Hospice and Medicare D
In 2003 Medicare developed an outpatient prescription benefit that is commonly referred to Medicare D. This has been beneficial to Medicare beneficiaries as it assists them in the cost of their maintenance prescription medications and any acute medications that they may need. This program went into effect in Jan. of 2006.
Hospice is a managed care program covered under Medicare A. When an individual chooses hospice, the hospice becomes responsible for the cost of all medications related to their terminal diagnosis and related conditions that are designed for comfort and symptom control and all other medications related to symptom control as recommended by the hospice pharmacist and the hospice medical director.
The Office of Inspector General (OIG) published a report in June 2012 entitled “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice”. This is definitely a provocative title. As you read the report it becomes evident that the OIG believes that there are certain categories of drugs that hospice should always pay for and should not be billed to Part D. These are: analgesics, Antinauseants, laxatives, and antianxiety drugs. Additionally they looked closely at two terminal diseases, COPD and ALS, and felt that all drugs related to these diseases should be covered by hospice.
What I have found in working with people is nothing is black and white. The response of Front Range Hospice to this entire issue has been very thoughtful and extremely aggressive and we believe that we are paying for every pill that we should be paying for. We are contracted with a Pharmacy Benefit Management Company that specializes in hospice and provides us an evidence based medicine approach to our drug formulary. Our formulary is a starting point. We do go outside of the formulary when we have documentation that a patient has tried what is on the formulary and has either had a negative reaction or poor results.
We will not be paying for all medications prescribed for pain or for the terminal illness if there is evidence that it does not work. For instance, if a 75 pound female whose healthy adult height was 5’7” comes on service with end stage dementia and she is bed bound, no longer continent, no longer speaks, and 100% dependent for all activities of daily living we will not be paying for a fentanyl patch, Namenda, or Aricept if ordered by her primary care physician. Evidence based medicine tells us that a fentanyl patch needs fatty tissue to work and Namenda and Aricept are for early to mid-stages of dementia. If the family choses to keep her on these drugs, they should be paying privately and not billing Medicare D. Hospice has no control over what the family does and all we can do is educate.
Front Range Hospice has reviewed all of its medication profiles (sheets), and primary and related diagnosis with our hospice pharmacy and our Medical Director. For those medications that we do not feel are hospice pay, we have sent in the proper form to the Medicare D provider for each of our patients. We have been appalled by the lack of response of some of the Medicare D providers. It is impossible to reach a human being and now the patient or family must make the decision to either go off the medicine or pay privately and fight the insurance company. In the meantime, the Medicare D provider continues to collect the premium.
Personally, I do anticipate a fix for this is coming. I still have faith in our federal government. We can all speculate what that will look like but at the very least the Medicare D provider will be required to respond within a short period of time and a clear appeal process will be laid out. I personally will do everything within my power to advocate that the subscriber not be held up in the pharmacy. I am only one voice. I will keep you informed.