Annals of Long Term Care

Change is coming—in the form of the Stimulus Package, as well as President Obama’s healthcare reform plan. Actually, change is clearly upon us. The elements of this change have been happening slowly over the last several years, of course. Much occurred well before President Obama’s Stimulus Bill, the American Recovery and Reinvestment Act of 2009, was signed into law.

In 1993, key members of Congress led by Senators Max Baucus (D-MT) and Edward Kennedy (D-MA) agreed on four principles that appear to remain as the foundation for our current round of reform. These principles are:

Think of the world of accessing medications as a big bull’s eye. In Medicare’s perception, that is exactly the way that the market for pharmaceuticals should be viewed. Medicare believes it must play a very active role, as it believes that many key players will aim poorly, completely missing their desired target. And in the worst-case scenarios, prescribers’ aim will be so poor that they may actually wind up hitting patients who have adverse events because of access to an inappropriately prescribed medication. Rofecoxib is an example of “poor shooting” because of inadequate oversight

Unlike the rest of the U.S. economy, reimbursement for healthcare is not a simple matter of supply and demand. Reimbursement decisions are based to an increasing extent on politics. Not surprisingly, this nonmarket approach has resulted in quality concerns in healthcare. Less-than-optimum healthcare outcomes are in part due to the lack of capital and incentives available from the current reimbursement system—a reimbursement system that unfortunately has become a matter of politics, forcing physicians and other providers to manipulate or “game” the system in order to obtain more appropria

Oversight of long-term care (LTC) prescribing is getting a little more difficult because, on top of the restrictions on access imposed on prescribers as a result of Medicare Part D, there are now additional pressures being applied by LTC state surveyors. These new surveyor pressures are the results of the revised survey guidelines concerning pharmacy services and unnecessary medications that were introduced on December 18, 2006. In addition to these factors, it appears likely that legislative changes planned for Medicare Part D may place even greater restrictions on prescribing.

The Need fo

Before the new plan year starts on January 1, marking once again the beginning of the prescription drug benefit cycle, many Medicare beneficiaries will find themselves having a difficult time obtaining their medications because of the gap in coverage. This gap in coverage, commonly referred to as the “donut hole,” is the period in the Medicare Part D benefit when the beneficiaries are completely responsible for the cost of their medications.

While many long-term care (LTC) residents are not subject to the donut hole, a fair number of them unfortunately are. The Kaiser Family Foundation