As Medicare beneficiaries grapple with the new prescription drug benefit, physicians report that they are spending considerable time explaining the benefit, rewriting prescriptions, and dealing with prior authorization requests.
“We are having to jump through hoops,” said Dr. Christopher R. Morris, a rheumatologist in Kingsport, Tenn.
Dr. Morris said he has been receiving prior authorization requests from a number of the Medicare drug plans for relatively inexpensive rheumatoid arthritis treatments like oral methotrexate and Imuran (azathioprine). Plan administrators are asking physicians to prove that the drug is not covered under Medicare Part B before they will approve payment.
The burden is on the physician to prove the drug is not covered, Dr. Morris said. If payment for the drug is denied, physicians and patients then face going through the plan's appeals process to get coverage.
The high volume of prior authorization requests has been very disruptive to his office, and it's been even worse for patients who can't get their medicine, Dr. Morris said.
Dr. John A. Goldman, a rheumatologist in Atlanta, is seeing a similar situation.
This creates yet another unfunded mandate for physicians, Dr. Goldman said, but they will have to work around it. “We've got to make do with what we can to help our patients,” he said.
Physicians weren't armed with the necessary information to properly advise patients about the new Medicare Part D benefit, 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.
And even after exploring the Medicare and drug plan Web sites, Dr. Wright said he still has unanswered questions about 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, he said. 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.
For patients who are eligible for both Medicare and Medicaid, a different set of problems exists, Dr. Wright said. These patients were automatically enrolled in a Part D drug plan before the beginning of the year. But technical glitches have resulted in no record of enrollment for some patients. Further, some dual-eligible beneficiaries were signed up for plans that don't cover their medications, Dr. Wright said. Although they can switch plans, figuring out the formulary list for the various plans can be difficult for patients, he said.
As of Jan. 13, 14.3 million Medicare beneficiaries have been enrolled in a Part D plan, according to the Department of Health and Human Services. The bulk of those enrolled—6.2 million—are beneficiaries who are dually eligible for Medicare and Medicaid and 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 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 with AIDS who are on 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 patient is either not in the system or is listed incorrectly and thus asked to pay a high copay or deductible, she said.
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