Medicare Part D: Seeing Through the Political Spin

43 million people are eligible for Medicare Part D. Roughly 20% of the population of the United States. Lost in the confusion and the difficulties with the implementation of Medicare Part D is the realization that the U.S. government, in its endless bureaucracy and politics, just enrolled 37 million people into a prescription drug benefit that will on average save a typical Medicare beneficiary $1100 per year.¹ This was no small feat. It’s easy for pundits and experts to bemoan the barriers and difficulties of such an endeavor—but the reality is that it worked. There will be no delay in the enrollment period or the penalty phase for most seniors, although some relief will be afforded to low-income individuals who miss the deadline.²

The communication and education, while accelerated, was pieced together and pulled together despite a seemingly directionless and haphazard approach. There is no precedent for this level of implementation. To be able to enroll this number of individuals and to have settled into a new drug benefit 150 days from implementation is profound. Some level of appreciation needs to be extended to the Centers for Medicare & Medicaid Services (CMS), the pharmacies, and the educators who brought the plan to the people. The shortcoming of the plan was the accelerated implementation period that was defined by Congress. Only one small group of eligible Americans will pay more for their prescription drugs in 2006 than in 2005—and they are the lucky ones with few or no medication needs. What they get is insurance for the potential heart attack, stroke, or hip fracture that changes their medication requirements from few to many.

In many cases, this insurance is less than $20 per month.³ As of May 11, 2006, only a small group of eligible Americans remained, prior to the May 15 deadline, without creditable coverage. In a press conference on May 10, 2006, Dr. Mark McClellan, administrator for the CMS, stated, “There are likely 3 million [remaining] people who are eligible for the low-income subsidy and for who we are going to continue to do outreach efforts before or after May 15.” The outreach to this population will continue, but there always will be those who choose not to enroll for one reason or another. Medicare Part D is voluntary.

Long-term care (LTC) residents were not targeted in the Medicare Modernization Act of 2003. Many of the issues affecting this population were not considered in the original legislation. Anyone familiar with lobbying the U.S. Congress understands that sometimes the scope of legislation does not address the diversity of the population impacted. This is the case with LTC. Only 2 million of the eligible 43 million seniors reside in skilled nursing facilities (SNFs), representing 4% of Medicare beneficiaries but using 25-50% of all Medicare Part D drugs.⁴ Therefore, special guidance from CMS coincided with the release of the implementation plan due to heavy advocacy for this population, and the specifics of that guidance have been realized in practice.

One such guidance is for dually eligible individuals living in LTC—those with both Medicare and Medicaid. A Special Enrollment Period (SEP) exists for residents who find themselves in prescription drug plans (PDPs) that do not provide the medications they need. This may occur upon admission or discharge from a SNF, or at any time during a SNF stay. The new plan that they choose would become effective the first day of the month following their enrollment, with the previous plan continuing coverage until that time. In some cases, it may be easier for nursing home residents and nursing home staff to change plans rather than endure a plan with restricted medications and prior authorization procedures. Some identify the above scenario as a risk for SNFs that may be required to pay the cost of any noncovered medications. This is certainly a potential risk, but the practical solutions, foreseen by many LTC pharmacies, alleviate this concern.

A coordinated approach using formularies and internal procedures can make efficient work of required prior authorizations and enable access to restricted medications without an interruption in care or a bill to the nursing facility. Retail pharmacies and community physicians have been dealing with such work-arounds for years. The other glaring concern from most conscientious clinicians is the risk of not having access to necessary medications. Again, guidance from CMS followed the implementation process to ensure that high-cost antibiotics, psychoactive medications, certain intravenous medications, and cancer drugs had broad coverage to avoid scenarios of disrupting beneficial therapy. This guidance, along with the regulation of at least two medications per class and the global movement of insurers toward “tiered” benefits, has kept the access to medications fairly open. Certainly, classes of medications have noncovered and restricted agents (ie, proton pump inhibitors, angiotensin-converting enzyme inhibitors, and statins). But even within those classes, the utility of tiered copays opens access for those willing or needing more expensive and specific medications.

For dually eligible residents in LTC who have been assigned to or who have chosen tiered plans, the tiers themselves have little meaning because these individuals do not pay copays or differences in copays. For these individuals, the formularies are wide open. The last voiced concern has been the difficulty managing the medications not eligible for coverage, most notably the benzodiazepines. Many states have “nondiscriminatory” language in their Medicaid provision that does not allow one group to be denied medications that are allowed to another group. For benzodiazepines, this means that if the state Medicaid department allows diazepam for the younger population, it must provide it to the older population, regardless of where their primary coverage exists. So state Medicaid departments may cover benzodiazepines for seniors whose PDPs do not. This is not the case in every state, and doesn’t exist for non–dually eligible individuals, but benzodiazepines are generic and relatively inexpensive if no other option exists.

Before we induce a state of fear around the difficulties with Medicare Part D, we should take note of the comprehensive effort and task it was to implement in the first place. The fact that we have weathered a difficult implementation and have set our sights forward should be gratifying in the face of the monumental bar that has been passed. Is the Medicare Part D program without faults? Certainly not, but it does represent a step forward in providing basic prescription medication coverage and relief from the high costs of medications. The language provides for further refinement going forward in the form of Medication Therapy Management Service (MTMS). This little-described language has the ability to dramatically change the way prescription medications are prescribed and managed. In a system that has yet to address utilization, MTMS has the potential of re-directing the U.S. health care system into one with efficient and effective checks and balances for medications and their costs.

The success of this provision lies now with the PDPs, CMS, and the countless practitioners who recognize that America’s ability to afford health care depends upon their ability to thwart a growing addiction to prescription remedies, and promote a system of appropriate medication use at appropriate costs. The author reports no relevant financial relationships.