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Part D: Implications to Home and Community-

Based Waivers

Charles Milligan, Executive DirectorCenter for Health Program Development and Management

University of Maryland, Baltimore CountyOctober 7, 2004

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Areas to be Discussed Formulary Distribution channels Transition period HCBS Waiver Case Managers Transportation Risk of Cost

Shifting/Institutionalization

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Formulary In FY 04, Maryland had 3,147 dual

eligibles in two waivers. The top 10 Rx:

Top 10 Drugs No. Beneficiaries

   

FUROSEMIDE 996

PREVACID 757

LISINOPRIL 666

NORVASC 568

LIPITOR 513

PLAVIX 467

CIPRO 426

ZITHROMAX 413

ZOLOFT 401

AMBIEN 394

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Formulary (con’t) But that’s not the challenge. The

challenge is that these 3,147 beneficiaries:

Received a total of 218,954 prescriptions in FY 04 (an average of 69.6 each);

Received 1,630 unduplicated medications; and

399 separate medications were received by only ONE beneficiary each

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Distribution Channels Medicaid beneficiaries receive drugs from

many sources;network issues will arise:

Over-reliance on mail-orderfor maintenance medications could cause problems

Independent Drug Store7%

Institutional Pharmacy

1%

Chain Drug Store92%

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Transition Period Will it be affordable, and considered not to be

Medicaid fraud, for a state to dispense a 90 day supply of Rx in December 2005?

Even assuming auto-enrollment occurs, can/will Medicare plans approve all of the medications necessary, on a timely basis, for HCBS beneficiaries to remain in the community?

The number of people, and medications they take which must be transitioned, is extensive

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Transition Period

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4

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0 3 6 9 >=12

Percent ofBeneficiariesReceiving thisNo. of Rx PerMonth

In FY 04, 68% of HCBS Dual Eligibles in MarylandReceived Four or More Drugs Per Month

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HCBS Waiver Case Managers At present, HCBS waiver case managers

generally do not need to coordinate access to Rx for HCBS beneficiaries across multiple vendors and formularies

If this role is incorporated into the job description of HCBS waiver case managers, it might change the caseload ratios and/or payment rates related to case management services

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Transportation Medicaid provides non-emergency

transportation only to ensure access to Medicaid-covered benefits – in January 2006 this will not include Rx for dual eligibles

Thus, once Rx no longer is covered by Medicaid, HCBS waiver beneficiaries may have more difficulty simply picking up their medications

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Risk of Cost Shifting and Institutional Care For HCBS beneficiaries covered for Rx

under Medicare, the financial incentive to spend funds on Rx to avoid institutional care will not be aligned across payors

For institutional residents covered for Rx under Medicare, the financial incentive to develop good community-based plans of care, which depend on Rx, will not be aligned across payors

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Conclusion The formularies AND how the Rx’s are

distributed both matter Access to medications may depend on

transportation and case managers, where Medicaid will not have any formal role

Thoughtful transition planning will be difficult, and might benefit from 90 day supplies in 12/05, which might both be expensive and constitute Medicaid fraud

The financial incentives to spend money on Rx to keep people out of nursing homes are not aligned across payors