The Eye of a Medicare Hurricane
Monday, January 23, 2006
If a health plan pays a pharmacy for medicine it dispensed to an elderly patient, before realizing that the person already had switched to a different health plan, how do the insurance companies settle up? If a pharmacy run by a federally funded health clinic wants to cover some costs that its Medicare patients are supposed to pay on their own, is that legal? And how much of a refund should patients get if they have chipped in to cover part of the price of their medicine before the government determined they are so poor that they should not have had to pay in the first place?
Such brainteasers would have been unimaginable through most of the four decades that Medicare has provided health insurance to the nation's elderly. But since Jan. 1, when the program's new drug benefit began, such questions surface routinely. Often as not, they land on Tracey McCutcheon's desk.
As acting deputy director of the Medicare Drug Policy Group at the Center for Medicare and Medicare Services (CMS), McCutcheon is deep in the weeds of the largest, most complex and -- judging from its first three weeks -- messiest expansion of the program in its history. From a first-floor office in an immense government building in a western suburb of Baltimore, she works 12-hour days, taking conference calls, combing through statutory language and rethinking the fine print of 60 pages of federal regulations she helped to write.
"Lots of moving parts," is the way she describes her job, with understatement.
McCutcheon, 52, is not a longtime federal bureaucrat. She had worked for several of the Washington area's major hospital systems and health plans, most recently for a disease management offshoot of Inova Health System. When she began thinking about what she wanted to do next, she realized, "I may have sort of a regulatory bent" -- drawn, as she was, to solving problems, making systems work and complying with government rules.
She began to commute from her home in Silver Spring to a job as "health insurance specialist" at CMS headquarters in February 2003. She remembers that, in the first days, her boss remarked that Congress was starting to look serious about prescription drug legislation it had been debating for years. The bill passed late that year.
Today, McCutcheon is a GS-15 with a staff of about 50, now that she has been promoted to acting deputy of a group within the agency that sets policy for health plans. Her speech and writing are sprinkled with obscure abbreviations: TrOOP (true out-of-pocket cost, or the sum Medicare patients must pay in deductibles and co-pays before the drug coverage begins) and LIS (low-income subsidy for poor older people).
Shortly before the benefit took effect, McCutcheon found herself debating what the word "person" means. The context was an aspect of the Medicare law that says out-of-pocket costs are to be paid by the beneficiary or other person on their behalf. The challenge was to find a way to allow charitable organizations to chip in.
Currently, she and her staff are rethinking a rule that allows health plans to "co-brand," when they place on the prescription drug card they give patients the name of a second company, such as a drug store. The worry is that patients might mistakenly believe they can fill prescriptions only at the store named on the card.
Such matters are arcane, but they also have broad implications for whether insurers remain in the program, whether pharmacists are willing to fill prescriptions and -- most of all -- whether the nation's older patients come to believe the federal insurance for medicine is worthwhile.
As complaints and confusion about the drug benefit have spread around the country this month, McCutcheon said, "some of the specific issues that come up have been surprising." Still, she said, "you never bring up a huge program and have everything perfect."