So the buzz is around the office today about new Medicare Part D changes that are going to majorly and adversely affect patients and their families, and also be the death knell for hospices throughout the country.
See the following link for the actual final determination and new rules that are supposed to be effective May 1, 2014:
The Readers' Digest version of this new policy is that patients, once enrolled onto hospice services, will only be covered for medications directly related to the palliation and symptom management of their illness. In example, Sally Jones is admitted to hospice with a Dx: Cervical Cancer. Medicare will now only cover medications directly related to this illness (e.g. Analgesics, Anti-Emetics, Laxatives/Stool Softeners, Anti-Anxiety). But if Sally Jones also suffers from COPD and is also s/p CABG, medications related to those diagnoses will no longer be covered under Medicare Part D and will become the liability of the patient or the hospice provider if they so choose to cover the medications.
So what this means is that hospice patients facing terminal illness for one problem may very well become at greater risk secondary to other comorbidities than their primary diagnosis. Additionally, this will add financial stressors to families already dealing with terminal illness. Coupled with the cuts already hitting hospice providers last year, this is surely going to sink some hospices altogether. And we'e already seeing patients getting their rejection notices for medications two months ahead of this change being implemented.
I'm curious to know thoughts on this. Is this buzzing within your own work culture? Better freshen up those resumes, ladies and gents, because this could be a game changer.
I've worked as a surveyor/regulator for my state and CMS in the past, and, in my experience, these kinds of rule changes are always reactive, not proactive. In other words, they are usually implemented as a response to some widespread, longstanding problem, which I suspect, in this situation, is likely inappropriate/excessive charges (or, at least, sloppy work) by too many hospices around the country.
I would expect that it is not a "death knell" for hospices so much as a "wake-up call." Hospices that are committed to providing people appropriate services will manage to continue to serve families within the new guidelines and requirements. Hospices that are primarily looking to maximize revenues/incomes will be in some trouble.
This is amusing to me, only insofar as hospices existed and did fine PRIOR to the existance of the Part D coverage at ALL!! Hospices picked up the cost of related drugs, and un-related meds were at the discretion of the family and physician. I agree, not a "DEATH knell", but a "wakeup and get with the program" call.
Example: hospice pt with cops dx; comorbidities HTN, DM.
Meds:
-Albuterol (hospice covered)
-Ambien (not hospice formulary, been long term therapy not r/t dx anyway. Medicare part D/supplemental says no longer formulary so won't cover)
-Humalog (non covered thru hospice, Medicare part D pays)
-Roxanol (hospice pays)
-lopressor (Medicare part d/supplemental pays)
-cymbalta (pt has long standing depression, not hospice formulary or covered by hospice, Medicare part D/secondary says no longer on their formulary so not covered)
As far as ambien and cymbalta, they are no longer covered or formulary for Medicare D/supplemental. Of course pt can be switched to an alternative medication which is on their formulary. PCP just needs to approve change.
Did I get it right? This is my understanding.
When pts elect hospice, they don't generally drop their supplemental, as they still need prescription coverage for unrelated meds, as well as unrelated hospitalizations.
Correct me if I'm wrong....
Ambien (zolpidem) and Cymbalta (duloxetine) are both still included in the part D formulary, just not the brand name versions, only generic zolpidem and duloxetine are covered. Part D does cover a number of brand name meds even when generics are available when there is a difference in their effect in some patients, such as Coumadin.
Ambien (zolpidem) and Cymbalta (duloxetine) are both still included in the part D formulary, just not the brand name versions, only generic zolpidem and duloxetine are covered. Part D does cover a number of brand name meds even when generics are available when there is a difference in their effect in some patients, such as Coumadin.
Actually part D does NOT pay for ambien or cymbalta (brand or generic), as they expect part A (hospice) to cover (FOR HOSPICE PTS). Therefore, either a comparable is prescribed & covered by hospice, or the Pt pays out of pocket.
I spoke with a pharmacist in great detail just today regarding these two medications and that is what he told me. Regardless of it being formulary (Medicare) or not.....Part D expects Part A to cover.
Zolpidem is about $8/month out of pocket (should be hospice formulary at this price). Cymbalta/generic were both very unreasonably expensive, in my opinion.
