmacies "should be preserved," but did not say how. Experts on long-term care foresee a number of problems. "The way it's supposed to work under the new law is totally confusing," said Joan E. DaVanzo, vice president of the Lewin Group, which recently received a federal contract to study pharmacy services in nursing homes. "The mandates of the law run contrary to the practice of the industry. The law presumes that Medicare beneficiaries are sophisticated elderly people living in the community and using retail drugstores." In fact, more than one-third of nursing home residents have Alzheimer's disease or another form of dementia, so they cannot easily compare the costs and benefits of different plans. At least one-fifth of nursing home patients have difficulty swallowing. Many receive medications and nutrition through feeding tubes, so they require drugs in a liquid or crushable form. Nursing homes can offer information about the new benefit. But Ann R. Schiff, administrator of the home at Asbury Village, said they would not counsel patients or recommend specific prescription drug plans, in part because nursing home employees themselves might not fully understand the intricacies of the new benefit. Barbara B. Manard, vice president of the American Association of Homes and Services for the Aging, which represents 4,000 nonprofit nursing homes, said: "We can hand out brochures. We can invite speakers to come in. But we don't have the competence to advise people on choosing an insurance plan. That's not really our role." About 1.5 million people live in nursing homes at any given time, and 3.5 million spend some time in a home in the course of a year. "We don't have a clue how the system is supposed to work under the new law," said Laurence F. Lane, vice president of Genesis HealthCare, which operates 192 nursing homes in 12 states. "We don't know what will happen on Jan. 1, 2006"
	The new Medicare benefit, as envisioned by Congress, will be delivered by insurance companies and pharmacy benefit managers like Medco Health Solutions and Express Scripts, through drug stores like Walgreens and CVS. But the typical retail drugstore or pharmacy benefit manager has little experience with nursing home residents.
	Medco manages drug benefits for 60 million people of all ages. In an interview, its president, David B. Snow Jr., said none of them were in nursing homes. Another benefit manager, Express Scripts, serves 55 million people. A vice president of the company, Stephen E. Littlejohn, said nursing homes were "not on our radar screen." Walgreens operates 4,623 drugstores in 44 states, but a spokesman, Michael Polzin, said it had no program to supply drugs to nursing homes. CVS has more than 5,300 stores in 36 states, but a spokesman, Todd Andrews, said they provided drugs to "only a handful of very small nursing homes." Pharmacists express dismay at the prospect that nursing home patients will be in different drug plans covering different medicines. "If nursing homes have to deal with multiple formularies from multiple prescription drug plans, that will result in chaos and an increased potential for president of the company, Stephen E. Littlejohn, said nursing homes were "not on our radar screen." Walgreens operates 4,623 drugstores in 44 states, but a spokesman, Michael Polzin, said it had no program to supply drugs to nursing homes. CVS has more than 5,300 stores in 36 states, but a spokesman, Todd Andrews, said they provided drugs to "only a handful of very small nursing homes." Pharmacists express dismay at the prospect that nursing home patients will be in different drug plans covering different medicines. "If nursing homes have to deal with multiple formularies from multiple prescription drug plans, that will result in chaos and an increased potential for medication errors," said Thomas R. Clark, policy director for the American Society of Consultant Pharmacists, whose 7,000 members specialize in drug care for the elderly. Two-thirds of nursing residents are on Medicaid, the federal-state health insurance program for low-income people. Under the new law, Medicaid coverage of prescription drugs ends on Jan. 1, 2006, when Medicare drug benefits become available. Mr. Clark and other experts said the range of drugs covered by Medicare drug plans would, in most cases, be more limited than what is available under Medicaid in most states. In any event, the drugs will be different from those now covered. Thus, the experts said, doctors will need to write new prescriptions for hundreds of thousands of nursing home residents, switching them from the drugs they now take to those approved by Medicare. Mr. Ades, a former president of the Maryland Board of Pharmacy, said, "Medicare beneficiaries in nursing homes could face myriad medication changes dictated by limitations in a plan's coverage or formulary design." In frail elderly patients, he said, such wholesale, abrupt changes are potentially dangerous. Mark B. Moody, the Medicaid director in Wisconsin, said, "We are very, very concerned about that transition." Dr. Richard G. Stefanacci, executive director of the Health Policy Institute at the University of the Sciences in Philadelphia, said, "If nursing home residents are faced with restrictive formularies, the outcomes could be devastating for their health." Dr. Lynn V. Mitchell, the Oklahoma Medicaid director, said: "Prescription drug plans will contract with retail pharmacies to ensure convenient access for Medicare beneficiaries. But we don't know whether long-term-care pharmacies will be part of those networks." Claudia Schlosberg, a health care lawyer who used to work at the Department of Health and Human Services, said: "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." Under the law, Medicare patients may have to pay more when they use a pharmacy outside the networks of their plans. "The vast majority of nursing home residents," Ms. Schlosberg said, "do not have the resources to pay this extra amount." Long-term-care pharmacies often charge more than community drugstores because they provide additional services. For example, they are on call 24 hours a day to make unscheduled deliveries of urgently needed medications. Without such specialized services, nursing home executives say, they could not meet stringent federal health and safety standards, and more patients would have to be  transferred to hospitals for treatment. Copyright 2004 ;The New York Times Company |