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Title: Medicare Part D: Don’t Let
it Sink Your Nursing Home Reimbursement
Author:
Joseph J. Tomaino, M.S., RN
Medicare Part D: Don’t Let it Sink Your Nursing Home
Reimbursement
Article Summary: This article summarizes the
challenges faced by nursing homes brought about by the
new Medicare Part D drug reimbursement program.
Practical and effective strategies to address these
challenges are offered.
On January 1, the new Medicare Part D program went into
effect. While this program offers relief to the many
older Americans who had no coverage for their
medications, and who often had to decide between buying
food and taking their medicine, it has offered new
challenges to long term care providers. Prior to Part D,
the medications given during a Part A Medicare stay in a
nursing home was largely the responsibility of the
nursing home, with a few exceptions. This remains the
same with Part D, and the same cost control strategies
(e.g. discontinuing use of low molecular weight heparin
medications used for prevention of DVT as soon as
patient is ambulatory) that have been used with this
population of patients are appropriate to continue. The
new wrinkle is the coverage for medications of the
patients who are dual eligible and not on a Part A
stay-- the chronic or long term population of residents.
These residents have had to select a provider for their
coverage under Part D, even though the medications
continue to be filled by the facility pharmacy or vendor
pharmacy. Each of these providers has a separate
formulary of covered medications. A drug that may be
preferred by one provider may not be by another. This
has presented a challenge for facilities to educate
their medical providers on these variances. Calls to
physicians and nurse practitioners from the pharmacy,
laminating formulary coverage grids of the various
providers, and meetings of staff and pharmacy
consultants are strategies that should be utilized for
this purpose. Medicare Part D verses Part B Issues:
Medicare has been issuing guidance regarding the
determination if a medication qualifies for coverage
under Medicare Part D or Part B. Some clarifications
include:
• While certain medications given through nebulizer or
pump are covered under Part B in a home care setting,
they are not in the nursing home setting
• Part B covers three categories of drugs: oral
anti-cancer, oral anti-emetic drugs given within 24 to
48 hours of chemotherapy and immunosuppressive drugs for
transplants paid for by Medicare. The list of these
covered drugs changes frequently, and should be
consulted periodically.
It is best to check with your local fiscal intermediary
for clarification on the above issues, since there may
be local interpretation of Medicare guidance. The final
challenge is the long term care resident who is not
covered by Medicare at all. For these residents, their
medications are not covered by Part D. In most cases
they were covered by Medicaid previously. In New York,
these residents are now covered by a small add on to
their daily rate, but many providers are finding that
this rate is far from adequate to cover the medications.
Facility staff should track these residents and their
associated costs, and apply the same cost reducing
strategies used for the Medicare Part A patients where
the facility is singularly responsible for the cost of
the medications. Part D will continue to present a
challenge throughout 2006. Be sure that you are tracking
your pharmacy costs, implementing your cost reducing
strategies, and keeping your staff informed of the
latest facts.
Joseph
Tomaino is a patient care executive, educator, and
consultant. His business, The Tomaino Group, provides
consultative services and products that support the cost
effective provision of quality patient care in acute,
sub-acute, long term care, and home care settings.
©
Copyright, 2006 All rights reserved, Joseph J. Tomaino,
The Tomaino Group, 834 Heritage Court, Yorktown Heights,
NY 10598
www.continuingcareinsite.info Email:
jtomaino@continuingcareinsite.info.
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