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New APA Study Documents Problems With Medicare Part D Plans Restricting Access to Medications for Dual Eligibles With Mental Illness

May 1, 2007

At a press conference today, the American Psychiatric Association (APA) released a survey of psychiatrists with important new findings on how dual eligibles with mental illness are faring under the Medicare Part D drug benefit.  Among the important findings in the study are that the psychiatrists surveyed in the study reported:

  • About 1/3 of patients (30.6%) could not access needed medication refills in the early months of 2006 – despite requirements put in place by CMS (the federal agency that oversees Medicare) requiring Part D drug plans to make such refills,
  • Medically necessary medications were terminated or interrupted for more than a fifth of patients (22.3%) because of plan formulary requirements,
  • Changes to patient’s ongoing medication was mandated – apparently, for no other reason than cost – for about one in five patients (18.3%) who had been stable on their original medication.

The study also finds disturbing consequences resulting from the efforts of Part D prescription drug plans to restrict access to medications – often in violation of CMS requirements designed to ensure broad access to antipsychotics, antidepressants and anticonvulsants.  The surveyed psychiatrists reported that among dual eligibles in their care:

  • More than one-fifth of patients (21.7%) suffered an increase in suicidal behaviors or thoughts,
  • Nearly one in five (19.8%) required an emergency room visit and more than one in ten (11%) required hospitalization.

Click here to read the APA study, which was published in the May edition of the American Journal of Psychiatry.

Click here to read an editorial accompanying the article.

It is important to note that this study reaffirms findings and positions that NAMI has advocated for more than two years:

  • That it is critical for Part D drug plans to meet their obligation for broad coverage of medications to treat mental illness – specifically to cover “all or substantially all” of the medications in 6 classes, including antipsychotics, antidepressants and anticonvulsants – currently required by CMS.  NAMI supports efforts to Congress to codify this requirement as part of the permanent Medicare law.
  • Congress should change Part D to waive cost sharing for dual eligibles residing in board and care homes, psychiatric residential facilities and congregate living arrangements – as is proposed in S 1107, legislation proposed by Senators Gordon Smith (R-OR) and Jeff Bingaman (D-NM).
  • Congress needs to amend Part D to allow for coverage of benzodiazepines which are currently excluded from coverage.