Looking at Medicare Part D One Year Later
From the March ACP Observer, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
More than a year after inception, Medicare Part D is still a topic of heated debate among politicians, physicians and seniors.
For beneficiaries, the drug benefit appears to have had mostly favorable results—in recent surveys, more than 70% of enrolled seniors report positive experiences with Part D and only 5% intend to switch plans at the end of 2006.
"I've had maybe one out of a thousand patients complain about it," confirmed Kay M. Mitchell, FACP, a general internist in Jacksonville, Fla., and co-chair of the ACP's Medical Service Committee.
Kay M. Mitchell, FACP, (left), a general internist in Jacksonville, Fla., assigns one nurse, Malou Reyes, to handle all the Part D paperwork.
Ask a thousand physicians their thoughts about Part D, however, and you get far more than one complaint. CMS' William Rogers, MD, has heard them all.
As director of CMS' Physicians Regulatory Issues Team, Dr. Rogers has spent the last year and a half troubleshooting the implementation of this enormous government program. "I compare it to having six months to build and launch the space shuttle," he said.
Any angry phone calls dealing with Part D went to his team, which by early 2006 fielded so many questions and complaints about Part D that they held weekly conference calls with as many as 1,300 participants. Seniors were still sorting through plan options, often looking to their physicians for help. Every plan required a different prior authorization form, and drugs were denied for little-understood reasons, for example, the overlap between Part B and Part D.
Many of those issues have been resolved and most physicians' questions now center on frustrations with the prior authorization and formulary processes, said Dr. Rogers. He and his team at PRIT do what they can to solve problems, negotiating with contract managers and talking to the AMA Part D workgroup, of which the College is a member.
The workgroup meets every six weeks to discuss issues brought up by physicians and beneficiaries. Its accomplishments include standardizing the form for exceptions and appeals, and more recently, ensuring that prior authorizations will remain in effect for patients who kept the same Part D plan from 2006 to 2007.
Complaints and problems are to be expected during the implementation of the largest change in Medicare history, said Dr. Rogers. "We're very sensitive to the fact that Part D does present new administrative responsibilities to physicians without any compensatory increase in their payment," he added.
Over the first year of the Part D program, physicians around the country have developed their own approaches to minimizing the effects of those responsibilities.
Many offices have assigned Part D specialists—a single person who handles all the Medicare Part D paperwork. In the office of Joseph W. Stubbs, FACP and chair of ACP's Medical Service Committee, that's how it works. "We have one person in our office of eight doctors who does nothing but prior authorizations all day," he said.
"There's no way we're going to be able to reduce overhead back to where it was [before Part D]. At the same time, my office staff is getting more savvy and so it is getting better," he added.
Dr. Mitchell has taken a different approach. In her 12-physician practice, each physician has a nurse who handles all the Part D paperwork for that physician's patients. She recommended the system, noting that the nurses' familiarity with the patients saves the time that anyone else would have to spend reviewing charts in order to complete the forms.
Giving a little extra
As a rheumatologist, Christopher R. Morris, ACP member, deals with more than the average number of Part D issues. Methotrexate, corticosteroids and azathioprine, three medications commonly used for the treatment of inflammatory diseases, are not included on any plans' formularies because they are available to some patients via Part B coverage.
Inflammatory arthritic disorders are common; for instance, over 2.5 million Americans have rheumatoid arthritis, and most of them take such drugs. Unfortunately, oral methotrexate is covered by Part B for a few rate cancers, so internists were required to show that the patient actually had the more common arthritic condition, rather than qualifying for Part B coverage for a rare disease. Prednisone and azathoprine, commonly used in patients with lupus, vasculitis and other inflammatory conditions, are covered under part B for transplants, so they also require prior authorization for non-transplant diagnoses.
"Given that one third of our total patient number are on Medicare, this is not an insignificant problem to rheumatologic practices," Dr. Morris said. When he realized that appeals would be required to obtain the drugs for his patients, he contacted the PRIT to find out how his office could be designated to represent patients in the appeals process.
"The important change that PRIT brought about, in terms of helping rheumatologists, is that if we write the words "Medicare D" and an appropriate diagnosis on the script, we are not required to fill out prior authorization forms. This saves significant hassles in terms of physician and staff time and efforts."
The appeals process is important, but the problem of B vs. D has a far greater impact on his rheumatology practice.
"Patients are not knowledgeable enough in the intricacies of the medications [to handle the appeals]. If the medication is not something that is normally used or normally approved, obviously they're not going to understand the medical literature or the benefits of the medication," he said.
Now Dr. Morris and his staff have patients sign a designated representative form before prescribing a drug that is likely to be denied, so that patients don't even have to come in to the office (which, in rural Tennessee, is often a long drive) to have their claims appealed.
Not every practice has the capability to get so involved in Part D issues. "The best I can do is look at the patients' medications and try to offer them whatever medications are currently on the formulary of their plan," said Alex Foxman, ACP member and general internist in Beverly Hills, Calif.
Dr. Foxman said that he has spent 30 minutes to an hour per patient on Part D education, and can't afford to be an advocate for every one. "Otherwise we'd go out of business," he added.
