No co-pay, no drug: Right or wrong?

December 11, 2006

Q: Medicare Part D patients are often unprepared for the realities of the new drug plan. If a dual-eligible patient can't cover his co-pay, should the pharmacist send the patient home without the drug?

A: When seniors were brought into the Medicare Part D prescription plan, many of them were new to the complexity of prescription insurance, but they expected to pay a share of costs to receive the benefit. Dual-eligible patients were previously asked for co-pays under Medicaid, but they were never sent home without a drug if they could not pay. After switching to Medicare Part D, however, if patients refused to or were unable to pay their co-pays, pharmacists have the option of not dispensing the drugs to them. This is a rude awakening to many patients.

Independent and chain pharmacists report that some dual-eligibles left prescriptions at the counter, scrounged up the co-pay, and returned to pick up their drugs hours or days later. Pharmacists often provided an emergency three-day supply or ran a tab for cash-strapped patients. Some kindhearted pharmacists and technicians also dug into their own pockets to help indigent patients, while others phoned health department caseworkers to secure assistance for those who couldn't pay.

Impossible for pharmacists or patients to forget, the demise of the Oregon Health Plan is an invisible but steady undercurrent in Oregon, motivating patients to continue their medication and impelling pharmacists to prepare patients for the financial realities of the times. Though patients often express their anger over co-pays, very few have failed to find a few dollars for needed medication.

Pharmacy staffs in chain stores are required by ownership to balance the register at the end of each day. Independents need to maintain their cash flow to keep their doors open. As dispensing volumes increase from Part D while the overall revenue drops, managers have cut staff to help bridge the gap. Drug prices charged by wholesalers have not decreased. One Oregon independent said, "There is no free lunch" and kindly but firmly coached his patients to plan for the inevitable.

Without group discussion, pharmacy management in aggregate seems to be siding with patients, investing staff time in teaching patients about the plans, and accepting some losses as part of the cost of Part D. Is it ethical, or even rational, for managers to assist each patient with his or her needs and write off co-pays and prescriptions if it ultimately leads to closing their business?

Without realistic reimbursement for drugs and services, pharmacies that have served patients for years may begin to disappear one by one, along with their patients' source of medication. Despite new giveaway plans by several chains, created for their public relations effect, pharmacy cannot be sustained by giving away drugs and valuable services.

Looking into the eyes of patients every day as executives seldom do, pharmacists should not and cannot be expected to bridge the overlooked gaps in Part D legislation. As drug manufacturers post record profits, pharmacists should not and cannot give away prescriptions and their livelihood. After giving patients a few doses of medication and several warnings, we cannot continue to send dual-eligible patients home without demanding the very modest co-pays required.

THE AUTHOR has written a book, We Will Be Healed: Spiritual Renewal for Health Care Providers, to be published by ACTA Publications in January 2007. She has practiced long-term care and community pharmacy in Oregon for more than a decade and has served on numerous professional and community boards.