DEAR EDITOR:

The debate on comprehensive healthcare reform is raging in Washington and town halls all across the United States. While we discuss comprehensive health reform over the next few weeks, it is important that we do not overlook policy reforms that have already been enacted and would most likely be a part of any new healthcare act that comes out of current round of deliberations and would come into effect in the near future. One such reform is Medicare Improvements for Patients and Providers Act of 2008.
Among many of its provisions, Section 175[1] is of particular importance as it mandates Medicare prescription drug plans and Medicare Advantage plans to include benzodiazepines in their formularies for prescriptions dispensed on or after January 1, 2013. It is important to outline that this act is a part of the current health reform bill being deliberated by the Senate Finance Committee.[2] This makes it highly plausible that whatever form the healthcare reform bill takes in the future, benzodiazepine prescription coverage by Medicare part D would be a part of it. In 2003 the Medicare drug benefit, the Prescription Drug, Improvement, and Modernization Act (MMA) was enacted and it excluded benzodiazepines along with many more classes of medications. At that time, this action was rationalized on overuse, dependence potential,[3] and the implication of benzodiazepines in increased risk of falls in elderly[4] and ensuing morbidity. The MMA along with increased overseeing on part of some of the states resulted in a 50- to 60-percent reduction in benzodiazepine use.[5] It is very likely that we would observe a rapid increase in benzodiazepine use once Medicare Improvements for Patients and Providers Act of 2008 comes into existence in 2013. There is a general consensus on the benefits that benzodiazepine offer in a variety of psychiatric and nonpsychiatric conditions.[3] However, the abuse and side effects profile of benzodiazepines is a genuine concern among consumers as well as prescribers. In preparation of a potential surge in benzodiazepine use, it is imperative that we take steps to mitigate some of the adverse outcomes associated with benzodiazepine use. Right after MMA was enacted and some states followed with complex triplicate prescription policies, it was believed that this would lead to increased use of other psychotropic medications to substitute the use of benzodiazepines. However, this was not noticed. There is a possibility that in many cases benzodiazepines were overprescribed.[6] It is very important that we as healthcare providers enact self-monitoring policies that make prescribing benzodiazepines to ineligible consumers almost a nonentity. Until this happens, we will always be in danger of loosing our prescribing privileges as a result of future restrictive policies.

References
1. H.R. 6331: Medicare Improvements for Patients and Providers Act of 2008, Page 9. Accessed from http://www.govtrack.us/ July 20 2009.
2. Description of Policy Options. Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to All Americans. May 14 2009, Page 27. Accessed from http://finance.senate.gov/ July 20 2009.
3. Bambauer KZ, Sabin JE, Soumerai SB. The exclusion of benzodiazepine coverage in medicare: simple steps for avoiding a public health crisis. Psychiatr Serv. 2005;56:1143–1146.
4. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159–2168, 2173-4.
5. Wagner K, Ross-Degnan D, Gurwitz JH, et al. Effect of New York state regulatory action on benzodiazepine prescribing and hip fracture rates. Ann Intern Med. 2007;96–103.
6. VanHaaren AM , Lapane KL, Hughes CM. Effect of triplicate prescription policy on benzodiazepine administration in nursing home residents. Pharmacotherapy. 2001;21(10):1159–1166.

With regards,
Deepak Prabhakar, MD, MPH
Resident Psychiatrist
Department of Psychiatry and Behavioral Neurosciences
Wayne State University
Detroit Medical Center
Detroit, Michigan