Keep Medicare Part D's Six Protected Classes Protected
Recently, the Centers for Medicare and Medicaid Services (CMS) proposed an extremely troubling regulation that would weaken Medicare Part D, the federal health insurance program that helps 45 million American seniors and people with disabilities afford prescription drugs.
Part D is somewhat unique among government programs. The federal government doesn't provide coverage directly. Instead, it allows people to purchase coverage from private insurers, who offer a range of different plans. The government subsidizes these plans but otherwise lets Medicare beneficiaries choose the coverage that's best for them.
However, Congress did put some guardrails on insurers when it created the Part D program in 2003. In particular, it required Part D plans to cover all medications in six "protected classes" of drugs, including antipsychotics, antidepressants, and anticonvulsants. These medicines help treat people with schizophrenia and other psychiatric illnesses.
The proposed regulation from CMS would amend the six protected classes rule and allow insurers to exclude many drugs from Part D plans. Millions of Americans who rely on these crucial medications would be left to fend for themselves in a healthcare system that is already overburdened and challenging to navigate. Congress must act to halt this regulation now.
Our nation is struggling to provide appropriate care for people with schizophrenia and other psychosis-based illnesses. Already, these patients die 10 to 28 years sooner (p. 11), and hundreds of thousands of people with serious psychiatric illnesses have been "re-institutionalized" in state prisons and county jails.
The real-life consequences of reducing access to antipsychotic medicines are frightening. CMS is advancing this rule as a cost-saving measure. But any short-term savings would be canceled out by increased government spending on emergency rooms and the penal system, since more people with serious brain disorders will end up in county jails throughout the nation.
In addition to antipsychotics and anticonvulsants, which are often employed in the treatment of persons with bipolar disorder, the six protected classes include immune-suppressants for treatment of transplant rejection, HIV/AIDs drugs, and cancer medications – some of the most important treatments for a wide array of conditions.
The regulation also authorizes insurers to use "fail first" policies on patients taking drugs in the six classes. These policies require patients to take cheaper, less effective medications first. Only when these drugs fail will the insurer allow doctors to prescribe newer, more effective drugs.
If patients must endure successive failures on the least costly medications first and bear the associated increases in cost, what message does that send? In particular, for patients with serious psychiatric illnesses, "failure" means a harrowing descent into a psychotic crisis often ending in an emergency room admission or worse.
We treat and interact with individuals who suffer from schizophrenia-related brain illnesses every day. These are clinically complex patients, in part, because their treatment regimen includes multiple medications. Due to genetic and brain differences across individuals, each antipsychotic and antidepressant medicine produces varied clinical outcomes and side effects.
When an individual is in crisis, it often takes time to find the correct medication regimen to properly treat the myriad of symptoms. This takes time and patience. If insurers limit which medicines are available, patients will suffer immensely.
The CMS proposed rule affecting the six protected classes in Part D would not save money – rather, it would cost lives. We implore Congress to stop this dangerous proposed rule and ensure the six protected classes remain protected.
Linda Stalters, M.S.N. is the founder and CEO of the Schizophrenia and Related Disorders Alliance of America. Raymond Y. Cho, M.D., SARDAA's board chairman, is a professor of psychiatry at Baylor College of Medicine.
