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Middleman: Illinois steps in to fill gaps in new federal drug program and faces unexpected hurdles

Glitches can be expected when 42 million people become eligible for a government-subsidized prescription drug program. So no one was surprised that there were plenty as the new national effort got under way. 

Illinois officials, in fact, expected some snags as it cast an additional safety net to help the poorest seniors and disabled people pay for their drugs. Despite the best intentions, however, the state hit some unexpected snarls, too. And more knots are sure to surface as the state and federal drug programs are reshaped.

Starting January 1, the federal government expanded its Medicare program for senior Americans to include coverage of prescription drugs. Previously, government had subsidized prescription costs only through the joint federal-state Medicaid program for low-income seniors and disabled people. The new benefit, called Medicare Part D, is designed to lower health care costs by providing subsidies for prescription drug coverage through private insurers. 

Meanwhile, Illinois joined more than two dozen other states in offering additional protections to ensure drugs stay affordable.The state's new assistance program, Illinois Cares Rx, was expected to pave the way for a seamless transition by helping low-income Illinoisans avoid paying drug costs out of their own pockets. The program also automatically enrolled low-income seniors in a prescription drug plan.

Yet a series of missteps in efforts to align the state and federal programs created more problems for the very people they are designed to help. 

A communications glitch, for instance, prompted federal officials to inform some 20,000 Illinois seniors they were automatically enrolled in one of the federal drug plans when they weren't. 

While the state anticipated problems with the Illinois Cares Rx transition, it had to react to another potential problem for up to 10,000 low-income seniors. A delay in processing information between the state and federal governments and the insurance companies put seniors at risk of paying more for medications because their income levels were not yet entered correctly in the computer database. 

To bridge the unexpected holes in service, Gov. Rod Blagojevich issued an emergency order so thousands of beneficiaries would not walk away from pharmacies without their medications. He promised to reimburse pharmacists who filled prescriptions for customers whose information was incorrect or absent.

While some beneficiaries have gotten their drugs, far too many have not, says Sinead Rice Madigan, director of the state Senior Health Insurance Program.

"It's certainly been a bumpy road." As state agencies are working around the clock to smooth out the bumps on a case-by-case basis, she says the governor's emergency measure and the insurance companies' responsiveness have been integral to dissipating some of the systemic problems.

When states play middleman, though, it opens the door to miscommunication, says research professor Jack Hoadley with the Health Policy Institute at Georgetown University in Washington, D.C. When people are automatically enrolled, all of the paperwork needs to be in order. "It's just one more set of computer runs, one more set of people [who] created the potential for there to be problems." Some of the problems have popped up on the front lines, as pharmacists, insurance agents and caseworkers battled — or spread — misinformation about how the state's prescription assistance would interface with the new federal benefit.

In Bloomington, Jackie Newman with the nonprofit East Central Illinois Area Agency on Aging says pharmacists have said their computers aren't set up to bill under the state's contingency plans for customers who haven't been assigned to a Part D plan. "We have insurance agents selling Part D plans to people, telling them that the plan will work with Illinois Cares Rx, and it won't."

About 130 miles northeast of Bloomington, inaccurate information has also consumed Terri Gendel's time. She's director of benefits and advocacy for the nonprofit Suburban Area Agency on Aging in Cook County. "We knew that [it] wasn't going to go perfectly, that some people were going to get communications that weren't meant for them," she says. "State, federal [and] private plans have sent out letters that were incorrect, as well."

Gendel is gearing up for another round of problems as patients return for refills this month. "Each stage of this, we are going to find people who need help with different kinds of problems."

It's likely other adjustments will be needed at the state level. Pressure has already mounted to expand Illinois Cares Rx assistance as early as next year. 

Gendel's agency works with the Make Medicare Work Coalition, a statewide network pushing the governor and lawmakers to extend the program to some 200 HIV and AIDS patients who cannot afford the out-of-pocket costs of a Medicare drug plan.

According to the AIDS Foundation of Chicago, the annual income of these patients is between $13,000 and $19,000, not much more than the average $12,000 annual drug costs per person. They do get financial help through the state and federal AIDS Drug Assistance Program (ADAP), but those resources are extremely strained, says John Peller, director of state affairs for the AIDS Foundation of Chicago.

"By expanding Illinois Cares Rx to pay out-of-pocket costs for these 200 people, we can move them off ADAP, help them get their medication from Medicare Part D and basically keep the ADAP program strong," he says.

Under the proposal, the state would spend less than $1 million but save the AIDS program more than $2 million. "It's helping maximize federal benefits for people in Illinois," Peller says. "It makes sure ADAP is there when people need it in the future."

The proposal sailed out of the Illinois House last month under the sponsorship of Rep. Sara Feigenholtz. 

"I have a very, very large constituency depending on these drugs," says the Chicago Democrat. "I want it to work."

Initially she hesitated, she says, to tinker with an AIDS drug program that has worked well under the Illinois Department of Public Health. "We had a very smooth running program when it was just one agency," she says.

Because the AIDS drug program grew by 10 percent a year, she says, she has become convinced that expanding Illinois Cares Rx would preserve a strong assistance program for future patients.

"People depend on this program to stay alive with complex and expensive drug regimens. I'd like to remain cautiously optimistic that we'll be able to do it, and if there's a few bumps in the road, then I'm sure there will be a lot of people moving quickly to remedy that," she says. "It's worth attempting."

In the midst of sweeping changes in the way Americans receive their medications, state officials see Illinois Cares Rx as a long-term solution to providing equal or better health care assistance to seniors who need it most. In the short term, they'll need to smooth out the glitches in delivering that assistance to 300,000 Illinoisans while keeping state agencies, pharmacies and insurance companies on the same page. 

 

What the states are doing 

Illinois is among more than two dozen states that are helping low-income seniors and people with disabilities get their medicines while the federal Medicare prescription drug program gets under way. 

Some of these states' measures are permanent, some are stopgap. 

Gov. Rod Blagojevich, for example, used his executive authority to allow pharmacists to bill the state after filling some prescriptions when there are glitches.

Seven other states enacted laws along similar lines, according to the National Conference of State Legislatures. They are California, Connecticut, Massachusetts, New Hampshire, New York, North Dakota and Vermont.

New York and Vermont proposed covering prescriptions even if the federal government stops reimbursing the states, a move that was expected as early as mid-February. Vermont designated $7 million to cover the gap, but expects these funds to run out this month.

California dedicated $150 million of its general revenue funds to cover the cost of a 30-day emergency measure. New Hampshire dedicated $500,000. The governor of Arkansas declared a public health emergency, as that state shelled out $2.7 million to help pharmacists fill 37,000 prescriptions for customers who were incorrectly placed on the eligibility list.

Bethany Carson


llinois Issues, March 2006

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