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Kenneth Thorpe Headshot

Proposed Medicare Changes Threaten Nation's Most Vulnerable

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DElight via Getty Images
DElight via Getty Images

Despite the fact that Medicare's per capita cost increases are at historic lows, policymakers continue to look for ways to put new constraints on program spending. There's nothing inherently wrong with that. In fact, given the rapid growth in the beneficiary population with the retirement of the baby boom generation, it's increasingly important to find ways to make Medicare more cost-efficient.

What's shortsighted, though, is instituting ill-conceived changes that will not only fail to rein in Medicare's long-term spending growth, but will inflict severe and unnecessary harm on our nation's poor and elderly who are suffering from serious physical and behavioral illnesses.

A proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) would make significant changes to the Medicare Part D prescription drug program. In short, the rule change affects what are known as the "protected classes" of pharmaceuticals under Part D -- classes of drugs in which, under current law, coverage must be provided for "substantially all" medicines. The logic in maintaining these protected classes is inarguable. Medicare beneficiaries coping with serious, chronic illnesses should have access to the medications that they and their physicians have deemed the most effective treatment for their conditions.

Medications are not interchangeable. One drug can have vastly different effects, and side effects, on different patients. Thus, Medicare Part D is structured to ensure that patients who require antidepressants, antipsychotics and immunosuppressants (critical drugs for patients who have undergone organ transplants) have access to the unique medicines they need to protect their lives and health.

CMS is clearly missing the mark with this proposed change. By removing the protected class designations, as the agency is recommending, Medicare will now provide coverage to far fewer medications in each class. Depression is unfortunately common among Medicare beneficiaries, with estimates of one in four suffering from major or chronic depression. Depression profoundly impacts a person's quality of life and increases healthcare costs dramatically when poorly managed.

Currently people suffering from depression and other behavioral illnesses have choices among 23 generic and seven brand-name antidepressants on a typical Part D formulary. Under the new proposal, access would be limited to nine generic drugs. For far too many patients, losing coverage for medicine to manage depression will drastically and negatively affect their health and their lives, and drive other costs up for Medicare.

It's easy to identify the people who will suffer the greatest consequences from this proposed rule change. Three out of every four older Americans suffer from multiple chronic conditions and depend on a variety of medicines. These patients and their physicians take care to ensure the right mix of medications to address their illnesses, maintain their health and avoid adverse drug interactions. The treatment complexity involved and risks to patients increase substantially with fewer drugs available.

Those with the fewest resources will bear the harshest impact. Studies consistently show that senior citizens at the lowest income levels have, on average, more chronic illnesses than those with greater financial resources. In fact, in 2011, 83 percent of Part D prescriptions for antipsychotic drugs were filled by Medicare beneficiaries receiving low-income financial assistance. This proposed regulatory change will unquestionably result in a degradation of health care for those who don't have the money to seek other options.

The sad irony here is that making these proposed changes to Medicare Part D won't result in the hoped-for cost savings. These protected classes of drugs aren't resulting in exorbitant costs to the Medicare program. The vast majority of the time, the prescriptions filled under the protected classes of pharmaceuticals, are low-cost generics. The tools to control costs already exist under the Part D program -- without unnecessarily restricting access and choices.

The best way to make Medicare more cost-efficient is to help patients better manage their chronic illnesses and avoid long hospitalizations and expensive acute care episodes. The CMS proposed rule change will do just the opposite. Restricting access to the medicines patients need to manage depression, avoid organ transplant rejection, and treat psychosis will drive healthcare utilization in far more costly ways. That's a betrayal of Medicare's promise of access to care for our most vulnerable, older Americans.