Of Illinois Politicians, Government Budget Woes, and Disappearing Medicare Drug Benefits

I have always thought of Senator Dick Durban (D), the senior U.S. Senator in IL, as pretty much of a gentleman. In a state where four out of our last 7 governors have been convicted and imprisoned (the last one, one Rod Blagojevich, was convicted on 18 counts of corruptions–although my uncle to this day contends that being stupid is not a crime, and, lest we pity poor Rod too much, we’re informed cheerily by the news that he’s taking his time in jail to truly think about his crimes–and, apparently, to learn to play guitar and to “run miles and miles around the quarter-mile track,” which distinctly reminds me of one of our worst pets as children, who ran ’round his squeaky habitrail for hours every night, keeping awake the dog and the parakeet.).

But I digress. Back to Senator Durbin, who has–as far as I know–never tried to sell someone else’s Senate seat, or, once he was at it, tried to sell drivers’ licenses, never used the S&L as his “personal piggy bank,” and has no known history of mail fraud, conspiracy, or perjury. [Kind of boring, really. It’s amazing we keep him around. Have you noticed we’ve begun sending our Reps to jail, too.  Can Senators be safe?]

This is all relevant; you have to take it on faith.

When I heard that the Obama administration actually thought it was a good idea (and you do wonder how much thought could have gone into this) to limit required coverage for 3 types of medicines, two of which are really requisite for treating mental illness, I woke from my writer’s block slumber. I mean, you can only muck around with me so much and quit covering so many of my medicines  before I decide it’s time to do something–and when all else fails, I figure I might as well write my Senator.

See, Medicare’s prescription drug benefit plan has only been around since 2006, and since then it’s been required to cover “all or substantial” drugs in six treatment areas:

1. Cancer drugs;

2. HIV drugs; and

3. Anti-convulsant or anti-seizure drugs.

These three were not to be touched under the newly proposed Obama plan.

As to the next three, trying to figure out why they got cut involved weeding through so much governmentese (just so you don’t feel left out of my experience, it went something like this [with the bottom line bolded for you in case your eyes glaze over around the “AHFS–6 classification system” part of it]:

We convened a consensus panel of CMS pharmacists and the Chief Medical Officer for the Center for Medicare to identify which drug categories or classes met our proposed criteria for clinical concern. The panel was supported by a contractor that performed background research and provided specific information on Part D utilization by drug category or class and associated widely-accepted treatment guidelines for each drug category or class, when available. The panel reviewed all Part D drugs with utilization in 2012 using the American Hospital Formulary Service (AHFS)–6 classification system. We chose the AHFS–6 classification system as a framework because it provided us with a tool to logically, and in stepwise fashion, apply the criteria to all Part D drugs. A detailed synopsis of the panel’s findings is posted at http:// http://www.cms.gov/Medicare/Prescription- Drug-Coverage/PrescriptionDrug CovContra/RxContracting_Formulary Guidance.html. The consensus panel determined that of the current six drug categories or classes of clinical concern, three (anticonvulsants, antineoplastics, and antiretrovirals) meet both of the proposed criteria, and three do not (antidepressants, antipsychotics, immunosuppressants).”

Ok, translation: the administration’s proposal would remove the protected status from three classes of drugs, a status that has been in place since the program’s inception: immunosuppressant drugs used in transplant patients, antidepressants and antipsychotic medicines. Although the immunosuppressants get less wide play in the popular press, the latter two classes include many well-known (not to mention blockbuster) drugs, such as Wellbutrin, Paxil and Prozac to treat depression, and Abilify and Seroquel to treat schizophrenia or mania, among other illnesses.

So. . . .the criteria for booting out these latter 3? There were 2:

1. “Hospitalization, persistent or significant disability or incapacity, or death likely will result if initial administration (including self-administration) of a drug in the category or class does not occur within 7 days of the date the prescription for the drug was presented to the pharmacy to be filled;” and

2. “More specific CMS [that’s the Centers for Medicare and Medicaid Services] formulary requirements will not suffice to meet the universe of clinical drug- and disease-specific applications because of the diversity of disease or condition manifestations and associated specificity or variability of drug therapies necessary to treat such manifestations.”

