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Am Fam Physician. 2006;73(3):395-396

See related Graham Center One-Pagers: Medicare Part D: Who Wins, Who Loses?,Out-of-Picket Prescription Costs,andMedicare Part D's Coverage Gaps.

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.4The 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 athttps://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.

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