Consumers should beware of Part D pitfalls, warn experts

December 11, 2006

Medicare Part D is still not for wimps, be they health professionals or consumers, any more than it was in early 2006, according to a Kaiser Family Foundation (KFF) analyst. Indeed, there is high risk that many beneficiaries are getting into plans, both for 2006 and 2007, that are not good for covering their medications and there could be health consequences, said Patricia Neuman, Sc.D., director of the foundation's Medicare Policy Project.

Medicare Part D is still not for wimps, be they health professionals or consumers, any more than it was in early 2006, according to a Kaiser Family Foundation (KFF) analyst. Indeed, there is high risk that many beneficiaries are getting into plans, both for 2006 and 2007, that are not good for covering their medications and there could be health consequences, said Patricia Neuman, Sc.D., director of the foundation's Medicare Policy Project.

Noting the good news that most Medicare beneficiaries do have some form of prescription coverage and that Medicare's Web site offers good information, she nevertheless warned that Part D is a system "predicated on the assumption that people will make good decisions to get the drugs that they need at the best possible costs."

Almost 25% of all beneficiaries are enrolled for 2006 in one of two plans, with AARP MedicareRx having 14% of all enrollees, said Neuman, who spoke at the recent annual meeting of the Pharmacy & Therapeutics Society in Washington, D.C. She said she suspects that, rather than doing comprehensive research, many beneficiaries simply went for a low premium or with a name they trust.

KFF analysts now believe that three or four million people covered by Part D will spend themselves into the "donut hole," or the coverage gap, in 2006, said Neuman, pointing to research indicating many people are noncompliant with medications when their plans don't pay for them, resulting in hospitalizations and emergency room visits.

Noting, for example, that the plans cover 91% of all beta-blockers but only 70% of cholesterol agents, Neuman said: "That may not be a bad thing. I'm not casting judgment. But if you take a medicine that isn't covered, it's clearly an issue at the individual level." She noted that 51% of pharmacists said that most of their patients' formularies lack sufficient coverage, according to a KFF poll in April through June. Forty-three percent said the formularies were sufficient, and 6% did not answer or said they did not know.

Sixty-seven percent of R.Ph.s said they had patients who left the pharmacy without their Rxs because their drug wasn't on their plan's formulary, and 49% had customers who left because they couldn't afford the co-pay.

Neuman also found KFF physician surveys disturbing. Of the 78% of doctors who said they serve some patients enrolled in Part D plans, 53% said the formularies lacked coverage for most of those patients, 44% said they were not very familiar with their patients' plans, and 59% said when they prescribe a drug for a Medicare patient, they rarely or never check the formulary.

That means, Neuman said, that the patient is sent back to the pharmacy, which must be the bearer of bad news if the drug is not covered. The R.Ph. may be able to work it out with the physician, or the issue may go to appeals, but "it certainly is not seamless from the individual's point of view." Acknowledging the pharmacotherapy expertise in her audience, she said, "Somebody should be looking at whether these decisions have quality implications."