The program of the mental health
THOSE OF US IN CLINICAL practice are well aware of the many problems associated with the high cost of psychotropic medications, particularly for the elderly. On several occasions within the last year, I have had an elderly patient who stopped taking his or her psychotropic medication because the individual could not afford the cost of the medication. The situation is complicated by the fact that many of these elderly individuals who suffer from a psychiatric condition also have numerous comorbid physical conditions. A typical example: When cost is a factor and the choice boils down to taking a medication for depression or a medication for what is perceived as a life-threatening condition (e.g., a cardiac condition), the cardiac medication wins out. It is clear therefore, that in the short term, the Medicare Prescription Drug Benefit will assist many elderly to obtain the medications that they need at a lower cost, particularly those elderly individuals who suffer psychiatric conditions.
On December 8, 2003, George W. Bush signed legislation that will entitle the 41.7 million disabled and elderly beneficiaries of Medicare (many of whom are psychiatrically disabled) to new coverage of prescription drugs. The drug benefit takes effect January 2006. Additionally, a temporary drug-discount program is to be established as a stopgap measure to assist individuals before January of 2006.
The Medicare Benefit Program represents the largest expansion of Medicare since its enactment in 1965. Such resources will reduce the overall costs of prescription drugs, which, for the entire U.S. population in 2002, increased at a rate of 15.3% and represented 10.5% of all personal health expenditures that year.
Although no one questions the need for assisting the elderly with prescription costs, it is less clear what the exact goal of the program is and what the long-term benefit of the program will be. Those who are cynical of the legislation claim that the overall nature of the program sounds more Democratic than Republican in philosophy and emphasize that this is an election year. Consequently they contend that a partial goal is for Bush to inoculate himself against the Democratic charge that Republicans are the enemies of Medicare and thus Republicans would oppose enactment of an expensive new benefit for those covered by the program.
The second, more serious set of issues, involve the manner by which the legislation evolved, exactly what the benefit will be for the elderly, and the exact cost of the program. Considering the evolvement of the legislation, the final Medicare measure was an odd mixture of provisions that are part of the give-and-take of a political process. More importantly, however, its enactment demonstrated the enormous power of the presidency, once a chief executive takes up with an issue. President Bush paid little mind to Democrats who sought to thwart achievement of his goals. He also ignored the protests of conservative-leaning think tanks, editorial page writers, columnists, and Republican legislators who argued persistently that the Medicare legislation was a band-aid measure that failed to adequately modernize the program.
The cost-saving to the elderly is also not clear. The Department of Health and Human Services estimates that, with the drug-discount cards, Medicare beneficiaries will be able to obtain savings of 10% to 15% on their total drug costs. The actual savings will depend on how successful the issuers of drug-discount cards, pharmacy-benefit managers, health insurers, chain drug stores, and others are in negotiating discounts with drug manufacturers and what proportion of the discounts are passed along to the beneficiaries. The drug discount program will end when the Medicare drug benefit takes effect in January of 2006.
The most talked about and controversial issue involves the cost of the program and the manner by which cost estimates were given to legislators and the public. On March 24, 2004, Richard Foster, a top Medicare official, told Congress that he had considered quitting in protest to what he called an unethical Bush administration effort to stop him from telling lawmakers the cost of the Medicare legislation. He told the House Ways and Means Committee that he wanted to fight what he called inappropriate decisions to keep Congress from finding out that his cost estimates for the program were more than $100 billion higher than theirs. The administration has acknowledged it believes the law will cost $584 billion over 10 years. This compares with $395 billion estimated by congressional budget analysis.
Today the focus is shifting from the debate in Congress to implementation issues of this 678-page law. I believe that, all of the above issues put aside, it is the implementation process that most closely involves psychiatric mental health clinicians. Every 2 months the Kaiser Family Foundation conducts a survey concerning health care topical issues important to the public. This survey is designed and analyzed by staff at the Foundation and colleagues at the Harvard School of Public Health. Findings from the January/February 2004 poll show that that while about two-thirds of seniors report following the debate closely, just 15% say they understand the new prescription drug law very well and 7 in 10 do not know that it passed and was signed into law. Findings from the March/April 2004 poll show that when asked if the new Medicare law includes a prescription drug discount card, about 6 in 10 seniors “didn’t know enough to say” or said it wasn’t included. Awareness of the subsidy for low-income seniors is even lower, with only 18% of seniors aware of a new $600 subsidy to help low-income seniors with their drug costs.
Tags: mental health