Editorials
Medicare Part D: Practical and Policy Implications for Family Physicians
See the Graham Center One-Pagers on pages
401, 402, and
404.
The Medicare Part D prescription drug benefit offers financial relief for many beneficiaries. However, it has attracted criticism for its complex structure, its onerous cost-sharing provisions, and its sizable taxpayer burden-the program's expenses are estimated at $724 billion over 10 years. The long-term impact of Part D remains unknown in the context of soaring prescription drug costs and overall Medicare solvency. However, we do know that (1) the enrolling process is dauntingly complex for many older patients; (2) not every patient stands to benefit or to benefit equally; and (3) most patients expect their physician to be knowledgeable about the benefit program. It is essential that family physicians understand the basic features and limitations of the benefit. It is also important that family physicians remain politically active in pursuit of legislative options for simplification and for more cost-effective coverage of their patients' medications. In this issue of American Family Physician, a series of three One-Pagers from the Robert Graham Center1 attempts to shed some light on the implications of Medicare Part D. The following brief overview of the benefit offers additional background information and context.
Before the passage of Part D, it was estimated that two thirds of Medicare patients had some prescription drug coverage through employers, Medicaid, Medicare managed-care programs, supplemental insurance, or private drug cards. This coverage was inadequate for many persons. In 2003, the average Medicare beneficiary spent $800 to $1,000 on prescription drugs, accounting for nearly 25 percent of their out-of-pocket health care costs.2 Almost 70 percent of older patients with chronic illnesses but no medication coverage in 2003 reported forgoing prescription medications because of their cost.3 Political campaign promises and strong public support for federal intervention pushed a drug benefit to the legislative forefront, but it met with cost constraints and resistance from the pharmaceutical lobby. The compromise yielded Part D's universal eligibility, multi-tiered cost-sharing mechanisms, and provision of the benefit by for-profit drug plans. Coverage was created for all 43 million Medicare beneficiaries, of whom 29 million are expected to enroll in the program's first year.4 The legislation creates 34 prescription drug plan regions, within which private plans compete for the business of individual Medicare beneficiaries. Drug plans are being offered by traditional insurers and stand-alone pharmacy benefit managers who negotiate directly with drug manufacturers to buy medications and with pharmacies to sell them.
Most participants have more than 40 plans from which to choose and must do so before May 15, 2006, to avoid a 1 percent-per-month premium penalty. In a recent poll,5 73 percent of respondents said that having so many options "makes it confusing and difficult to pick the best plan." Patients who are cognitively or otherwise impaired will face even greater challenges. Moreover, the most highly touted decision-making aids-such as the online drug plan comparison tool-are the least accessible. According to a 2004 study,6 only 2 percent of respondents had visited the Medicare Web site (http://www.medicare.gov). Low-income patients are eligible for additional benefits, but they must enroll for these separately from the Part D enrollment-an additional challenge that may be prohibitive.
It is important that family physicians are informed about the Medicare Part D prescription drug benefit and how it may affect their patients. In the One-Pager on page 401, we examine which patients stand to gain and lose the most from enrollment. The One-Pager on page 402 identifies the continued financial risk that some patients will face because of out-of-pocket expenses and loss of other drug coverage. Finally, in the One-Pager on page 404, we explore how the complex cost-sharing mechanisms of the standard Part D benefit may impact medication use.
The American Academy of Family Physicians has launched an educational campaign for its members. Those interested can visit the Web site at http://www.aafp.org and click on the "Help Your Patients with Medicare Part D" link (or the pill bottle) for helpful Part D information and links to other Web sites. In addition, consider setting aside some time during scheduled visits to discuss the drug benefit, hosting a Part D educational session at your practice, or referring patients to Medicare-sponsored information sessions or the toll-free telephone number 800-MEDICARE (800-633-4227). Other straightforward interventions include asking patients whether they have prescription coverage through an employer and whether it will continue; identifying support for patients who need help with plan choices and enrollment; referring low-income patients to Social Security or Medicaid offices for subsidy enrollment; updating medication lists; and replacing brand-name medications with generics as indicated. Finally, as the principal primary care physicians for older patients in the United States, family physicians should encourage policy makers to address the continued escalation in medication costs that is not addressed by Part D.
