As Medicare beneficiaries grapple with the new prescription drug benefit, physicians report that they are dealing with a large number of prior authorization requests.
“The last thing that medicine needs is more paperwork,” said Dr. Christi N. Heck, director of the adult comprehensive epilepsy program at the University of Southern California, Los Angeles.
When the drug benefit was launched in January, the nursing staff in her clinic was overwhelmed with paperwork, Dr. Heck said. They were having to justify prescriptions for a range of medications, from the newest and most expensive to the older, cheaper alternatives, she said.
Dr. Heck said that she is also concerned that drug plans may change their formularies in the future and that patients will not have access to all of the epilepsy drugs they need.
Dr. Gregory L. Barkley, clinical vice chair of neurology at Henry Ford Hospital in Detroit, Mich., and a member of the board of directors of the Epilepsy Foundation, called the Medicare prescription drug program a “major victory” but pointed to problems with its implementation.
The staff at his clinic has done a lot of extra work to confirm existing prescriptions for patients, he said. In January, the nurses were making a dozen calls a day related to prior authorization for drugs.
Further, patients may not have access to the drugs that are best for keeping their condition stable because of copay tiers set up by some Medicare prescription drug plans, Dr. Barkley said.
Access to medications has been a problem mainly among patients who are dually eligible for both Medicare and Medicaid and had their drug coverage transferred to Medicare on Jan. 1, said Dr. Steven J. Zuckerman, a neurologist in solo practice in Baton Rouge, La. Many of these patients did not receive information about their drug plan or get their drug card, he said, and had difficulty getting their drugs at the pharmacy.
The problem is most urgent for epilepsy patients who are stable on a certain medication but affects all patients taking medications, he said.
But not everyone has seen problems with the new program. Dr. Marc R. Nuwer, professor of neurology at the University of California, Los Angeles, and a member of the American Academy of Neurology's Medical Economics and Management Committee, said he has seen few problems among his patients.
The lack of complaints may be because it's still early, Dr. Nuwer said, and some patients may have stocked up on medications prior to the Part D start.
But the program's exclusion of benzodiazepines is of concern, Dr. Nuwer said. Although dual-eligible patients—those who receive benefits from both Medicare and Medicaid—have been transitioned over to Part D drug plans, state Medicaid programs may still cover such excluded drugs.
It may take more time to really evaluate the program, he said, but he expects that overall Part D will be a benefit for patients. “In the big picture, it's a plus.”
The biggest challenge so far has been getting patients to enroll, said Stephen McConnell, vice president of public policy and advocacy at the Alzheimer's Association in Chicago. The enrollment process is difficult for patients with Alzheimer's, who generally have multiple chronic conditions, he said.
In an effort to help patients, the association will be offering a new tool—Rx Compare—on its Web site this month that is aimed at helping all patients with multiple chronic conditions. The tool, which includes printable worksheets, will help patients ask the right questions when looking at various drug plan options, Mr. McConnell said.
Another challenge, he said, is ensuring that all antidementia drugs are available. Currently, officials at the Centers for Medicare and Medicaid Services have established separate drug classes for cholinesterase inhibitors and glutamate pathway modifiers. However, Mr. McConnell said he is concerned that they will be combined into a single class for 2007.
Under the current framework, drug plans are required to cover two drugs in each drug class, but there are three cholinesterase inhibitors on the market and one glutamate pathway modifier (memantine). The drugs operate and function very differently, he said, and cholinesterase inhibitors tend to work better in treating early and middle stages of the disease, while memantine works better for later-stage disease.
As of Jan. 13, the Department of Health and Human Services reported that 14.3 million Medicare beneficiaries have been enrolled in a Part D plan. The bulk of those enrolled—6.2 million—are dual eligibles who were assigned to Part D plans. In addition, 4.5 million have enrolled in Medicare Advantage plans, which include drug coverage, and 3.6 million have signed up for stand-alone drug plans under Medicare.
AARP—which sponsors a prescription drug plan for its members—reports that overall the benefit implementation is going well. George Keleman, campaign manager for the AARP Medicare Rx Outreach Campaign, said the problems reported relate to communication systems between Medicare, the drug plans, and the pharmacies that have mainly affected dual-eligible beneficiaries.
Dr. Donna E. Sweet, an internist in Wichita, Kan., and chair of the board of regents for the American College of Physicians, has seen those problems firsthand in her practice. The biggest problem has been among her dual-eligible patients who have AIDS and have a three- or four-drug regimen that must be taken to keep from developing resistance.
“They are leaving the pharmacy without medications,” she said.
The problem isn't that the drugs aren't covered by the participating drug plans but that the patient is either not in the system or is listed incorrectly and thus asked to pay a high copay or deductible.
Among her other patients, she's noticed that the very elderly—those aged 90 and older—are opting out of the process entirely. For those patients who have selected a Medicare drug plan, Dr. Sweet said that she has spent a lot of time reviewing medications and figuring out which ones can be switched to better correspond with the patient's formulary list. “It's a tremendous amount of staff and physician time,” she said.
Dr. Maurice Wright, medical director and staff internist of the So Others Might Eat Medical Clinic in Washington, which provides primary care services to needy patients, including Medicare beneficiaries, said that even after exploring the Medicare and drug plan Web sites, he is unsure how to help his low-income Medicare patients apply for the “extra help” subsidy.
That low-income subsidy is especially important for his Medicare patients who do not qualify for Medicaid, according to Dr. Wright. And without information about how to enroll, they can't choose a drug plan because they don't know how much it will cost, he said.
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