September 30, 2004

Restrictive Medicare Benefits

This is a follow-up to a previous article (Schizophrenia newsblog post, Sept 27 2004) about new Medicare drug benefits, to be enacted in 2006.

According to the formula that is currently on the table, the number of prescription drugs covered by Medicare will be severely limited. The insurance plan will only be required to include two medications in each therapeutic drug class. There are currently no guidelines that specify how many classes a plan must cover.

This will potentially eliminate costlier (but possibly efficacious) medications in favor of cheaper ones.

Responses to medications are highly individualized, particularly in the realm of brain disorders. Psychiatrists and can spend weeks or months finding a regimen of medications that controls a particular set of symptoms. Under this new coverage, such flexibility may no longer be possible.

There is not enough current knowledge, clinical data, or specificity of action for most psychiatric drugs. This leaves doctors prescribing for their patients on a case-by-case, trial-and-error basis. In this sort of system, having many different options to try may be vital to finding a successful combination.

"You're basically tying the hands of your best clinicians," says Darrel A. Regier, director of research at the American Psychiatric Association. "You'd basically set psychiatry back 30 years" to a time when doctors had very few options for treating severe disorders.

Their are other concerns for people with psychiatric disorders who are currently covered under Medicaid. They are due to be switched to Medicare benefits in the near future (assuming that they qualify for both programs), and the new prescription drug benefits may not include their particular medications.

"Patients with state coverage now could run into trouble if they are forced to stop or switch their drugs when Medicare takes over in 2006," says Michael F. Hogan, PhD, director of the Ohio Department of Mental Health.

For the full article, see "Mental Illness Drugs Battle Medicare Plan" (Sept 27, 2004). Available at

The Centers for Medicare and Medicaid Services (CMS) is currently soliciting public commentary on these new draft regulations. The number and quality of comments recieved could make an impact in which provisions are accepted or rejected in the final draft. Please submit your own comments, and/or encourage your state affiliate to submit comments that reflect your particular interests or concerns. See NAMI's page on "Comments to CMS on Medicare Regulations" for more details.

Read the original newsblog report on changing medicare benefits (Sept. 7, 2004).


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