Part D: Still a long way from "good"

June 2, 2006

Like their patients, doctors want the problem solved before givingit their blessing.

It's been six months since Washington launched the Medicare Part D drug benefit. Since then, almost 9 million Americans have signed up with a stand-alone prescription drug plan (PDP), bringing to 31 million the number of beneficiaries who receive coverage from either a PDP, a Medicare Advantage plan, a former employer, or some other source.

Beneficiaries' overall impression of the program still tilts toward the negative. In a Kaiser Family Foundation poll released in April, only 30 percent of seniors who responded gave the Medicare Part D benefit a favorable rating, a result no doubt of the lingering effects of its famously rocky start. Despite this, most seniors say they're satisfied with their individual plan, and more than eight in 10 report no problems getting their prescriptions filled.

Physicians' reaction to the program, like their patients', is a mixed bag. Although seven in 10 say they know the nuts and bolts of Medicare Part D better today than they did eight months ago, more than 90 percent say they still find key aspects of it confusing, according to a poll released in April by Epocrates, a medical-software company. "Patients expect me to be an expert on a program I neither designed nor fully understand," says Robert W. Matthies, an FP in Prescott, AZ.

Part D has also meant extra administrative and other hassles for physicians, with no extra compensation. "Doctors are being asked to do a lot more without getting paid," says Neil Kirschner, of the American College of Physicians.

CMS, the industry, and doctors themselves are addressing some of these hassles, while others remain a problem:

Multiple forms. Until recently, doctors (or patients) who wanted a nonformulary drug covered were often asked to submit one type of "exceptions" form by one plan, and a very different type of form by another. That variation from plan to plan clearly bothered doctors, acknowledges Karen Ignagni, president and CEO of AHIP (America's Health Insurance Plans), the trade association representing Part D and other health plans. Working with the AMA and other groups, the industry developed a standard request form for the most commonly used Medicare prescription drugs. Physicians may also use the form to request a prior authorization ( http://www.cms.hhs.gov/MLNProducts/Downloads/Form_Exceptions_final.pdf). A project now underway will develop a second, more detailed request form for biotech and other specialized drugs.

Formulary changes. Doctors like Robert W. Patterson, an FP in Sanford, NC, have been frustrated by drugs that appear on formularies and then disappear. "At my patient's urging, I changed her blood pressure medication to a preferred drug listed on her plan's formulary," says Patterson. "Almost immediately, the plan notified me that the drug was no longer on it. I had to prescribe two more times before I could find a drug that was once on the formulary and that was still on it."

Certainly, Part D rules prohibit arbitrary or sudden formulary changes. "Plans must have CMS approval," says internist Sunil K. Sinha, a medical officer in the Medicare Drug Benefit Group, CMS. "They just can't change their formularies whenever they want to." Before a change takes effect, they must also give beneficiaries 60 days' notice. Still, even with these safeguards, some doctors feel there's too much formulary-churning going on.

To calm concerns, on April 27, AHIP issued a statement that, among other things, supports CMS' efforts to restrict plans from changing beneficiaries' medications during a contract year. The two exceptions-when the FDA or the plan itself raises safety or efficacy concerns or when, as a substitute for a brand-name drug, an FDA-approved generic alternative becomes available.