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The Doctor Is Crucial Missing Link In The Medicare Debate
By ROBERT E. DAVIDSON, PH.D.
Published on 12/4/2005
The Day has printed a series of articles on the details of Medicare Part D,
the new prescription drug benefit for older people and those with
disabilities. You have read about the gaps in coverage, the "doughnut hole,"
and the incredibly complicated procedures and choices that threaten the
beneficiaries. Many people say that they won't participate, though if they
change their minds later they will have to pay a 1 percent monthly penalty
for each month that they could have signed up and didn't.
However, two groups caught in the middle have been overlooked: pharmacists
and doctors. Pharmacists will have to collect co-pays from poor people.
Unlike the Medicaid co-pays of recent years, these are not optional. The
patient must pay or leave empty-handed.
The pharmacist also must get prior approval for many drugs under most plans.
She must call the doctor, who must write or call the insurance company,
which must authorize the purchase. This, too, is not likely to happen while
someone waits. The way most doctors operate, it will take at least 24 hours.
Patients should understand that filling a prescription may take several
days, several calls and visits, and possibly aggravated advocacy. Doctors
must prepare to do some of that advocacy. Patients and family members must
do the rest.
All 44 plans in Connecticut have different rules. Even those from the same
company differ on the requirements for getting or paying for a specific
drug. Some demand that you pay the difference in cost between a preferred
drug and the one prescribed. Others require that you try and fail on one or
two other drugs before you can get the one that your doctor prescribed. The
doctor can write a letter claiming that you have already tried and failed on
the others so that you may be "grandfathered" in on January 1, but later
prescriptions may have different procedures.
Prior authorization is not new. Doctors got used to it in the early days of
managed care and made their peace with it. They learned the rules and
standards for each plan and built the necessary letter writing into their
computers and schedules. Every year at renewal time, my doctor advises me as
to which plans are easiest to deal with.
This will be harder, because it affects so many people all at once. The
phone lines will be jammed. The clerks and the nurses behind them will be
overwhelmed just as they are learning the rules. Tempers will fray,
prescriptions will be unfilled, and people will suffer. Many will go home
and not try again.
Doctors have a special responsibility here because they are the
professionals. Patients are amateurs, with limited knowledge of medicine,
medications, and insurance procedures. Doctors know whether medications that
are nominally in the same class really do work as well. They know which ones
to prescribe or avoid for overweight patients, how they interact with other
pills a patient takes, or have side effects that patients won't tolerate.
They must use this knowledge proactively to assure continuity of care.
What can doctors do? They can put a Part D option on their phone triage
systems. They can talk to their patients individually when they come in and
write to them as a group to warn of pitfalls and procedures and delays. They
can prepare prior authorization letters in advance. Most of all, they can
allocate time and staff to answer pharmacists' calls promptly so that
patients know what will happen, even if they can't resolve the situation
immediately.
Doctors should not simply say that this is someone else's problem. They
should not leave it to pharmacists to explain everything while a person
waits in a long line of angry people. They should not blame all of it on the
government because the procedures are the work of the insurance companies
that created the plans and formularies.
Doctors don't like Part D any more than anyone else. However, they cannot
wait for the program to collapse like a levee in New Orleans because too
many people will drown. The chaos may generate hearings in Congress next
spring, but there will not be a quick fix. Like the rest of us, doctors will
have to cope.
But unlike the rest of us, they can make it easier for their patients by
minimizing the disruption and delay and by being as nice to pharmacists and
angry patients as they can. Here is their chance to be old-fashioned
healers, to treat the bureaugenic condition of anxiety as their grandfathers
did before we had today's medical miracles. It is a different kind of
medical work. They won't get paid for it and maybe they shouldn't have to do
it, but in Medicare Part D, they do. I hope they will.
Robert E. Davidson, Ph.D. is the director of the Eastern Regional Mental
Health Board, a non-profit planning and evaluation agency for mental health
programs. He may be reached at 886-0030 or [email protected].
