American College of Physicians: Internal Medicine — Doctors for Adults ®

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Part D hopes and hassles begin to play out

Prior authorization tops list of headaches as internists navigate the new system

From the May ACP Observer, copyright 2006 by the American College of Physicians.

By Bonnie Darves

When Wisconsin geriatrician Michael L. Malone, MD, recently prescribed a Lidocaine patch for a frail elderly patient with multiple comorbidities, the patient's new Medicare Part D plan denied coverage. That denial set off a frustrating chain of events that was still unresolved 48 hours later.

"By the time you make the calls, fill out forms and wait for faxes, it's anywhere from 30 minutes to an hour of 'person time'--and for our clinical program, that's several times a day," said Dr. Malone, medical director of Aurora Senior Services in Milwaukee and head of geriatrics at Aurora Sinai Medical Center. To streamline that process, his six-geriatrician office has tapped into its experience to compile its own tip sheet for surviving Part D, the Medicare drug benefit that debuted this year. (See "Advice from the trenches: 10 tips to survive Medicare Part D.")

Time management is only part of the problem, leading some to characterize what can be a boon for patients as a major administrative hassle for physicians. Prior authorization issues, in some cases involving commonly prescribed drugs such as antidepressants, have topped the hassle-factor list.

Is help on the way? The Centers for Medicare and Medicaid Services (CMS) has definitely made strides to rid the program of some bugs. But a flurry of new enrollments is expected this month. (May 15 is the last day beneficiaries, except for low-income beneficiaries eligible for extra subsidies—can enroll and still pay a lower premium. The next enrollment period begins Nov. 15, 2006.) That means that even those physicians who have had little interaction with Part D to date may find themselves coping with Part D growing pains.

Helping patients

Amid the headaches, the program is actually doing what it's supposed to do, at least for many patients.

For example, survey results contained in an April report from the Medicare Rx Education Network—a nonprofit Part D education group that ACP is a member of—found that 78% of enrollees in stand-alone plans were either "very" or "somewhat" satisfied with their plan. And CMS data indicate that the average beneficiary who previously had no drug coverage can save as much as 50% on prescription costs.

"I've had a few patients come in very excited, saying that they are saving money already with their Part D plans," said geriatrician Kay M. Mitchell, FACP. Dr. Mitchell noted, however, that only an estimated 10% of her patients found a plan that covers all of their medications.

Others, though happy to have some coverage when they had none before, say the new benefit is turning out to be a wash. "Some of my patients have found that their [Part D plan] copayments are higher than the cost of generics, so they're not using their plan," said Bruce C. Smith, FACP, a geriatrician with Overlake Senior Health Center in Bellevue, Wash.

But many patients haven't yet gotten to the point of cost-to-benefit analysis. "The most frequent comment I hear from patients," Dr. Smith said, "is that they're simply baffled at the complexity of Part D and can't quite figure out what to do." (The April Medicare Rx Education Network survey also found that the two most common reasons why beneficiaries weren't enrolling were confusion about options, and fear that they'd make the wrong choice and be stuck with it.)

Some internists don't fare much better. College Regent Stephen G. Pauker, MACP, vice chair of medicine at Tufts New England Medical Center in Boston, for example, made headlines last fall with a Boston Globe op-ed piece that delivered a blow-by-blow account of his experience trying to enroll his mother in a Part D plan online. He had to determine which of the 59 plans offered was the best option for his mother's 12-drug regimen.

"It took me several hours. In many cases the [drug] co-payments weren't there—and you can't make an informed decision without knowing that," Dr. Pauker recalled. "It's very confusing, and most people on Medicare can't really deal with computers, much less figure out how to download PDF files."

As for Dr. Smith, his parents had "played around with the [Medicare] site" before giving up. His experience was relatively quick—about an hour and a half to identify a plan that would work for both of them and get them enrolled—because his parents are not on very many drugs.

Physicians say it's tempting to help patients because of the potential benefits. "You don't want to recommend a single plan, but you do want to help them find one that covers most of their medications and is at least no more expensive than what they're doing," said Dr. Mitchell, Governor for ACP's Florida Chapter and assistant professor of internal medicine in the Mayo Clinic community internal medicine division in Jacksonville. "There are more than 170 plans in Florida, so you can imagine being [age] 85 and having to sort through that."

