Plan to Limit Some Drugs in Medicare Is Criticized
By KATIE THOMAS and ROBERT PEAR FEB. 21, 2014
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Emily Shetty, a lobbyist for the Leukemia and Lymphoma
Society, said Medicare beneficiaries, who include older and disabled Americans,
should be treated with special care. Daniel Rosenbaum for The New York Times
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An alliance of drug companies and patient advocates, joined
by Democrats and Republicans in Congress, is fiercely opposing an Obama
administration proposal that would allow insurers to limit Medicare coverage
for certain classes of drugs, including those used to treat depression and
schizophrenia.
Opponents warn that the proposal, if enacted, could harm
patients. Federal officials say it would lower costs and reduce overuse of the
drugs.
The proposed rule, which would lift a requirement that
insurers cover “all or substantially all” drugs in certain treatment areas, is
just one of a series of changes to the drug program that are being opposed by
the unlikely alliance. Even insurers and drug benefit managers, who have
previously supported added limits on drug coverage, oppose the rule. They
object to provisions including changes to so-called preferred pharmacy
networks, where consumers are steered toward a limited network of pharmacies,
and to reducing the number of plans that insurers can offer in any one region.
A House subcommittee plans to hold a hearing on the proposal
next week, and the rule is open for public comment until March 7.
“We’ve been scratching our heads over this,” said John J.
Castellani, the chief executive of the Pharmaceutical Research and
Manufacturers of America, the drug-industry trade group. Medicare Part D, he
noted, is the rare government program that not only gets high marks from
consumers but also has cost taxpayers billions of dollars less than originally
expected. “Why is the administration trying to make such extensive changes to a
program that isn’t broken?”
Mr. Castellani’s organization was one of more than 200
groups that signed a letter this week asking that the rule be withdrawn.
Earlier this month, Republican and Democratic members of the Senate Finance
Committee warned that the proposal could “diminish access to needed medication”
without saving much money.
The administration’s proposal would remove the protected
status from three classes of drugs that has been in place since the program’s inception
in 2006: immunosuppressant drugs used in transplant patients, antidepressants
and antipsychotic medicines. They include many well-known drugs, such as
Wellbutrin, Paxil and Prozac to treat depression, and Abilify and Seroquel to
treat schizophrenia. Three other categories — cancer, H.I.V. and anti-seizure
drugs — would retain their status as protected classes and insurance companies
would be required to continue covering nearly all drugs in those treatment
areas. Medicare has traditionally required the broad coverage because patients
with these conditions must often try several drugs before finding one that
works.
In proposing the change last month, the administration said
that the policy was envisioned as a temporary measure to help ease patients’
transition to the new Medicare drug program, and that since then, insurers had
lost their leverage in negotiating with drug companies because the drug
companies knew the insurers were required to cover their drug costs and were
therefore less willing to offer lower prices.
In its proposal, the Obama administration cited a 2008 study
by the actuarial and consulting firm Milliman that showed that the six
protected classes accounted for anywhere from 17 to 33 percent of total
outpatient drug spending under Part D of Medicare. In addition, it said that
the costs of those drugs were on average 10 percent higher than they would be
without the requirement to cover substantially all drugs in these classes.
The administration predicted savings for both beneficiaries
and the Medicare program if prescription drug plans could remove some currently
covered drugs from their formularies. It could also give insurers additional
tools to limit overuse of certain drugs, such as the prescribing of
antipsychotic drugs to nursing-home patients with dementia, a common practice
that is widely viewed as inappropriate.
“We believe the Part D program has been a phenomenal
success,” said Jonathan Blum, principal deputy administrator of the Center for
Medicare and Medicaid Services, which oversees the Part D program. But, he
added, “We also see vulnerabilities in the program, and we have proposed for
public input into ways to improve it.”
Leaders of numerous patient advocacy groups, many of whom
met last week with White House officials to express concern about the proposed
rule, said they were worried that patients could be harmed if the policy
changed.
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