Family Physicians Grapple with Medicare Part D Glitches

Some call the launch of Medicare Part D prescription benefits a disaster. Others say the "glitches" in the system will be ironed out. Most, however, can recount a tale of confusion over eligibility, copayments, deductibles or participating pharmacies. And few will venture a guess about the long-term efficacy of the program.

"It's too new," said FP Andrew Merritt, M.D., of Marcellus, N.Y. Although some physicians indicated they had not received any Part D calls from pharmacists or patients, for those who have, Merritt's experience is typical. " Right now it's a nightmare," said Merritt.

The issue for physicians is too many Medicare Part D plans and formularies that can be extremely difficult to access. The confusion ensnared thousands of physicians when pharmacists began calling them after the plan went into effect on Jan. 1 to request substitute prescriptions for patients with plans that didn’t cover their medications or that classified them in high-copayment tiers.

Particularly hard-hit were low-income patients or those who previously had qualified for Medicaid drug coverage. This group was required to select a Part D plan by Dec. 30. Those who didn't were randomly assigned to plans.

"They were enrolled in plans without regard to their medications," said Merritt. "But they didn't get the plan's formulary in the mail, so they had no idea that the plan didn't cover their medication."

Neither did Merritt. The plethora of Part D plans offered to his patients would require him to find and download as many as 35 formularies. Online services that offer free formularies can help, but their usefulness is limited by PDA or computer memory capacity. Many physicians can't download all the formularies of the numerous plans their patients may use. "I'd have to go online and download a formulary for each patient," Merritt said.

He first responded to pharmacists' requests by calling the toll-free appeals number to request a temporary approval. The line was busy all day.

"In fact, I'd get a message saying the lines were overloaded and asking me to call back later. Then it would hang up on me," he said. "It wouldn't even put me on hold."

He went to plan B: Consult the patient's chart, identify potential substitute medications, call the pharmacists and ask them to enter a new prescription to see if the patient's plan would cover it. If the new prescription wasn't in the formulary, Merritt would try another substitute until he found one that was covered.

That approach, however, has its perils, particularly for patients who are stabilized on a medication. Physicians have expressed concern over quality of care and potential liability when they change a prescription without first seeing the patient. In fact, Medicare Part D contains a regulation requiring a 30-day grace period before plans can enforce rules regarding prior authorization for certain prescriptions so physicians have time to actually see patients; however, it seems few CMS and plan officials were aware of that regulation.

"I really hate to change the patient from a drug that is doing its job without side effects, but sometimes there is not much choice when the patient cannot afford -- or does not want -- to pay extra," said FP Don Ratliff, M.D., of Belmont, Miss. "So I change the drug to one that is covered, start the dosage titration search all over again, start dealing with side effects all over again, start ordering hepatic function panels all over again until the patient is stabilized on the new drug."

Such concerns, combined with widespread reports of patients unable to get their medications, spurred several states to pass emergency rules or laws. In general, the emergency provisions address issues faced by low-income patients who formerly had prescription coverage under Medicaid or who qualified for subsidies for their deductible or copayment. Several state Medicaid officials reported thousands of calls from patients who had been refused their medications because

The states' stop-gap actions will cost between $500,000 to several million dollars over the next several weeks and puts those states' budgets at risk. CMS officials have indicated that, by law, the federal government cannot reimburse the states for costs to fix the problem. However, Rep. Ben Cardin, D-Md., and Sen. Frank Lautenberg, D-N.J., have announced they will introduce legislation to authorize reimbursement to the states when Congress reconvenes Jan. 31.