CMS is fixing drug benefit snafus

Federal drug benefit inspires integration work

At a Senate hearing today, Medicare’s top official defended his agency’s performance in implementing the new Medicare drug benefit, including the performance of more than a dozen new information systems.

Dr. Mark McClellan, administrator of the Centers for Medicare and Medicaid Services (CMS) at the Department of Health and Human Services, said that despite the problems that have plagued the program in the first month, on the whole it is a success.

Senators recounted anecdotes about breakdowns in communications and services, including ill constituents who could not get their prescriptions filled, pharmacists who had to give customers medicines that the program was supposed to pay for, and frustration among people on Capitol Hill and across the country in getting questions answered after the new benefit took effect Jan. 1.

Although CMS beefed up its computer systems and call centers in preparation for the new drug benefit taking effect, McClellan told the Senate Special Committee on Aging that CMS improved its data system this month to address the problems.

Some of the issues stem from ineffective data communication links, McClellan said, adding that CMS has contracted with EDS “as an independent reviewer to help resolve specific data translation issues with the plans, states and pharmacies.”

“It seems to me that not enough was done to ensure a seamless transition,” said Committee Chairman Gordon Smith (R-Ore.). However, Republican committee members generally emphasized the value of the new benefit for senior citizens and people with disabilities, while Democrats criticized the program and its implementation.

Planning for the program’s start-up included developing a new IT system in less than a year, McClellan said in his written testimony. “CMS ensured that more than one dozen critical systems development efforts were implemented in time to meet [legislative] deadlines,” he wrote, although such an effort would normally take 19 to 24 months.

His testimony emphasized the complexity of the challenge. He pointed out that Medicare beneficiaries have to be enrolled in privately operated prescription drug plans, people’s use of the system must be tracked to ensure correct payments, private drug plans have to be paid, and the Medicare drug system must interface with payment systems at the Social Security Administration. CMS is exchanging data with more than 400 new business partners, he added.

“Through contracts with telecommunications clearinghouses that currently service the majority of retail pharmacies, the pharmacies will be able to perform real-time eligibility determinations and will be able to route claims to primary and, if applicable, secondary plans for proper adjudication to accurately coordinate benefits,” McClellan wrote.

He told the committee that such eligibility checks are completed in less than 1 second.