The Graham Center One-Pagers in this issue explain the complex benefit design for Part D and the pitfalls it poses for some patients. As family physicians help patients negotiate this complex benefit, they should pay particular attention to those at risk of going without needed medications. Part D will help many patients, but we should help ensure that it does no harm.
The Authors
GIRIDHAR MALLYA, M.D., is a third-year family medicine resident at Thomas Jefferson University Medical College, Philadelphia, Pa. In June he will join the Robert Wood Johnson Clinical Scholars Program at the University of Pennsylvania, Philadelphia.
ANDREW BAZEMORE, M.D., is assistant director of the Robert Graham Center.
Address correspondence to Andrew Bazemore, M.D., The Robert Graham Center: Policy Studies in Family Medicine and Primary Care, 1350 Connecticut Ave. NW, Suite 201, Washington, DC 20036 (e-mail: abazemore@aafp.org). Reprints are not available from the authors.
REFERENCES
1. Mallya G, Bazemore AW, Phillips RL, Green LA, Klein LS, Dodoo MS. Medicare Part D: who wins, who loses?; Out-of-pocket prescription costs a continuing burden under Medicare Part D; Mind the gap: Medicare Part D's coverage gaps may affect patient adherence. Am Fam Physician 2006;73:401-2, 404.
2. Caplan C, Brangan N. Out-of-pocket spending on health care by Medicare beneficiaries age 65 and older in 2003. Data Digest 101. Washington, D.C.: AARP Public Policy Institute, 2004. Accessed online January 6, 2006, at: http://assets.aarp.org/rgcenter/health/dd101_spending.pdf.
3. Safran D, Neuman P, Schoen C, Kitchman MS, Wilson IB, Cooper B, et al. Prescription drug coverage and seniors: findings from a 2003 national survey. Health Aff (Millwood) 2005.
4. Actuarial Research Corporation, The Henry J. Kaiser Family Foundation. Estimates of medicare beneficiaries' out-of-pocket drug spending in 2006: modeling the impact of the MMA. Executive summary. Accessed online January 6, 2006, at: http://www.kff.org/medicare/7201.cfm.
5. The Henry J. Kaiser Family Foundation, Harvard School of Public Health. The Medicare drug benefit: beneficiary perspectives just before implementation. Accessed online January 6, 2006, at: http://www.kff.org/kaiserpolls/med111005pkg.cfm.
6. The Henry J. Kaiser Family Foundation. E-health and the elderly: how seniors use the Internet for health-survey. Accessed online January 6, 2006, at: http://www.kff.org/entmedia/entmedia011205pkg.cfm.
Identifying Effective Alternative Therapies for Common Conditions
Increasingly, our patients ask us about alternatives to prescription drugs for managing common conditions. This issue of American Family Physician features an article about nonhormonal therapies for hot flashes1-a concern we regularly encounter in our patients who are navigating the menopausal transition. Other health concerns physicians are commonly asked about include lowering lipids without drug therapy; managing cancer symptoms using alternative modalities; and treating hypertension, heart failure, angina, and diabetes using nutrients or herbal therapies.
Most physicians are not comfortable treating a disease or managing symptoms such as hot flashes without clear data to support a given intervention. We are properly wary of instituting, or even supporting, a patient's use of an "alternative" or "complementary" treatment unless we can be convinced that the research to support it is sound. More and more we see articles in major journals supporting what previously have been considered "alternative" therapies, yet we are slow to change our ways. We seem much more comfortable trying an "alternative" use of a prescription drug-such as a selective serotonin reuptake inhibitor (SSRI) for hot flashes-than an herb or nutrient with which we have less experience, such as soy or black cohosh. As Dr. Carroll points out in her article,1 there is relatively similar evidence for the effectiveness of SSRIs and soy isoflavones for reduction of hot flashes (approximately a 60 percent reduction in hot flashes on average for both treatments), yet fewer side effects occur with the soy interventions. What is our hesitation to incorporate useful nonconventional therapies into our practice?
