Will Proposed CMS Rule Threaten Access for Seniors?

by Amanda Conschafter, Blog Editor

Medicare has money problems; that’s no secret. But health experts worry that a newly proposed rule to reduce costs by ending Part D’s access guarantee for specific medications could shake Medicare’s fundamental purpose: to keep America’s seniors healthy.

CMS’ plan seems simple. Eliminate protected status for three classes of drugs – commonly used antidepressants, antipsychotics and immunosuppressant therapies. Once the private insurers serving Medicare beneficiaries no longer are required to cover full access to these drugs, they can negotiate more effectively with manufacturers for lower prices – saving the program money.

But medical professionals and health policy experts foresee a different outcome. The National Council for Behavioral Health, The National Kidney Foundation, The National Alliance on Mental Illness and others fear that eliminating protections for these drugs will simply complicate patient access to them. Dr. David Shern of Mental Health America said, “These policies fail to acknowledge that physicians and consumers should make individualized treatment decisions, recognizing the unique and non-interchangeable nature of human beings and psychotropic medications, and acknowledging that lack of access to medications has both human and fiscal consequences.”

Those “human and fiscal consequences” are at the heart of the rule’s controversy. CMS seeks to drive down expenses by strengthening its negotiating muscle with America’s pharmaceutical companies. But without guaranteed access, patient suffering may be prolonged. And the resulting costs arising from side effects, incident recurrence, related diagnostics and other expenses may in fact hurt, not help, CMS’ bottom line.

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