Pharmacists and doctors alike report difficulties in the first year of implementation of Medicare Part D.
At Hillside Family & Community Medicine in Pawtucket, a clerk now works full time on prescription issues, helping patients figure out which drugs their Medicare Part D plan will cover, dealing with denials, and compiling the materials for prior-authorization requests.
Only a fraction of Hillside’s patients are senior citizens, said Dr. Michael Fine, but the volume of calls and paperwork required by those patients’ insurers has made the investment necessary.
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At the University Health Foundation in Providence, the geriatric practice gets about a dozen calls a day regarding Medicare prescription coverage, said Dr. Lynn McNicoll.
And now that people are starting to hit the “doughnut hole” in their plans, McNicoll said, a new wave of crises has begun – patients who suddenly have to come up with hundreds of dollars to pay for their drug regimens, and in reaction, are just stopping taking their medications or are asking for replacements.
“It’s horrible. It’s a nightmare,” McNicoll said. The Medicare prescription plans, for the most part, aren’t really suited to most senior citizens’ financial realities, she added. “A lot of people went for the cheapest programs, and now they’re suffering.”
McNicoll’s view is very different from what the Centers for Medicare & Medicaid Services, the federal agency that oversees the new entitlement program, has been reporting.
As recently as last week, Roseanne Pawelec, a Boston-based spokeswoman for the CMS, said the new drug program has been a success, with seniors, doctors, pharmacists and public officials locally and across the nation reporting no major problems, after the first few weeks’ glitches.
And a report released by the Kaiser Family Foundation this month, based on two surveys conducted nationwide between April and July, shows that 86 percent of pharmacists and 71 percent of doctors believe the new program is helping Medicare beneficiaries save money.
But the report also shows that McNicoll’s experience, and that of her colleagues at Hillside, is not unique: 59 percent of doctors in the survey said they’ve had Medicare patients who had problems getting their prescriptions, and 10 percent said they’d had at least one patient who suffered a “serious medical consequence” as a result of such problems.
The pharmacists’ survey also brought to light serious issues that drugstores – especially those that are independently owned – have faced in the program’s first few months.
Eight in 10 pharmacists surveyed said they had customers who had trouble filling their prescriptions, and two-thirds said they had customers who had left without their medication because the drug was not on their Medicare plan’s formulary.
Almost six in 10 pharmacists said they had customers who had paid out of pocket because the pharmacy couldn’t verify their enrollment in a Medicare drug plan, and nearly half said they had customers who had forgone their medication because they couldn’t afford the required co-pay.
Medicare Part D also has hurt many pharmacies financially, the survey showed: 73 percent of independent pharmacists (and 40 percent of chain pharmacists) reported filling prescriptions without knowing for sure that they’d be reimbursed; 67 percent of the independents (and 12 percent of the chains) said they had to wait longer than usual for payments to arrive.
And 27 percent of the independents said they had to take out a loan or line of credit because of cash-flow problems the Medicare Part D program had created.
Jack Hutson, executive director of the Rhode Island Pharmacists Association, said the survey results ring true for his group’s members, who are now lobbying for changes to the Part D program to make it more manageable for patients and pharmacists alike.
David Feeney, owner of Oxnard Pharmacy in Warwick, said his store has filled “tons of prescriptions” without knowing for sure whether it would be reimbursed, and it has given many customers a few days’ pills just to hold them over while coverage issues were resolved.
Oxnard and other pharmacies often wait several weeks for payment, Feeney added, and many plans insist on sending paper checks, instead of making electronic deposits, further delaying the cash flow.
Pawelec said CMS has surveyed the prescription plan providers, and “the vast majority” have contract terms that require payment within 30 days. CMS won’t interfere in the drafting of those contracts, she said, but it will step in if the plans don’t comply with their contracts.
Another issue cited by both Feeney and local doctors is that insurers are changing their formularies mid-way through the year – a practice that Pawelec said is allowed by CMS.
As it is, Feeney said, doctors have been having trouble matching their patients’ drug needs with the drug plans’ formularies – figuring out whether among antidepressants, for example, a particular plan will favor Prozac or Zoloft or Celexa.
But even patients who carefully chose their plans to ensure that the drugs they take will be covered have gotten unpleasant surprises, Feeney said, showing up for their refills only to find out that what was covered in August is no longer covered in September.
The whole process of determining what will or won’t be covered is “kind of trial and error,” Feeney said. The only sure bet, he said, is that generic medications are almost always covered.
Dr. Fine said insurers seem to want doctors to justify their prescriptions for “anything that costs money, anything that’s not generic,” unless they’ve negotiated a good deal for a specific drug – in which case everyone with acid reflux, for example, may be asked to take Prilosec. “Usually it doesn’t matter, so we often end up changing” the prescriptions, Fine said.
Dr. McNicoll, whose practice includes many patients on complex drug regimens, said she finds the whole thing disturbing. It’s important to address the patients’ financial needs, she said, but not all drugs are equal, and switching can be risky, especially with psychotropic medications.
“It’s a cocktail,” she said. “You change one of the ingredients, and everything can change.”
Fine said that, as patients begin to hit the doughnut hole, he’s getting many requests for free samples and new prescriptions for cheaper drugs. For many patients, the big Part D savings aren’t lasting, he said, and he considers the whole program to be a mess.
“I think if people really understood the economics of this, maybe they’d really be outraged,” he said. “But the amazing thing about people as consumers is their incredible willingness to pay more and more money for very little benefit.”
