Oversight hearings draw earful from R.Ph.s

June 4, 2007

On the heels of oversight hearings on the first anniversary of the Medicare Part D program, patient advocates and pharmacists shared their insights.

Advocates named formulary policies among the most perplexing aspects of a complicated program that needs better outreach, a simplified choice process, and curbs on abusive marketing. Pharmacists cited unfair-or nonexistent-negotiation with plans, low reimbursement rates, payment delays, and delayed price updates as their sore points. Senators from both political parties expressed gratitude to pharmacists for helping to launch the complex program and pledged their support for fair and timely compensation in return.

Information that Senators obtained from R.Ph.s in their home states and at the hearing caused them to question whether it is fair to allow PDPs to change formularies midyear without giving beneficiaries the opportunity to change plans as well. Beneficiaries disabled by mental illness and their need for stable drug therapy regimens were a particular concern.

Coverage determination and exception requests are vague and complicated processes, said patient advocates. Pharmacists said they need consistent, reliable answers from plan personnel to assist the dispensing R.Ph. Schule asked CMS and Congress to consider whether utilization management tools are undercutting the formulary safeguards Congress incorporated in the Medicare Modernization Act.

Making the best choice for each beneficiary is difficult enough without consideration of formulary policies, utilization review requirements, and exception requests that differ from plan to plan. The sickest patients, those who take numerous drugs, are unable to find one plan to cover them all. CMS officials referred to the requirement that patients be granted coverage through the remainder of the contract year for drugs taken off the formulary, but R.Ph.s and patient advocates reported that it is unusual for coverage to last longer than 60 to 90 days.

Forcing beneficiaries to use mail order, either as a requirement or through strong financial incentives, is not in the interest of the sickest patients, according to Schule. Tim Tucker, R.Ph., of Huntingdon, Tenn., urged that medication therapy management, designed as a cornerstone of the Part D program, be pursued as a way to make Medicare a truly effective drug plan for seniors.

Representatives from the Senior Health Insurance Information Program recommended better data sharing among CMS, PDPs, Social Security, and state Medicaid programs because problems are taking trained case workers months to resolve. Aggressive marketing and coverage questions are particularly problematic for people who qualify for a low-income subsidy and have an extended enrollment period, many of whom are ill, disabled, illiterate, or lack computer savvy. Disputes between Medicare and state agencies about jurisdiction over insurance agents also can delay action on marketing abuses.

Closing remarks by Baucus characterized CMS as being too slow and too passive in enforcing program policies and bringing requests for legislative action to the attention of Congress. The Senator noted that he had learned firsthand about challenges facing patients and pharmacists by spending a full day working in a community pharmacy in his home state of Montana.

THE AUTHOR is associate professor, Department of Pharmacy Health Care Administration, University of Florida College of Pharmacy.