But those good intentions could backfire, Dr. Pauker pointed out. "We don't get paid for counseling patients about Part D, and providing economic advice is not something doctors are supposed to do," he said. He added that he is concerned about the possibility of lawsuits should patients decide they were incorrectly counseled.

A recent pilot survey of Boston-area physicians conducted by Dr. Pauker and nephrologists Jonathan Sosnov, MD, and Klemens Meyer, MD, found that only 53% of 188 respondents felt somewhat comfortable directing patients to Part D resources. (Only 18% could correctly define the annual Part D "doughnut hole," that coverage gap enrollees must fund out of pocket when their total annual drug costs are more than $2,250 but less than $3,600.)

The College, in fact, has advised internists not to counsel patients on their specific plan choice. William Rogers, MD, medical officer for the CMS' Office of the Administrator, explained that the CMS Part D marketing guidelines detail what physicians—and plans or brokers, for that matter—can and cannot do as far as steering patients to plans. He suggested, however, that physicians are "probably OK" if they make recommendations and "don't stand to benefit financially" from the advice.

Looking for relief

Internists report that fielding enrollment questions from patients is only one of many time-killers associated with the new drug benefit.

Many physicians are still wading through dozens of formularies to adjust their prescribing to patients' plans. They are also coping with strict dosage and quantity limits on some drugs and with response delays after filing a formulary exception appeal.

And they complain about filling out different exception and prior authorization forms for each plan.

"For physicians, particularly rheumatologists, oncologists and neurologists, the big impact has been prior authorizations," Dr. Rogers said. Sorting out Part B vs. Part D prior authorizations—a handful of drugs formerly paid for under Part B because they were administered incident to physician services but are now covered by Part D—has been particularly problematic. The prior authorization applies not only to big-ticket items like oncology drugs and rheumatoid arthritis injectables, but also to inexpensive drugs like prednisone.

Yet some relief is in sight. "Prior authorizations aren't going to go away," Dr. Rogers said, "but yes, we're very aware of opportunities to streamline that process." At press time, the CMS had instructed Part D plans to cover Part "B/D" drugs if physicians indicate a Part D diagnosis and write the words "Part D" on the prescription. (Physicians who follow these instructions but are still required to submit a prior authorization should e-mail the CMS. (Also see "Sparking a new industry.")

The CMS also announced a big break for physicians: The agency posted a new standardized form—the College collaborated with the AMA-convened work group that developed that form—to use for exceptions, appeals and prior authorizations for most commonly used prescription drugs. The CMS is asking all Part D plans to use the form, and plan representatives say they expect wide acceptance. But Dr. Rogers is taking a wait-and-see approach to the new form's use.

"It may not be possible to develop one form for all drugs," he said. "If you had a standard form that worked for every plan, it would ask for a lot of information that would be unnecessary."

He also pointed out that the CMS recently required all Part D plans to prominently display links to their forms on their Web site—and make those one-click links accessible without a password. The CMS site also now contains links to each drug plan form.

And he urged internists to use a readily available resource for prior authorizations and formulary variations: ePocrates, an electronic prescribing software program. A basic version, available at no charge, contains all Part D plan formulary information, and can be used on a PC or PDA. (See "Part D resources.")

Ready or not

If you think such problems don't apply to you because you've had minimal interaction with Part D, experts say you should think again: The number of patients enrolling in Part D—and the hassle factor—may grow.

For one, patients whose health status is stable may just now be depleting their 90-day supply of prescription medications. "We see these patients only every three or four months, so we're now just getting them back in the office," explained Dr. Mitchell, who is also Co-Chair of ACP's Medical Service Committee.

But perhaps more importantly, as of press time, an estimated 29+ million—of the 43 million eligible—are enrolled in a Part D plan or have at least equivalent coverage, according to the CMS. Washington's Dr. Smith said that only 20% of his patients, half of whom are in nursing homes, had signed on for a plan. Those that haven't enrolled have until May 15 to do so (except low-income beneficiaries) and take advantage of lower premiums.