The Doctor Is Crucial Missing Link In The Medicare Debate
By ROBERT E. DAVIDSON, PH.D.
Published on 12/4/2005
The Day has printed a series of articles on the details of Medicare Part D,
the new prescription drug benefit for older people and those with
disabilities. You have read about the gaps in coverage, the "doughnut hole,"
and the incredibly complicated procedures and choices that threaten the
beneficiaries. Many people say that they won't participate, though if they
change their minds later they will have to pay a 1 percent monthly penalty
for each month that they could have signed up and didn't.
However, two groups caught in the middle have been overlooked: pharmacists
and doctors. Pharmacists will have to collect co-pays from poor people.
Unlike the Medicaid co-pays of recent years, these are not optional. The
patient must pay or leave empty-handed.
The pharmacist also must get prior approval for many drugs under most plans.
She must call the doctor, who must write or call the insurance company,
which must authorize the purchase. This, too, is not likely to happen while
someone waits. The way most doctors operate, it will take at least 24 hours.
Patients should understand that filling a prescription may take several
days, several calls and visits, and possibly aggravated advocacy. Doctors
must prepare to do some of that advocacy. Patients and family members must
do the rest.
All 44 plans in Connecticut have different rules. Even those from the same
company differ on the requirements for getting or paying for a specific
drug. Some demand that you pay the difference in cost between a preferred
drug and the one prescribed. Others require that you try and fail on one or
two other drugs before you can get the one that your doctor prescribed. The
doctor can write a letter claiming that you have already tried and failed on
the others so that you may be "grandfathered" in on January 1, but later
prescriptions may have different procedures.
Prior authorization is not new. Doctors got used to it in the early days of
managed care and made their peace with it. They learned the rules and
standards for each plan and built the necessary letter writing into their
computers and schedules. Every year at renewal time, my doctor advises me as
to which plans are easiest to deal with.
This will be harder, because it affects so many people all at once. The
phone lines will be jammed. The clerks and the nurses behind them will be
overwhelmed just as they are learning the rules. Tempers will fray,
prescriptions will be unfilled, and people will suffer. Many will go home
and not try again.
Doctors have a special responsibility here because they are the
professionals. Patients are amateurs, with limited knowledge of medicine,
medications, and insurance procedures. Doctors know whether medications that
are nominally in the same class really do work as well. They know which ones
to prescribe or avoid for overweight patients, how they interact with other
pills a patient takes, or have side effects that patients won't tolerate.
They must use this knowledge proactively to assure continuity of care.
What can doctors do? They can put a Part D option on their phone triage
systems. They can talk to their patients individually when they come in and
write to them as a group to warn of pitfalls and procedures and delays. They
can prepare prior authorization letters in advance. Most of all, they can
allocate time and staff to answer pharmacists' calls promptly so that
patients know what will happen, even if they can't resolve the situation
immediately.
Doctors should not simply say that this is someone else's problem. They
should not leave it to pharmacists to explain everything while a person
waits in a long line of angry people. They should not blame all of it on the
government because the procedures are the work of the insurance companies
that created the plans and formularies.
Doctors don't like Part D any more than anyone else. However, they cannot
wait for the program to collapse like a levee in New Orleans because too
many people will drown. The chaos may generate hearings in Congress next
spring, but there will not be a quick fix. Like the rest of us, doctors will
have to cope.
But unlike the rest of us, they can make it easier for their patients by
minimizing the disruption and delay and by being as nice to pharmacists and
angry patients as they can. Here is their chance to be old-fashioned
healers, to treat the bureaugenic condition of anxiety as their grandfathers
did before we had today's medical miracles. It is a different kind of
medical work. They won't get paid for it and maybe they shouldn't have to do
it, but in Medicare Part D, they do. I hope they will.
Robert E. Davidson, Ph.D. is the director of the Eastern Regional Mental
Health Board, a non-profit planning and evaluation agency for mental health
programs. He may be reached at 886-0030 or [email protected].
