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Healthonomics: Handling the Changes Wrought by Medicare D


We’ll let the pundits haggle over whether Medicare D is helping seniors. We’re concerned with how it’s affecting you. If changing formularies and requests for new scripts are wearing you out, try these recommendations for making things easier.

Many things have changed at Jim King’s Selmer, Tenn., practice since the 2003 advent of Medicare Part D, Medicare’s prescription drug benefit. For one thing, King, president of the American Academy of Family Physicians (AAFP), now makes a pointed effort to talk to his patients about whether they are actually taking their medications, especially during the last few months of the year. Because of the significant coverage gap - known as “the donut hole” - that Part D recipients experience after reaching about $2,100 in covered drug expenditures in any given year, many of King’s patients can no longer afford their drugs by November and December or even earlier. Often, they silently just go without.

“Patients won’t get their prescriptions filled, and they don’t tell us,” says King, one of seven family physicians at Primecare Medical Center. “They can’t pay for it out of pocket, and they are embarrassed. Now we tell them before they leave: ‘If you have problems getting your medicines, call us. We will help.’”

That’s another thing that’s changed: King - almost 30 percent of whose patients have Medicare - now stockpiles the samples that pharmaceutical salespeople leave so his practice can give them to Part D recipients who need them at the end of the year.

Another change? King has gotten tight with the local pharmacist. That’s because he’s on the phone with him so much now. The pharmacist calls to say a patient’s drug isn’t covered under a particular Part D plan (most markets have about 50 such plans, each with a different formulary), and would King like to discuss generic equivalents?

Then, of course, there’s all the extra time spent arguing with Part D plans, trying to make the case that a senior absolutely needs a drug that the plan doesn’t want to cover. “We spend a lot of time jumping through hoops, faxing paperwork, being on hold,” King says.

The result: much of his patients’ visits are spent not on patient-care matters, but on managing their Part D plans’ requirements so that their bodies - and pocketbooks - can cope.

King is certainly not alone.

Any practice that has Medicare patients has gone through some uncomfortable shifts lately thanks to the arrival of Medicare Part D, which has helped seniors get at least some of their drugs covered now, but has been trying for doctors, as it imposes a restrictive managed care-type structure on prescribing.

And since, in most cases, a senior’s Medicare card doesn’t say he has Part D, the paperwork and phone call morass comes days after the patient visit, when the patient has been to the pharmacy and had his prescription turned away.

Formulary fiascos

The issue of Part D formularies is particularly troublesome to physicians’ practices, says Robert Bennett, government affairs representative with the Medical Group Management Association (MGMA).

In a typical scenario, explains Bennett, a senior might be on five or six drugs, and it takes time and testing to figure out which among a class of drugs is best for her, as well as determining the right dosage and observing how all her drugs interact with each other.

Under Part D, though, after a senior is stabilized on all her drugs, her plan might suddenly remove one from the formulary, so she has to pay out of pocket for it or switch to a generic version, which involves having her physician test and monitor her through the drug change. Or the plan might alter the quantity limit so that the patient can’t get her usual 30 pills for the month, but only 15. Or, if one drug in a class with no generics goes generic, there may be pressure to switch to it, with, again, all the necessary monitoring.

And a formulary that suits a patient’s needs well this year might change completely the next year, leaving her paying large sums out of pocket, Bennett says.

A physician can argue that a patient needs to be on a certain drug and does not do well on alternatives, or needs 30 per month, not 15, but then she must cough up myriad medical records showing the patient’s prescription history, and that process is very time consuming, Bennett says.

“The doctor sees all of this as meddling, as micromanaging their decisions on how to treat the patient,” he says.

In many cases, adds Vicki Gottlich, senior policy attorney for the nonprofit Center for Medicare Advocacy, physicians’ offices are having to hire new staff members just to handle the Part D paperwork burden. In other cases, doctors are charging patients for the extra time it takes to deal with formularies that appear to change randomly and appeals efforts that take hours.

Much more monitoring

And interestingly, because of the monitoring that’s needed to safely switch to cheaper drugs, patients under Part D plans need more office visits and lab work, adds Gottlich. The push toward generics may be saving money for Part D plans, but it’s costing the Medicare Part B plans, which cover office visits.

However, Medicare Part D looks like it’s here to stay in its current form for the time being. But doctors who have weathered the changes that Part D has brought can offer tips for not letting it get the better of your practice and your relationships with patients. Take Andrew Merritt, a partner in a two-doctor primary-care practice in Marcellus, N.Y. Rather than spending hours studying the many Part D formularies in his market, he is now in the habit of just prescribing the cheapest possible drug for all patients, no matter what their plan.

