Prescription spending caps and seniors

Many seniors quit taking drugs for chronic illnesses such as diabetes and high blood pressure when they exceed their drug plan's yearly spending limits, according to a recently released study by the Rand Corp.

Even when drug benefits resume at the start of a new health plan year, a significant number of seniors do not resume their prescription medications, according to the findings.

The study, which examined the behavior of seniors enrolled in a national private health plan, provides insight into how seniors may act under provisions of Medicare's new drug benefit plan that will leave about one-third of enrollees without drug coverage for some part of each benefit year.

"Prescription use falls significantly as patients reach their benefit caps," said Geoffrey Joyce, the study's lead author and a senior economist at Rand. "Most of the drugs we studied help prevent long-term complications of chronic disease so there are likely to be adverse health consequences for seniors who hit their caps."

Researchers studied prescription drug use from 2003 to 2005 among more than 60,000 people enrolled in a health plan offered to retirees by a large national employer. Enrollees had a choice of two drug plans that offered annual drug benefit caps of $1,000 or $2,500 and one drug plan that had no spending limit. Participants had to pay a portion of individual drug purchases in each of the plans.

The study examined enrollees' use of drugs used to treat high blood pressure, drugs that target cardiac problems, diabetes drugs, ulcer treatments, and antidepressants. Researchers also studied prescription pain medications that have over-the-counter substitutes.

About 6%-13% of the people enrolled in drug plans with caps reached their spending limits in each of the years studied, with about half the affected enrollees going without benefits for more than 90 days, according to the study.

High spenders in the capped plans were more likely to discontinue use of their medications than people enrolled in the plan with no spending limits, according to researchers. Discontinuation rates differed by type of drug, ranging from 15% for anti-cholesterol medication to 28% for cardiac drugs. Rates were higher for pain medications and anti-ulcer drugs where over-the-counter alternatives were available. Among patients who stopped taking a medication in the capped plan, more than half did not restart their prescriptions during the first three months after benefits resumed.

"Given the importance of these drugs, it's distressing that the resumption rates are not higher," said Dana Goldman, the study's senior author and director of health economics at Rand. "Drug caps are a cost-saving measure, but our findings raise the issue of whether in the long run they may lead to other medical costs such as increased hospitalizations."

Joint Commission offers new COPD program

The Joint Commission is accepting applications from facilities interested in obtaining certification for chronic obstructive pulmonary disease (COPD) management.

The program was developed in collaboration with the American Lung Association and requires organizations to meet standards and performance measurement requirements. Successful efforts include:

  • A standard method of delivering or coordinating care;
  • Implementation of evidence-based clinical practice guidelines;
  • A secure and timely system for sharing information across settings and providers, which safeguards patient rights and privacy;
  • A comprehensive performance improvement program which uses outcomes data to continually enhance existing treatment plans and clinical practices;
  • Clinical practices that support patient's self-management activities.

Providers reminded NPI required beginning Jan. 1

Claims without it 'unprocessable'

Beginning Jan. 1, 2008, the Centers for Medicare & Medicaid Services (CMS) will require hospitals and other health care providers to use a National Provider Identifier when they bill Medicare fiscal intermediaries and Medicare administrative contractors, the agency said in a recent notice.

Claims that contain only a legacy provider identifier in the primary fields will be returned as "unprocessable," CMS said. The agency said it was taking "the next step toward full implementation of the NPI" because the "vast majority" of institutional providers already include the NPI on their Medicare claims.

Providers may include both an NPI and legacy identifier in the primary fields through April 2008. CMS recommends, however, that they submit at least some claims with only an NPI to ensure their claims will be processed successfully when an NPI alone is required beginning May 1, 2008.

Rejected claims, delayed reimbursement, and potentially lost reimbursement will result if hospitals don't have the proper processes in place, cautions Beth Keith, CHAM, senior management consultant for ACS Healthcare Solutions.

Providers should have taken the following steps, Keith says:

  • Obtained NPI numbers for all required providers;
  • Cleaned and corrected existing provider master files;
  • Mapped a crosswalk with NPI numbers and UPIN, payer identifiers, etc., for all providers

The change affects providers' information technology systems as well as their reimbursement, Keith notes, in that current claims processing systems must accommodate the NPI identifier.

ED visits up by 5.1 million according to CDC report

Visits to hospital emergency departments increased by 5.1 million in 2005 to 115.3 million, according to a recent report by the Centers for Disease Control and Prevention.

That is an average of about 30,000 visits per ED, nearly one-third more than in 1995. The ED visit rate for patients without health insurance was about twice that of those with private insurance, according to the report. Infants under age 1 had the highest visit rate by age. The leading diagnosis for children under 13 was acute upper respiratory infection.

Other top diagnoses by age were bruises, adolescents; abdominal pain, adults under 50; chest pain, adults 50-64; and heart disease, seniors. About 12% of ED visits resulted in hospital admission. The leading diagnosis at discharge was heart disease.