No Silver Lining – the Cost of Medicare Part D Prescription Drug Plans
When Medicare Part D (Medicare prescription drug benefit) was enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006, it was haled as blessing to our seniors and anyone else covered under Medicare. The plan was for the federal-government to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries. I have written elsewhere about this program’s actual effects on its beneficiaries (http://www.physicianspractice.com/articles/underdog-doc-takes-payers-patient), but it is important to write again now as the landscape is changing. Of course, the Medicare Part D program was an incredible business initiative for health insurance companies to jump in and begin wielding there ever sharp carving knives. In Pennsylvania, where I practice, I counted 15 companies, including one partnered with Walmart. Nothing like competition for a slice of the dollar to create an environment focused solely on that very dollar. One of the ways they have consistently been able to keep their daily balance ledgers in a comfortable place to keep their stockholders happy is by becoming every more stringent with prior authorization requirements. On average I work about 10 extra hours a week, all unreimbursed, to make sure patients get their needs met. I realize this poses an extra burden on doctor’s offices, but continuity and quality of care are at risk.
Recently, I was asked to complete the omnipresent prior authorization request for an elderly man’s sleep medication. His Medicare PDP (prescription drug plan) insisted that the sleep medication he had been taking would only be permitted for 90 nights a year. 90 nights a year! So for the other 275 nights of the year his insomnia was supposed to disappear, magically, so Silver Script, the company involved, could save money. He had been taking it for years before ever seeing me and attempts to take him off of it lead to sleepless nights. When he doesn’t sleep for long enough he becomes severely anxious and that can set off his cardiac arrythmia. Weighing the risks and benefits, I decided to make sure the medication was approved. I faxed the requisite form and with the strong wording I usually use, I expected a response from Silver Script within a 24 hour period. Instead, I got another form and a phone call as well asking the same exact questions I had already answered. On the form it asked if I had tried other “non-high risk medications” (I had already provided that information in my fax). My frustration turned to a complete sense of incredulity upon reading their list of non-high risk medications: temazepam and doxepin. Temazepam is a benzodiazepine medication, in the same family of medications as Xanax, Klonopin and Valium and far more “high risk,” particularly in older individuals, then the medication I had requested. Doxepin is an old tricyclic antidepressant that is rarely used for depression but is often used in very low doses for sleep. Tricyclics can cause cardiac arrhythmias and therefore are not necessarily non-high risk medications either. To add to my growing state of alarm is the fact that the form came AFTER there had already been a phone conversation, during which I demanded to know why my original form had been completely ignored. The “pharmacy tech” on the other end kept apologizing and telling me she knew how frustrating this must be, though I wondered if she was sitting with an algorithm sheet of what to say to irate doctors in the same manner they have algorithms to ask questions about the prior authorization request in the first place.
Prior authorization requests are becoming increasingly common not only for more costly brand medications, but for quantities of medications allowed per month. That’s right – quantities are not also being more tightly regulated. It doesn’t matter if you’ve been taking a certain amount for a long time. Your doctor will become ever more likely asked to complete a prior authorization request to make sure your treatment can continue uninterrupted. What can you do to advocate for yourself?
- Know your benefits well, and if you are having trouble deciphering all the insurance company speak, find someone who can help you understand it.
- Don’t take no for an answer. That means don’t immediately accept a change in a medication that may have stabilized you in favor of some less costly generic medication (see my earlier post about generic medications and the possibility that they may be inferior http://www.danielblockpsychiatry.com/). In addition to the prior authorization your doctor or his/her designated administrator can demand a lower copay tier under your Medicare PDP. I have done it several times for patients.
- If your receive a negative outcome, there are appeals and grievance proceedings, but let’s face it. The 5-10 page document the insurer sends outlining the appeal process is cumbersome and full of dense language. Your doctor can cut through some of this bureaucratic mess by demanding to speak with a supervisor, but both you and your doctor can place a complaint with your state’s insurance commission. The link here is to an interactive map for the insurance departments of all 50 states: http://www.naic.org/state_web_map.htm
- Write to your State Representative and State Senator with your grievances. Remember, they depend on your vote to get into office. Let’s remind them they need to listen to their constituency if they hope to get re-elected.
- If you have access to the media, see if you can be interviewed by a local newspaper or radio/television program. Also, if you or someone you know is tech savvy, start a website or blog for complaints about insurers. This can be easily done using Facebook (www.facebook.com)
I am hoping that this post will help people on Medicare Part D plans or their families to maintain a sense of participation in their own care while understanding better the current climate in health care.