And internists are already bracing themselves for what may be a wave of formulary changes. (Plans are allowed to change formularies as long as they give patients written notice within 60 days and the change is approved by the CMS.) That hasn't been an issue yet, according to the CMS' Dr. Rogers, who said the agency "hasn't seen any [drug] withdrawals or bait-and-switch" activity.

But internists suspect formulary changes may become a much bigger issue once initial enrollment ends. "Right now the plans want people to sign up," he said, "so they have fairly open formularies." According to Dr. Rogers, however, plans that impose new prior authorizations will continue to cover those drugs without a prior authorization for patients already enrolled in the plan.

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Advice from the trenches: 10 tips to survive Medicare Part D

Internist Michael Malone, MD, medical director of Aurora Senior Services in Milwaukee, in concert with colleagues and staff at his six-geriatrician practice, created the following tip sheet to help physicians survive Medicare Part D:

1. When the pharmacy calls with a denial, get the drug plan's 800 number and the patient's plan ID number. Those will enable you to "move to the next step," said Dr. Malone, to obtain a prior authorization.

2. When you change a medication, thoroughly document in the chart why it was discontinued. You may need that information later to request a formulary exception.

3. When giving patients a medication sample, understand that the drug might not be continued on their prescription drug plan--so choose wisely.

4. Keep a resource log or folder of Part D information and key numbers handy, where everyone in the office can access it.

5. If patients receive a message or a letter indicating that a medication has been denied, tell them to call your office to pursue proper authorization.

6. Continue to ask patients if they're enrolled in a Medicare Part D plan—and if so, note which one in their chart.

7. Identify a champion in your office to assist you and patients with Part D issues and questions. That person can help the entire office navigate the system more efficiently.

8. Provide a handout or put up a bulletin board flyer in the office that lists resources for patients' Part D questions.

9. Try to use plans' prior authorization and formulary exception forms as efficiently as possible, anticipating the information that will be required and having it readily available. Create a template if feasible.

10. Pay attention to communications regarding medication denials. Within that denial language, you may find information about specific problems, such as a patient who's been prescribed two drugs in the same class by different providers. "Stay attentive," Dr. Malone advised. "Don't just sign off on denials without reading them."

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Part D resources

The College's Practice Management Center has created a Medicare Part D site. ACP also offers a Part D helpline at 800-338-2746, ext. 4535.

Other physician resources include:

  • American Geriatrics Society. The site features Medicare Part D resources, as well as a free continuing medical education program on Part D.

  • CMS' Physicians Regulatory Issues Team (PRIT) offers two types of resources: an e-mail resource that physicians can use to tell CMS staff about problems they are having with a Part D plan, and a weekly Part D conference call, Tuesdays, 2-3 p.m. ET, 800-619-2457. Password is "Part D."

  • ePocrates, for free access to Part D formularies.

  • Provider alerts and issues.

Patient resources include:

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Sparking a new industry

Commercial concerns are stepping in to fill a new Medicare benefit niche: helping seniors navigate what can be a convoluted Part D enrollment process.

The Pittsburgh, Pa.-based National Insurance Markets Inc., for instance, focuses primarily on highly specialized insurance products, such as extreme sport coverage. But it's now doing a bang-up business with its online business.

Since the site launched last summer, server activity has "been in the range of 200,000 hits per month," noted Susan Johnson, PhD, MBA, director of the company's online services. She and her colleague and husband Campbell Johnson, MBA, JD, represent several large national insurers that offer Part D plans—and have answered thousands of e-mail inquiries. For an individual analysis of a beneficiary's options and associated costs, the firm charges $19.95.

Several enrollment inquiries have come from physicians. In some cases, doctors were trying to help patients get the right advice, or office staff were looking for plan contact information to help smooth out formulary issues.

In other cases, Dr. Johnson said, physicians were themselves trying to enroll. "We've had retired physicians ask us to help because they were having difficulty understanding how the benefit works," she said. "That's because the concept is so new."

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