Apparently, immunosuppressants were so close they could almost taste it. They passed the first test (given that they lower the body’s ability to reject a transplanted organ, one would most certainly think so)–but failed the second (which is quite understandable, since not only do I myself not know what #2 means; a significant search on the Web didn’t illuminate its precise meaning greatly either).

As for Prozac and its ilk? They bombed altogether, failing to meet either of the criteria.

The antipsychotics were back to an even split–they met the first criterion–but not that elusive second one.

However, in a moment of true insight, the CMS actually seemed a wee bit nervous about cutting coverage of antipsychotics (and I mean, really, could this seem like a good idea? People go on about overuse/abuse of these drugs in nursing homes–but have they ever dealt with actively psychotic patients?).

In fact, the government must have had the image of the unmanaged psychotic in its head when it decided it would hold off on the antipsychotic change until 2015. As they explain, “This is because the risks associated with untreated psychotic illness, as differentiated from the broad category of mental illness, have the potential to be so severe.” Um, right.

These cuts were a  hard sell for me–it’s not that I take a drug in each of the classes–but a significant number of the names bandied about as coming off Formulary are more than familiar. So when the National Alliance for the Mentally Ill (NAMI), the nation’s largest nonprofit grassroots advocacy group for the mentally ill, asked me to email my Senator (they basically sent me a personal email, with a link to click to reach Mr. Durbin; it didn’t exactly take a huge amount of effort on my part), I was pretty much willing to cooperate.

While saying, in essence, absolutely nothing (although he does re-state the exact problem that I am writing to him about, which makes it look like this is a seriously long response, while making me wonder what he thought we were corresponding about; so feel free to skip the 2nd paragraph, if you are, in fact, reading any of it), the Senator honored my letter by answering it.  He made it at least seem like he really cared (ok, not in that President Clinton way–but I don’t really require that much); and acted like he would be just happy as a clam to hear from me again, should another issue arise (which I have absolutely no doubt it will, given the costs of many of these medications, and the state of government finances).

February 26, 2014
Ms. Rhona Finkel
. . . .
Dear Ms. Finkel:
Thank you for contacting me about the proposed changes to the protected class status of some medications under Medicare Part D. I appreciate hearing from you.
In January 2013, the Centers for Medicare and Medicaid (CMS) announced that it was reevaluating the criteria for protected drug classes under Medicare Part D. Currently, Medicare is required to cover all drugs in six protected classes – anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals and immunosuppressants. For unprotected classes, Medicare is required to offer two products in each drug class – often a brand name and a generic alternative. CMS is determining whether to change the current system.
Proponents of changing the current policy state that instead of mandating coverage of all drug products in a particular class, savings can be realized by identifying the most effective and efficient medications in each class. Opponents of change argue that these medications are not interchangeable and that preserving clinical judgment and personal choice in prescribing these medications is essential to achieving good clinical outcomes.
I have consistently supported health initiatives for Medicare beneficiaries. I will keep your views in mind as my colleagues and I grapple with the difficult task of controlling the growth of Medicare spending while preserving beneficiaries’ access to high quality care.
Thank you again for contacting me. Please feel free to stay in touch.
Richard J. Durbin
United States Senator”
Nice man, no?  You, too, can receive a letter like that the next time something like this arises.
And you know what? With all the people posting, tweeting, texting, screaming–whatever they do to make a fuss–well, it just worked.
On the 10th, CMS Administrator Marilyn Tavenner wrote to Congress that she was shelving the proposed changes–and advocacy groups took a victory lap (see “NAMI Celebrates Victory in Preserving Medicare Part D Access to Psychiatric Medications“).
So, please, keep an eye out, and be ready to throw a fit the next time the government tries to manage its sad state of financial affairs on the backs of the mentally ill.
Because if we don’t do something, we’ll have, as Woody Allen said in the beginning of Manhattan, “10 million crazy people on the streets of Manhattan.”  He was referring to the psychoanalysts’ habit of all taking vacations in August.
That’s a drop in the bucket–almost laughable–when you think of the results of radically cutting patients’ access to antidepressants and antipsychotics.

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