Exactly. Few seems to understand how far reaching this change is. It's more than covering the terminal diagnosis, it's bundling secondary diagnoses and conditions that contribute to the pt's decline, it's more cost burden on the hospice agency, and there's no planned increase in hospice reimbursements.
Specializes in NICU, PICU, Transport, L&D, Hospice.
Exactly. Few seems to understand how far reaching this change is. It's more than covering the terminal diagnosis, it's bundling secondary diagnoses and conditions that contribute to the pt's decline, it's more cost burden on the hospice agency, and there's no planned increase in hospice reimbursements.
Informative.
I agree that the hospice should pay for and manage the pain medication and POC for the dementia patient with a broken tooth. The hospice providers are the palliative specialists, after all, and will insure that adequate pain control is achieved at the least cost in quality of life or by financial cost.
When my cancer patient fell and broke her collar bone the hospice team paid for and managed her comfort relative to that fracture.
When the Heart failure patient requires antidepressants or sleep aids, the hospice should pay for them. When the COPD patient has back pain, the hospice should manage and pay for those medications.
When the pharmacy refuses to fill an insulin prescription for the COPD patient I expect that there will be some fireworks. The pharmacy needs to bill appropriately.
Actually part D does NOT pay for ambien or cymbalta (brand or generic), as they expect part A (hospice) to cover (FOR HOSPICE PTS). Therefore, either a comparable is prescribed & covered by hospice, or the Pt pays out of pocket.
I spoke with a pharmacist in great detail just today regarding these two medications and that is what he told me. Regardless of it being formulary (Medicare) or not.....Part D expects Part A to cover.
Zolpidem is about $8/month out of pocket (should be hospice formulary at this price). Cymbalta/generic were both very unreasonably expensive, in my opinion.
They expect part A to cover all medications related to the terminal diagnosis and palliation of symptoms. As far as I can tell, CMS is not saying that hospice patients can no longer have part D coverage (for non terminal Dx/palliation meds), but that prior approval must be obtained from the sponsor (which basically means it must be re-ordered specifically and truly necessary). It won't be as easy to continue a hospice patients statin through part D as it used to be, nor should it be. If it's unrelated to the terminal diagnosis, and survives the prior approval process, cymbalta could be continued and billed under part D, even under the new rules.
It seems what started all of this was hospice companies not covering pain medicine. The company I work for ALWAYS covers symptom related medications, even if not related to terminal dx. Its called GOOD CARE. Its absurd to me there are actually hospices not willing to cover these meds.
If you watched the video included on the link I listed above (hospice action network), they talk about this. The example they gave was an Alzheimer's pt with a toothache and that hospice was not responsible for the pain medicine because Alzheimer's is mental dz; therefore, not related to the toothache. I was floored by this particular example. Seriously?! Really!?!
Ridiculousness like not providing pain medicine for ANY pt was not worth the changes we are about to endure. BTW Medicare has stated they are going back and recouping the money for pain medicine not covered by hospices in the past few years.
Sadly this decision makes it hard to get referrals early enough in the dz to perform adequate teaching/counseling/support. Cancer pts are generally pretty functional (due to trajectory of illness) on admission, and will likely want to continue their "other" medications. If I were the pt, I would feel like "wow, Medicare isn't gonna cover my unrelated meds, they really want me to die quick"
Medicare is actually performing a pilot study in which hospice pts are allowed to receive aggressive trmt for their terminal dz. Wow.....from one extreme to the next......yep! That's a government to be proud of...
Cymbalta IS NOT covered under Part D. I spent a nice chunk of my day yesterday speaking with pharmacists (hospice & public). Part D said NO. The pt was switched to a hospice formulary antidepressant. Now, no I did not attempt to get PA because Medicare says Part D will only cover unrelated meds for hospice pts in those "rare & unusual circumstances" (likely insulin & such). I didn't feel needing cymbalta was rare/unusual.
Specializes in NICU, PICU, Transport, L&D, Hospice.
Again, it goes back to regulation changes reflecting a reaction to historical practice. Agencies were abusing the regulations soooo, the regulations got tightened.
toomuchbaloney
16,061 Posts
Sounds like you have it right.
Designer drugs, Ambien and Cymbalta need to go.
Most PCPs will comply if the patient agrees to use alternate med.