COVER
Grassroots
Medicare's Lupron Surcharge Goes Ahead in California
HARRY PINCHOT
for background on this issue, see menu links below
April 15, 1999 Attorneys from the firm of Latham & Watkins, who specialize in this type of issue, have researched the Medicare law to determine if local Medicare Payment Safeguard Administrators have the authority to apply the principal of "Least Costly Alternative" to drugs, specifically Lupron and Zoladex.
In the opinion of these attorneys the administrators do not have such authority -- and in fact the administrators' proposed actions are in direct conflict with the law as written by Congress.
This opinion was conveyed to the administrators in a 10 page letter sent to them addressing, point by point, various statutes and regulations of Medicare law which the administrators were acting contrary to. The letter was reviewed by the administrators and their attorneys during the month of March and this review resulted in an exchange of opinions between both sides.
After consulting with HCFA for guidance the local Medicare Payment Safeguard Administrators decided to move forward in implementing their proposal. At the CAC meeting held in Los Angeles today, the policy of "Least Costly Alternative" was adopted for use in reimbursing for LHRH agonists. This policy change will be published in the carrier bulletin dated June 1, 1999, and will become effective July 1,1999 for the state of California.
In listening to discussions today, it is apparent that HCFA's central office has been directing the state administrators in this effort. Regardless of whether you like Bill Clinton or Donna Shalala, it has become clear over the last six month that the president's administration has been hiding behind the local state Medicare administrators and claiming that this is a local matter, when in fact they have been systematically taking your Medicare benefit dollars away from you and at the same time establishing a very dangerous precedent.
Who will be the next victim of these cowardly acts? The administration should have the courage to stand up and tell the voters that it is denying benefits and not blame the local administrators. Of course this would cost points in Clinton's popularity poll.
I learned today that the following states have quietly adopted this same policy. The effective dates for these states is May 1, 1999: AK, AZ, CO, HI, ND, NV, SD, OR, WA and WY.
Effective on May 1, for the above states and July 1 for California a patient wishing to use Lupron will be required to pay the difference in cost between Lupron and Zoladex. Should his physician deem it "medically necessary" the physician can submit an application for an exception. Permission would only be granted, however, on a per injection basis and approval could take as long as 60 days. If the application is denied Medicare would reimburse only at the lowest cost. When the next injection is needed a new approval must be applied for.
I have shared the work product of our attorneys with an appeals judge, who assures me that our attorneys have developed a solid case. Unfortunately, at this early stage we have already exhausted funds available to fight the insurance companies. In order to continue I am looking for new funding. Without substantial funds the opposition could defeat us by simply outspending us. If you have real legitimate leads for funding to continue this fight I would like to hear from you. I wish to express my sincere gratitude to all who helped in this fight and to those of you who wrote letters of opposition and collected signatures.PCAN Formed
Harry Pinchot Resists LCA
Fred Mills "Why I Oppose LCA"
Medicare's Lupron Charge
Patient Choice and Medicare's Research Window Dressing
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