The Bigger Picture: Managing Medicare D

September 1, 2007

The new Medicare prescription drug plan may be good for patients, but it’s a headache for you.


“Medicare D has been hard on offices,” says Robert Goldszer, MD, associate chief medical officer at Brigham and Women’s Hospital in Boston.

Indeed, practices all over are complaining loudly about the extra work Medicare D has created. Staff and physicians spend too much time requesting prior authorization from Medicare D plans to prescribe off-formulary drugs. And patients who enter Medicare or change their Medicare D plan typically end up calling their physician to request new, on-formulary prescriptions.

That’s no small issue. Writing a new script means pulling a patient chart, searching for formulary information, and calling the patient and the pharmacy.

Even before Medicare D was implemented, the Medical Group Management Association (MGMA) estimated practices were spending $10,000 annually, per physician, on phone calls with pharmacies related to prescription refills. SureScripts, an e-prescribing company, claims refills management costs $50,000 a year per practice.

So prescription-related work is burdensome enough. And now there is Medicare D work on top of it.

Three quarters of physicians with Medicare patients have been asked by a pharmacy or patient to change a prescription to a drug covered by the patient’s plan, according to a survey by the Kaiser Family Foundation. Two out of three pharmacists said a Medicare beneficiary has left without his prescription because the drug wasn’t on his plan.

“Our goal is to have the physician seeing patients and having a smile on their face. This is anti both,” says Goldszer.

So what to do?

First, prescribe wisely. Obviously, you need to use what works for your patients, but if you take a moment to look up what’s on the patient’s formulary as you prescribe, you might save yourself 15 minutes later on dealing with a preauthorization. “Lots of physicians complain about preauthorization, but what a lot of physicians don’t seem to know … is that they can look up a prescription drug plan formulary and write, say, a statin that doesn’t require a preauthorization. It’s an ounce of prevention type of thing,” says Rob Bennett, government affairs representative for MGMA.

For no charge, you can look up formularies online from a handheld or other device at epocrates.com. Medicare has its own list, though epocrates’ is more intuitive, says Bennett.

Another way to minimize formulary hassles is to make a habit of prescribing generics in the first place, whenever it makes medical sense. Medicare D formularies typically cover those drugs. CMS data demonstrate that generic use among those enrolled in the Medicare drug benefit is 13 percent higher than in private, non-Medicare D plans. The formularies are having the desired effect - for the payers.

Be aware, too, what types of things are never covered, like barbiturates, erectile dysfunction, and fertility drugs.

Also consider creating a Part D specialist in your office, a single person who handles all the Medicare D-related work. She’ll become an expert in the formularies, know how to fill out appeals, and will, eventually, reduce the time devoted to the task as it becomes routine to her. Depending on the size of your practice, this could be one or more nurses. Their clinical background will help them make sense of formulary lists and be articulate when requesting preauthorization.

Goldszer’s team is considering hiring a pharmacist or pharmacy student to handle preauthorizations and formulary changes once they are approved by physicians. Several small practices might pool their resources to do the same, hiring one pharmacist to help all of them.

In short, practices have to suffer some of the onslaught of Medicare D-related requests. But you need not suffer it foolishly.


Pamela L. Moore, PhD, is senior editor, practice management, for Physicians Practice. She can be reached at pmoore@physicianspractice.com.
This article originally appeared in the September 2007 issue of
Physicians Practice.