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doi: 10.1097/01.COT.0000287840.39971.3b
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CMS Issues Final Rule on Medicare Drug Payment

After long and heated public debate, the Centers for Medicare and Medicaid Services on January 21 issued its final rule governing Medicare drug benefits.

The good news is that the 41 million Medicare beneficiaries will have access to the drugs they need. The bad news is that insurance companies will have a strong arm in controlling drug costs. Everyone who has anything to do with health care will be affected.

Highlights of the new rule are as follows:

  • Every prescription drug plan must provide “adequate coverage of the types of drugs most commonly needed” by Medicare beneficiaries, including those for high-cost and/or chronic illnesses like cancer.
  • Drug plans are allowed to establish a formulary, which must include at least two drugs for each illness, and may refuse to pay for drugs not on the list. Insurers need to cover only one drug in a category if only two drugs are available and one is superior.
  • However, if a physician certifies that a particular drug is medically necessary, the drug plan must cover it, regardless of whether it is on the formulary. In addition, the plan must accept the prescribing physician's judgment. This stipulation is particularly important to oncologists.
  • Many elderly poor who are currently covered by Medicaid will be automatically switched to Medicare, which, as of January 1, 2006, will be the sole source for drug coverage. CMS has assured these people that there will be no gap in coverage.
  • The new rule offers subsidies to employers that encourage them to continue providing drug benefits to retirees. Many such retirement programs, which are extremely expensive, have been dropped in recent years.
  • Every prescription drug plan that agrees to sell drugs to Medicare beneficiaries at discounted prices must establish a geographically convenient network of retail outlets.
  • If a patient is denied coverage, there is an appeal process, although it is lengthy and complicated.
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NCI Announces New Integrative Cancer Biology Program

The National Cancer Institute announced $14.9 million in funding for a new Integrative Cancer Biology Program (ICBP).

It will apply a multidisciplinary effort among all fields of cancer research in a systems-wide approach to gain new insights into the development and progression of cancer.

The program will integrate a range of new technology, including genomics, proteomics, and molecular imaging to create computer and mathematical models that could predict the cancer process.

The ICBP will highlight nine integrative biology centers, which will “provide the nucleus for the design and validation of computational mathematical cancer models,” an NCI news release said.

The centers also will serve as a training and outreach program, helping develop technology to be communicated to other cancer researchers.

The ICBP centers will collaborate with other NCI program groups such as the Cancer Biomedical Information Grid.

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Medicare Help-Line Fails GAO Test of Accuracy & Completeness

Medicare's help-line, designed to provide information and assistance to its 41 million beneficiaries, failed miserably when the Government Accountability Office (GAO) tested it for accuracy and completeness.

The help-line provided accurate responses to queries less than two thirds of the time: 29% of the callers received incorrect answers and 10% got no answer at all.

The phone line (800-MEDICARE) is expected to receive increasing numbers of calls from beneficiaries who have trouble understanding the complexities of the new drug discount cards and/or who don't have access to the Internet (or who can't figure the user-unfriendly Web site designed to explain drug discount choices).

In the fiscal year ending September 30, 2004, the agency received 16.5 million calls—about triple the number in the previous year.

The Medicare help-line is supposed to be of service to beneficiaries, but employees who answer the phones are poorly trained and appear to be ignorant about Medicare policies, regulations, and procedures, the GAO report said.

Despite the fact that they are given a script to respond to queries, they often don't know which script to use or do not know enough to understand it. (Medicare provided even less accurate information to billing questions called in by physicians, as reported in this column several months ago.)

Said Mark B. McClellan, MD, PhD, Administrator, Centers for Medicare and Medicaid Services: “We were faced with an unprecedented volume of calls about a new part of the Medicare program that required new training efforts and many new customer service representatives. We believe we responded as well as we reasonably could given the unique and demanding circumstances.”

The help-line is outsourced to Pearson Government Solutions, an international media company, based in London, which also publishes the Financial Times and sells Penguin and Prentice Hall books.

The GAO test made 420 calls, consisting of six frequently asked questions 70 times each. When the questions were about the $600-a-year prescription drug credit for low-income beneficiaries, callers got the wrong answer 79% of the time.

© 2005 Lippincott Williams & Wilkins, Inc.
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