A plan to limit funding of prescriptions and physicians' services for Virginia's 350,000 Medicaid recipients has drawn sharp criticism from members of the medical profession, but state health care officials say the rules are needed to keep rising Medicaid costs within a strict budget.
The plan, which includes restricting Medicaid payments to six prescriptions a month and 12 doctor visits a year, is among four proposals to reduce Medicaid costs. Currently, there is no limit on either service. All four proposals will be considered at a public hearing today before the Virginia Board of Health in Richmond.
State health officials say the Virginia Medicaid program faces a $122.6 million deficit and the loss of $23 million in federal funds over the next two years. Virginia law requires a balanced budget, and state Medicaid Director Bruce Kozlowski said that could be accomplished by the proposed cuts plus those already in effect.
In Northern Virginia, some health care and social services officials criticized the proposed cuts, which come on top of extensive reductions that eliminated 12,000 Virginia Medicaid recipients from the rolls last month.
Northern Virginia officials and health care professionals expressed concern that the proposed restrictions would be particularly hard on those in nursing homes and other elderly Medicaid recipients. Currently, about 20 percent of those covered by Medicaid in Virginia are over 65, according to state officials, while nearly 35 percent of Virginia Medicaid funds go to nursing homes.
"I can't believe that our state health department could either recommend or support such an unacceptable proposal," Arlington Human Resources Director Martin P. Wasserman said of the plan to limit prescriptions.
Dr. R. A. Comunale, who has a private practice in McLean and serves as medical director for the Powhatan Nursing Home in Falls Church, agreed.
"The people in a nursing home have multiple, ongoing problems," he said. "On top of that, you might have a crisis."
A typical nursing home patient, Comunale said, often needs five or six medications a month to deal with chronic health conditions such as arthritis and heart and intestinal problems.
"It does not take very long to get to six orders," said Fairfax County pharmacist Jean Heichman. "There is no flexibility in the proposed changes that would include the seventh."
If the proposed limit is adopted, nursing home operators said, they will have to turn to patients or their families to help pay for additional medications. That will be impossible in some cases.
"We have some residents who have nobody to help them at all, and they have no money," said Beatrice McGinnis, director of nursing services at the Oak Meadow nursing home in Alexandria.
J. T. Butler, administrator of the Powhatan Nursing Home, said his facility will absorb the cost of extra medications for its residents if necessary.
"The patients themselves are not going to go lacking," he said.
Comunale and others said they also consider the proposed limit of 12 physician visits yearly a threat to the elderly.
"They have multiple, multiple problems," Comunale said of nursing home patients. "You never know when you'll be called on an emergency situation on one of these patients."
Some, however, consider the proposed restrictions, which would take effect in March, necessary to prevent abuses of the program. Butler said limiting the number of prescriptions the program will subsidize would help keep physicians from prescribing unnecessary medication.
"I'm not violently opposed to it," he said of the proposal.
Kozlowski defended the proposed restrictions, and said that the state Medicaid recipients use an average of 2.1 prescriptions a month and visit a doctor an average of 3.91 times a year. He added that the limit on visits would not include those required by federal Medicaid regulations, which primarily affect recipients in nursing homes.
Several health care professionals said the proposed limitations are reasonable for most recipients, but should not apply to nursing home patients, who tend to require more medical attention. But Kozlowski said that federal law forbids setting different rules for the elderly, and exempting nursing home residents from the restrictions would be unfair to other Medicaid recipients.
"We're responsible for other folks, too, and with what's left, we've got to make it all happen," he said.
He criticized health professionals for their opposition to the proposal and said some might be motivated more by financial concerns than humanitarian ones, since they stand to lose money if the restrictions are adopted.
"I find it objectionable that the poor and the elderly are being used for these purposes," he said.
Comunale, however, said his objection to limiting subsidized prescriptions has nothing to do with money.
"It's not going to affect me financially, it's going to affect the elderly from a health point of view," he said.
The proposed changes, a number of health professionals said, could end up costing money rather than saving it, because if patients use up their six prescriptions or 12 physician visits, they might have to be hospitalized to get the care they require.
"You're taking them and putting them in a higher-priced environment, and that's not going to save any money," said Heichman.
At today's hearing, the Board of Health will also consider a proposal to change the system of reimbursement to about 60 pharmacies in the state that package drugs in individual doses for nursing homes. Under the new system, which would take effect in October, the pharmacies would receive less for packaging the drugs. Kozlowski said the change would save $1.3 million over the next two years.
A fourth proposal would subject intermediate-care nursing home facilities in hospitals to the same reimbursement ceiling for operating costs as programs not based in hospitals. Currently in Northern Virginia, the ceiling for hospital-based facilities is about $9 more per patient per day than for those not connected with a hospital.
Kozlowski said the change, which would take effect next July, would force hospital-based facilities to operate more efficiently.
"There's a lot of hospital costs being shifted into the nursing home area inappropriately," he said.
The four proposals will be the subject of a public hearing before the Virginia Board of Health at 9 a.m. today in House Room D, in the General Assembly Building, Ninth and Broad streets, Richmond. The board is expected to make a decision immediately after the hearing.