One problem we have is how to find a reliable nutritional supplement or herb, as these products are not standardized or overseen by any government entity. A resource that can be useful to at least determine proper potency and lack of unwanted additives in nutritional products is available online at http://www.consumerlab.com. This subscription service independently evaluates herbal and nutritional products and regularly publishes the results of these evaluations on its Web site. The Cochrane Database of Systematic Reviews (http://www.cochrane.org/reviews/index.htm) also has many abstracts that can be accessed without charge on numerous herbal, nutritional, and other unconventional therapies, such as acupuncture for headache2 and massage for low back pain.3 The National Library of Medicine's PubMed Web site (http://www.ncbi.nlm.nih.gov) provides easy access to medical literature about any topic. The National Institutes of Health's National Center for Complementary and Alternative Medicine Web site (http://nccam.nih.gov) has continuously expanding resources to educate physicians and the public about research results regarding therapies heretofore considered unconventional or "alternative."
Something we do not often realize is that even the "standardized" pharmaceutical agents that are heavily regulated by the U.S. Food and Drug Administration (FDA) are not identical batch to batch or pill to pill. The FDA allows a range of potency from 90 to 110 percent for any given name-brand drug, and 80 to 125 percent for generics.4 How many of us are aware of this?
Most physicians that I have talked with would like to see abandonment of the phrase "alternative medicine," and I agree with them. We need to speak in terms of medicine that works (or at least has enough research to support its current safety and effectiveness) and medicine that does not. We have a problem, however, in that an inbred bias exists to promote the use of the therapies with which we are familiar-largely drugs and surgery-and we too often ignore the ones with which we are less comfortable, even when the data are poor for the former and supportive for the latter. A good example is the wealth of data, and even meta-analyses, supporting the use of certain nutrients such as policosanol to lower cholesterol5 and saw palmetto to improve symptoms in benign prostatic hyperplasia.6 We tend to downplay the dangers of pharmaceutical agents, such as statins for lipid lowering, because they are the mainstays of recommended therapy and we feel safe, in a therapeutic and medicolegal sense, in continuing to use them as our preferred treatment. Yet we often could produce results approaching those of standard therapy, with fewer side effects, by taking the nutritional approach. Why are we hesitant? Our clinical guidelines recommend statins early in treatment, and insurance reimburses for prescriptions but not usually for nutritional supplements.
We have many obstacles to the use of "alternative therapies" in our practices-financial, institutional, longstanding pro-pharmaceutical bias, and insufficient information at our fingertips about the safety and effectiveness of the alternatives. However, more and more of our patients want us to overcome these challenges and help them follow a path to health that includes less-toxic nutrients and herbs when appropriate, combining the best scientific knowledge with an open mind.
The Author
JANE L. MURRAY, M.D., earned her medical degree from the University of California at Los Angeles and completed her residency in family medicine at Santa Monica (Calif.) Hospital. Dr. Murray served as Director of Education for the American Academy of Family Physicians from 1986 to 1991 and as Chair of the Department of Family Medicine at the University of Kansas Medical Center from 1991 to 1998, when she left to co-found the Sastun Center of Integrative Health Care.
Address correspondence to Jane L. Murray, M.D., 5509 Foxridge Dr., Mission, KS 66202 (e-mail: jmurraymd@sastuncenter.com). Reprints are not available from the author.
REFERENCES
1. Carroll DG. Nonhormonal therapies for hot flashes in menopause. Am Fam Physician 2006;73:457-64.
2. Melchart D, Linde K, Fischer P, Berman B, White A, Vickers A, et al. Acupuncture for idiopathic headache. Cochrane Database Syst Rev 2001;(1):CD001218.
3. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low back pain. Cochrane Database Syst Rev 2002;(2):CD001929.
4. Generic drugs. Med Lett Drugs Ther 2002;44:89-90.
5. Chen JT, Wesley R, Shamburek RD, Pucino F, Csako G. Meta-analysis of natural therapies for hyperlipidemia: plant sterols and stanols versus policosanol. Pharmacotherapy 2005;25:171-83.
6. Wilt T, Ishani A, MacDonald R. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev 2002;(3):CD001423.
| Copyright © 2006 by the American
Academy of Family Physicians. |