The future of Part D
Proactive approaches like Dr. Morris' are costly now, but they may soon become a financial necessity, said Richard Stefanacci, DO, executive director of the Health Policy Institute at the University of the Sciences of Philadelphia. Under pay for performance, the success of patients' drug therapy, such as taking statins to reduce cholesterol levels, could directly correlate to physicians' payments, he said.
"The days of being a physician where you just made the right diagnosis and wrote the right prescription are over," said Dr. Stefanacci. "While physicians aren't directly compensated at this point for their involvement in Part D, that's going to change, and I think it would bode well for them to get involved now rather than later."
Dr. Mitchell, who will address the issue at Internal Medicine 2007 in San Diego (see sidebar for more information), expects to hear complaints from attendees about the prior authorization and appeals processes.
"The problem is having to jump through a lot of hoops," she said. "There are a lot of drugs that probably should not be approved and there are cases where exceptions need to be made. That's why you have a process like this."
Streamlining the process
Some tools and techniques can simplify the hoop jumping. Dr. Rogers recommends the use of Epocrates, prescribing software which is available in a basic version online at no charge. He also reminds physicians to fax prior authorizations and to contact his office with Part D issues. "We're sure interested in hearing from physicians when new problems arise," he said.
To minimize formulary problems, Dr. Stubbs recommended prescribing generics whenever possible. "It's very clear all the formularies are trying to steer patients toward the generic drugs, which is not necessarily bad," he said.
Action by Congress could potentially lead to other improvements in the Part D process. While pending legislative changes to the benefit are not expected to directly affect physicians, Congressional proposals to shrink the doughnut hole may reduce the amount of time physicians have to spend dealing with patients' medication costs, noted Neil Kirschner, Ph.D., Senior Associate, Regulatory and Insurer Affairs for the College.
"The new Congress is very interested in the Part D program. They are going to do a great deal of oversight as well as trying to correct problems," he said.
Arvind R. Cavale, ACP member and endocrinologist in Southampton, Pa., will appreciate Congress taking a harder look at the activities of insurance companies involved in Part D. "It [Medicare Part D] has a lot of potential to do good for the seniors, but it has to be implemented more transparently," he said.
Data show that more Americans are cutting their prescription drug costs by switching to generic medications, according to the Centers for Medicare & Medicaid Services (CMS). The agency reported that generic use is especially high among those in the new Medicare drug benefit, with generics accounting for 59.6 percent of the drugs dispensed to people in Medicare Prescription Drug Plans and Medicare Advantage plans through the third quarter of 2006.
Generic medications are as effective as their brand-name counterparts and offer significant savings, CMS reported on its Web site. In addition, for enrollees in the Medicare drug benefit concerned about the coverage gap, generics can lower costs and delay reaching the gap or help avoid it altogether.
According to the National Association of Chain Drug Stores (NACDS), generic dispensing has increased among private third-party payers growing by 9 percent over the past year-from 48.4 percent in 2005 to 52.6 percent in 2006. The most recent CMS data demonstrate that generic use among those enrolled in the Medicare drug benefit is 13 percent higher than the private third-party demonstrating that the Part D program is delivering savings well above the national average to beneficiaries and the government alike.
The new Medicare data mark the third consecutive quarter of growth in generic use among those in the Medicare prescription drug benefit, indicating that beneficiary choice and broad formularies are yielding even greater savings as the program has progressed.
According to CMS Acting Administrator Leslie V. Norwalk, "Generics are as effective as more expensive brand-name drugs in treating chronic conditions and other health-care problems. That is why a growing number in Medicare and elsewhere are asking their doctors about this alternative. With tools such as the Medicare Plan Finder and the Medicare and You handbook, CMS is helping people better understand how they can save even more with generics, and to find the plans that cover the medications they need."
Norwalk adds, "The increased use of generics is great news for both consumers who are lowering their costs and the Part D program itself. These savings can be used to provide better value and expanded coverage to beneficiaries."
Due to lower-than-expected costs, the Medicare Part D program is already realizing significant savings relative to what the Congressional Budget Office predicted when the program started over a year ago. "We will continue to promote generics where they are available as an important strategy to keep the new drug benefit affordable over the long term," Norwalk said.
CMS recommends that patients talk to their doctors about generic medications and less-expensive brand-name alternatives. Information about additional cost savings through the use of mail-order pharmacies, generics, and less-expensive brand-name drugs is also available on the Prescription Drug Plan Finder section of Medicare's Web site.
- At Internal Medicine 2007, Medicare experts Kay Mitchell, MD, and Neil Kirschner, PhD, will discuss the second year of the Part D benefit, as well as changes to the overall Medicare benefit for 2007, in a one-hour session, "Medicare: Not Your Parent's Program?", on Sat., April 21 at 4 p.m.
- The College's Practice Management Center has a Web site devoted to Part D information, including patient education materials, FAQs, and standardized forms for downloading.
- CMS' Physicians Regulatory Issues Team (PRIT) can help physicians with individual or system-wide Part D issues. E-mail them at email@example.com or call (202) 236-3338.
- Free software for PC or PDA from Epocrates provides access to all of the Part D plans' formularies.
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