No immediate changes expected for Part D program

Pharmacists should not expect Congressional changes soon in the controversial Medicare Part D drug benefit program. But, even so, several administrative issues still need to be resolved, according to two experts.

At the same time, they said that pharmacists are confronted with consumer anger over rising healthcare costs, they are also faced with dispensing expensive prescription drugs to chronically ill patients. "How do we avoid unnecessary healthcare costs?" asked Mark B. McClellan, former administrator of the Centers for Medicare & Medicaid Services and now a visiting senior fellow at AEI-Brookings Joint Center for Regulatory Studies. "Prescription drugs are having more of an impact than ever before."

McClellan, along with Thomas R. Clark, R.Ph., MHS, director of policy and advocacy for the American Society of Consultant Pharmacists, spoke about major changes and issues in the federal drug benefit program at the recent ASCP midyear conference, Geriatrics '07, in Hollywood, Fla.

McClellan said that there is as much as a 100% variation for drug costs between different regions of the country and "this variation persists" even today. "Our health care still does too little and costs too much," he said. At the same time, he acknowledged the fact that consultant pharmacists are faced with dealing more with chronically ill patients, whose health issues are often exacerbated by medical complications. "They are the hardest patients to treat and have the greatest potential for something to go wrong," he said.

Overall, according to McClellan, implementing Medicare Part D, starting in Jan. 1, 2006, went much more smoothly than everyone expected. Even though there were "a lot of bumps in the road," the active involvement of consultant pharmacists helped improve "satisfaction rates," he said. "The emphasis on giving beneficiaries a choice was the right way to go. The highest satisfaction rates come from dual beneficiaries. Costs are coming down steadily, and premiums are coming down by 40%."

Superficially, Medicare's requirement for disclosure on manufacturers' rebates could have an impact on moving patients to preferred drug selections, McClellan said. "Rebates are going to come under increasing scrutiny. There are some indications that rebates may be fading away in the years ahead."

There also needs to be more education about drugs to the elderly, McClellan told the group. "There has been a lot of drug switching," he said. "People on Medicare can get big savings by switching to generic drugs." The same trend is happening in institutions, where patients are relying on consultant pharmacists to help them manage their costs. "There are several opportunities for reducing costs," he said. Medicare has several demonstration projects that support new innovations that save money and improve the quality of care.

To that end, ASCP is taking part in the Pharmacy Quality Alliance, a coalition of several groups, to improve the dispensing and appropriate use of drugs to Medicare patients. In March, the organization came up with 35 key areas of quality measurement for pharmacists, indicators such as medication adherence and generic efficiency. The National Committee for Quality Assurance will develop and test technical specifications.

Clark said the deductible of $265 on Part D will increase to $275 next year, while the initial coverage limit goes up from $2,400 to $2,510 in 2008. Dual-eligible patients living in an assisted-living or group home are not eligible for co-pay plans, he said, but there is legislation in the works to change that. "We continue to have issues with data transfer," he said. "There is a lag in payment for compounded medications because there are some protocols that are problematic from one part to another. Coordination between Part B and Part D continues to be an issue."

For example, infusion therapy is often eligible under Part B, but Part D does not pay for supplies and services. "One of the challenges with Medicare Part D is who pays for noncovered medications," said Clark. As an example, he cited vitamin injections, which are excluded, but nursing homes are under obligation to provide the medication even if the method of payment is uncertain.

"Nursing homes have chased payments for months," Clark said. "The pharmacy and nursing facility get into a dispute over who should pay, but now the noncovered issues are getting addressed more upfront."

Finally, Clark said a report issued on June 15 from the Medicare Payment Advisory Commission recommended that Medicare Part D should be able to cover low-cost drugs without going through prior authorizations.

THE AUTHOR is a writer based in Florida.