NEWS RELEASE

Columbia, MD - Physicians who care for frail elderly patients in long term care settings are still running into significant problems in obtaining appropriate medications under the Medicare Prescription Drug Benefit, according to a recent survey by the American Medical Directors Association (AMDA). In some instances, these problems have resulted in patients getting ineffective medications, getting medications late or not getting medications at all.

The survey shows some very modest improvements in some areas since a prior survey in June, but according to Executive Director Lorraine Tarnove, "Our members are still struggling with formularies and formulary restrictions that are making it difficult to provide appropriate drug therapy for nursing home patients."

According to the survey of long term care physicians,

• Nearly two-thirds (64%) indicated that they are still having trouble obtaining drugs due to requirements for prior authorization of drugs. These are drugs that are covered by drug plans on their formularies, but in practice may not be available due to administrative hurdles of prior authorization requirements. 70% had reported such problems in May.

• 43% of respondents reported continued problems with requests for exceptions for drugs that they feel their patients need that are not on drug plan formularies. Numerous physicians have reported that some drugs on the formularies are inappropriate for use in frail elderly patients, or are drugs that federal guidelines for long term care facilities recommend not be used or be used only with great caution. Other physicians report difficulties in obtaining approval for drugs that their patients have been taking for years. 55% of physicians reported such problems in May.

• 61% report problems obtaining certain drugs or types of drugs, a slight improvement from 73% in May. One physician reported that, "It seems like anything that is non-formulary results in hoops to jump through to try to get. I think they hope we will give up and give in."

• Of physicians who reported difficulty obtaining certain drugs, drugs to treat dementia were the most common, with 28% of physicians reporting problems primarily because of requirements for prior authorization (up from 23% in May). There is potentially significant impact on nursing facility patients who might benefit from these medications, as more than 40% of patients in long term care facilities have dementia. "Several drug plans have recently announced that they will no longer require prior authorizations for these drugs, and we are hopeful that access to dementia drugs will improve now," according to Ms.Tarnove.

• Additional drugs that haven proven challenging to obtain for nursing facility residents are proton pump inhibitors, which prevent and treat ulcers and other gastric diseases; pain medications; and erythropoietin, which treats anemia. There have also been reports of difficulty obtaining drugs to treat high cholesterol and high blood pressure, as well as infections.

Long term care physicians also report other significant administrative obstacles to obtaining medically necessary drugs. Each drug plan is allowed to develop its own procedures for drug approvals, exceptions and appeals, and physicians have to deal with many different drug plans for each nursing facility.

• Although the Centers for Medicare and Medicaid Services (CMS) has asked drug plans to use a common form for coverage determinations and exceptions, only 48.5% indicated that the majority of drug plans were using these common forms.

• 44% of respondents are spending more than 4 hours per week working with drug plans and pharmacies to obtain medications. "Although this is a bit better than the 52% reported in May, it is still an unacceptable burden on physicians to obtain medically necessary medications for their patients," according to Ms. Tarnove. She added that Medicare does not compensate physicians for this additional time.

• 5% of respondents indicated that drug plans require the physician to speak to them personally, in some instances to simply confirm what the physician has already communicated in writing.

Typically each nursing facility patient resident has 6 to 10 active medical problems and takes 9 or more prescription drugs. Considerable care must be taken with any changes in drugs to minimize potential adverse outcomes.

According to Ms. Tarnove, "AMDA is very concerned that the impediments to medically appropriate medications that many of our members are now experiencing will result in increased adverse drug reactions, as well as increases in adverse interactions between drugs and patients' other medical conditions."

According to AMDA President Steven Levenson, MD, CMD, "While drug plan concerns about cost and indications are understandable, clinical considerations (appropriateness, safety, and possible adverse consequences) must take precedence."

AMDA represents more than 8,000 medical directors, attending physicians, and others who practice in nursing facilities and other long term care settings. The majority of its members also maintain a private practice outside of their long term care responsibilities.

The American Medical Directors Association is the national professional association committed to continuous improvement of the quality of patient care by providing education, advocacy, information, and professional development for medical directors and other physicians who practice across the long-term care continuum.