“We don’t even look it up in their formulary,” Merritt says. “I choose the least expensive drug possible now. I write generically whenever I can.”

If there’s a conflict with a formulary - which there usually isn’t when prescribing generics - he waits for the pharmacist to call him and tell him, and then he’ll call the plan and try to resolve it. Yes, pushing Part D plans to cover certain drugs when they don’t want to is a hassle, Merritt says, but one that usually isn’t hard to win. “Most of the time, when we fax the prior authorization to them, it is not rejected,” he says.

Fax, fax, fax

And faxing is key, says Bennett. “It’s always better to fax the plan than to call,” he advises. “One, it leaves a paper trail, in case there’s a conflict. Two, they will get back to you when it works for them, so you don’t have to waste a lot of time on hold. And three, if you’re faxing, you’ve filled out a form that will give them most of the information they need, information you don’t have to hunt down when you’re on the phone with them.”

When it comes to forms, each plan has its own that in the past doctors had to fill out when going to bat for their patients on formulary issues. To relieve the burden of having to stock all those forms, the American Medical Association and other medical practice groups came up with a standard form, a nifty shortcut that many Part D plans accept, says Gottlich. That’s the good news.

The bad news, adds Bennett, is that if a very expensive drug is at stake and a protracted fight ensues on a patient’s behalf, many of the plans will make the doctor fill out their company-specific prior-authorization forms anyway.

For those practices who are handling Part D by trying to stay on top of the formularies, has become invaluable, says Bennett. The free Web site provides quick access to all the formularies of all plans, Part D or otherwise. But to get the most use out of it, says Bennett, doctors need to have a computer in the exam room, or at least a handheld PDA. That way, they can look up a patient’s formulary while sitting with the patient discussing a drug, prior to writing a prescription.

Another option is doing what King does: stockpiling drug samples to help seniors at the end of the year, when most of them - 4.2 million last year - are without prescription drug coverage. (Once a senior has spent about $3,850 out of pocket on prescriptions, he is out of the donut hole and has coverage again.)

Using samples, however, has a significant limitation, explains Jim Dearing, a member of the AAFP’s board of directors and a solo practitioner in Phoenix, Ariz.

“Usually the samples are the expensive, brand-name drugs, which Part D recipients can’t be on anyway,” he says. Thus, giving them those samples would involve taking them off their generics, watching closely to assess how they do on the samples, and then putting them back on generics at the start of the new year, when their coverage is restored. “It’s just not doable,” he adds.

Another option, Dearing says, is to suggest that patients get their generic drugs from Wal-Mart. The retailer recently started offering many generic-drug prescriptions at $4. Now other stores such as Target, Costco, and Kroger are following suit. Explains Dearing, if a senior with a Part D plan gets all their generic drugs this way all year, instead of going through their plan, it helps them stay out of the donut hole coverage gap longer.

Identify the decision maker

How to get patients educated on all this? Dearing suggests identifying the healthcare decision maker for the family. Is it the senior? The spouse? The son or daughter? Once you figure that out, have that person in during the patient visit while you are explaining the Medicare D changes. It may cost you some time initially, but it pays off in the end, for them and for you.

“Taking that time up front with the key caregiver is worth its weight in gold,” Dearing says. “If you do that, you’ve got the whole family fixed.”

Another tip: Be careful what specialists you refer to, advises King.

He explains that most primary-care physicians are now familiar with prescribing the cheapest possible drugs for seniors on Part D - but not all subspecialists are. And often, after a visit with a specialist, a senior will call or come see his primary-care doctor flummoxed about how he’s going to pay for the expensive drugs the specialist just prescribed, Dearing says.

From there, the primary-care physician has to call the specialist and talk to him about generics the patient might be able to take, or she may have to take over trying to fight with the patient’s plan to get the drugs.

Why not just push that burden onto the doctor who wrote the prescription? Because then the patient might get left out in the cold, Dearing says. Ultimately, as a senior’s primary-care physician, he feels it’s his duty to coordinate all patient care and drugs, even if it means more work for him.

“Just try to make sure you are referring to people you can work with,” he adds.

Though Medicare Part D looks like it’s here for the long haul, there may be some revisions to it in the not-too-distant future as Congress looks at how it can be improved, says Gottlich. She predicts there may eventually be limits on how many plans can be offered in a given market, and that the appeals process may be made less onerous.

And no doctors will argue with that, she adds.

Suz Redfearn is a long-time health reporter who has written for the Washington Post, Men’s Health, Slate, Salon, and Health magazine. She can be reached via

This article originally appeared in the March 2008 issue of Physicians Practice.

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