Medicare Part D revisions sorely needed

August 11, 2008

A new year is coming, and with it a new administration in Washington, a new Congress, and a new, skeptical look at Medicare Part D.

A new year is coming, and with it a new administration in Washington; a new Congress; and a new, more skeptical look at Medicare Part D.

When his 13-member bipartisan committee looked at Part D in mid-2007, it left no doubt about its findings. "The Private Medicare Drug Plans: High Expenses and Low Rebates Increase the Cost of Medicare Drug Coverage" was both the primary conclusion and the title of the committee report.

The Waxman committee report is a superb analysis of the defective Part D program. Its investigation highlights the deficiencies of this ill-conceived and poorly designed program. But its conclusions are not universally accepted. A May 2008 report for the Medicare Payment Advisory Commission (MedPAC) found that a majority of patients like Part D, with physicians close behind. Pharmacists are less satisfied and for good reason. Pharmacists bear the responsibility of fixing the multitude of problems that Part D has created for patients and prescribers.

Pharmacists are not alone in recognizing the problems of Part D. The MedPAC report found that patients and prescribers are unhappy with the coverage gap, formulary exclusions, and abysmal customer service from some Part D plans.

Medicare Part D is not a cohesive benefit program. It is a clutter of hundreds of profit-driven entities. Part D rewards plans for skimping on pharmaceutical care provided to millions of Americans in order to boost plan profits.

The basic design that incorporates multiple formularies, donut-hole coverage gaps, and a plethora of prescription drug programs, pharmacy benefit managers, and insurance administrations defies administrative oversight.

We applaud Congressman Waxman's decision to revisit and revise Medicare Part D. We recommend that the new Administration and Congress target five areas.

1. The bewildering multiplicity of administrative entities created by Part D makes it virtually impossible for even a well-informed beneficiary to evaluate alternative plans.

2. Individual plan formularies are not comparable. Formularies are driven by plan financial considerations, not by patient healthcare needs or rational prescribing.

3. The Centers for Medicare and Medicaid Services (CMS) has inadequate staff, funding, and expertise to oversee Part D programs and entities.

4. Beneficiaries and providers cannot effectively challenge formulary selection or coverage determinations in a timely manner. Many beneficiaries and their prescribers do not even realize that they have a right to contest coverage determinations.

5. Pharmacy and therapeutics committees are not accessible to patients or providers and operate with virtually no oversight by CMS or any other third party.

It is past time to redesign the Part D program so that it can function as intended to lower Medicare prescription drug costs while improving patient outcomes with more effective drug therapy.

Walter Way is professor emeritus of anesthesia and molecular pharmacology at the University of California, San Francisco. He is also medical director of Pharmacists Planning Service Inc. (PPSI), San Rafael, Calif. Fred Mayer is past president of the California Public Health Association and CEO of PPSI.