The Unintended Outcome of a Supplemental Formulary in Homebound Seniors

To the Editor: Before January 1, 2006, dual-eligible older adults in Florida received a comprehensive drug benefit through state Medicaid programs. Since that date, all dual-eligible beneficiaries must enroll with a Medicare Part D provider. Although 10 classes of drugs (Table 1)1 are excluded from Medicare Part D prescription drug plans, state Medicaid programs, including Florida, are required to continue to cover many of these medications for their dual-eligible enrollees.2 Nationwide, there are approximately 6 million dual-eligible beneficiaries, with 407,000 residing in Florida.3, 4 As part of a quality-improvement project, we studied 2,959 persons aged 65 and older who were enrolled in a Florida Home and Community-Based Medicaid Waiver program for dual-eligible, homebound older adults meeting nursing home eligibility. Clients in this program are free to choose from a variety of Medicare Part D providers. All clients receive a supplemental pharmacy benefit administered by a single pharmacy benefit management company. At no cost to the client, the supplemental plan covers benzodiazepines, barbiturates, cough and cold agents, quinine, aspirin, acetaminophen, nicotine patch, hemorrhoid creams, over-the-counter antifungal creams, and various vitamin and mineral products (B-complex, multivitamin, iron, and folic acid) otherwise excluded under Medicare. All non-Part D supplemental prescriptions filled during March 2008 and demographic information regarding age, sex, and ethnicity for all clients who received a benzodiazepine were analyzed. The care management company provided recent medication profiles of the clients receiving benzodiazepines. Two hundred three (6.9%) of the 2,959 clients received a total of 241 medications and vitamins through this supplemental drug plan. Benzodiazepines accounted for 70.1% of all prescriptions filled. For the 134 clients receiving a benzodiazepine, 95.4% of their prescriptions were refills rather than a new prescription. The prevalence of benzodiazepines was 137 of 2,959 (4.6%). The average age of the clients receiving a benzodiazepine was 81.8±8.6 (range 69–102); there were 22 (16.0%) men and 115 (83.9%) women. Seven persons were taking two benzodiazepines concurrently. The mean number of medications for each client was 10.5±4.7 (range 2–26). One hundred eleven clients (81.0%) were using other psychotropic medications. Benzodiazepines are excluded from Medicare Part D formularies purposefully to limit the use of these potentially “dangerous” drugs in elderly people, but as described above, this population of frail, dual-eligible recipients continues to receive benzodiazepines through a separate supplemental pharmacy benefit. Indeed, the main outcome of the supplemental plan is to provide benzodiazepines. Although the diagnostic indications for benzodiazepine use for these clients were not available, the continual use of these drugs in frail homebound older adults remains cause for concern.5 The use of benzodiazepines for longer than 1 month is an Assessing Care of Vulnerable Elders indicator of poor-quality care in vulnerable older adults.6 Under this supplementary formulary program, benzodiazepines and other medications excluded from Part D may escape all clinically oriented drug utilization review. There is no mechanism for the Part D provider to monitor patients taking benzodiazepines for potential drug–drug interactions, drug–disease interactions, and duplication of therapy. The need to coordinate and monitor drug therapy is especially important in a high-risk population, such as ours, with the clients on an average of 10.5 medications. Whether benzodiazepines should be excluded from Medicaid formularies for seniors or included in Part D plans with clinically based restrictions remains unclear, but the current system of drug coverage for dual-eligible beneficiaries circumvents thoughtful consideration of this issue. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Adam Golden was a paid consultant of American Eldercare Inc. (the Medicaid Waiver program discussed in this letter). Author Contributions: Adam G. Golden: study concept and design, acquisition of data, analysis and interpretation of data, and preparation of manuscript. Bernard A. Roos and Mark H. Beers: study concept and design, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: American Eldercare, Inc. had no involvement in the design of the study, analysis and interpretation of the data, writing of the report, or submission of this letter for publication.