Providers face Part D headaches too

With the May 15 open enrollment deadline arriving today for the Medicare Part D prescription program, the process has proven to be fraught with headaches not only for patients, but for health-care providers as well.

More than 40 different Medicare prescription plans are available in New Hampshire, leaving thousands of seniors and other subscribers to wade their way through a jungle of benefits, restrictions and options. And if patients are eligible for both Medicare and Medicaid, the situation becomes even more confusing.

Because there are so many plans, physicians and staff at hospitals and nursing homes have to be as knowledgeable of the various plans as Medicare administrators in order to guide patients through the Part D maze.

For Tom Antinerella, billing manager at Concord Hospital, a small but important distinction between the way Medicare reimburses hospital outpatients and hospital inpatients for medication administration has proven to be the most troublesome.

“Most hospitals originally thought Part D would not impact them to a great extent, but then they quickly found out that wasn’t the case,” said Antinerella. “Self-administered medication given to patients in an outpatient setting is now covered, whereas traditionally, that was not paid for. Beneficiaries might not be aware of this.”

He cites aspirin or insulin given in the emergency department as examples.

“Most hospitals cannot bill directly for Part D services. The patient has to submit the bill to their carrier, wait for reimbursement, then pay us,” he said.

Antinerella’s own experience in researching this particular situation has met with limited success. “It’s tough to find material relevant to self-administered drugs on the CMS Web site.”

He said he feels that this facet of Medicare Part D could actually be beneficial to hospitals in the long run, since it could potentially be a payment source they’ve never had before. However, he said, he has yet to see an upswing in payments coming in.

Another quirk of the federal government medication program is how and from where hospitals get paid for the treatment of so-called “dual-eligible” patients — those who receive both Medicare and Medicaid services.

Antinerella said that, prior to the implementation of Part D, a hospital would get reimbursed for medications given to Medicaid patients by Medicaid. As of Jan. 1, Medicaid patients were enrolled in one of the state’s many available Part D plans.

“Once a patient is enrolled in Part D, Part D must pay, but it may or may not reimburse for a certain drug, whereas Medicaid would,” he said.

“The problem is really educating the patients on how to get paid. That’s really been a challenge. We provide them with an itemized bill to submit to their drug plan to help them try and get reimbursed. We’ve done a lot of educating with our billing staff on how to counsel patients on billing,” said Antinerella.

Patient education on Medicare Part D is something that has become increasingly important at Dr. Gary Sobelson’s office as well. But his biggest issue is one of the most basic — counseling his patients on whether to sign up for the drug plan or not.

“Typical plans cost around $30 or $40 per month. Some people may benefit by saving hundreds of dollars a month on their medication bills, others might not save anything,” he said. “But the really interesting thing that many patients don’t know is that if you did not sign up by May 15, you will pay a penalty of 1 percent for every month for the rest of your life if you’re not enrolled and then do decide to sign up at a later date.”

For instance, if the initial monthly premium seniors could have had prior to May 15 was $40, it will cost them 24 percent, or nearly $50 a month, if they decide to enroll two years from now.

After May 15, seniors will not be able to sign up for a new Part D plan or change plans until the next open enrollment period beginning in November.

Sobelson, who has been practicing family medicine for 23 years and is immediate past president of the New Hampshire Medical Society, also is encountering the problem of explaining how drug formularies work to his elderly patients who might not be as familiar with approved drug lists as younger patients who have dealt with them through HMO plans.

The conundrum

Virtually every medication a Part D enrollee was on as of Jan. 1 was covered, but that benefit was meant only to be a gap measure, as seniors and their health-care providers adapted to the new plan. After April 1, that blanket coverage disappeared. Patients are now being reimbursed for medications that were on their carriers’ formularies of pre-approved drugs. Drugs not on the list require authorization for reimbursement or are not covered.

“Now doctors are flooded with requests to be switched to new medications. We’re calling it the ‘April Fool’s Day’ effect,” said Sobelson.

For younger, basically healthy patients with private insurance, a switch from something like one common antibiotic to another for a short course of therapy does not pose much of a problem.

For seniors, many of whom are on many different maintenance medications for conditions such as diabetes, high blood pressure and cardiac issues, this can be a very serious situation.

Appropriate dosing of the new medication and checking for interactions between new and existing medications are just two of the problems seniors and their physicians face with changing medications, said Sobelson.

“And while drug plans can change their formularies at any time, patients can only change their drug plans once a year,” he added.

Sobelson said that the dual-eligibles have been particularly affected by formulary issues, especially for those medications Medicaid patients receive free of charge from drug companies through various low-income patient plans.

The conundrum is that once patients have signed up for Medicare Part D, they are no longer eligible for these plans.

“Forty to 50 percent of my Medicaid population qualifies for one of these free drug plans, but Part D prohibits pharmaceutical companies from participating,” said Sobelson. “This may also have contributed to some of the procrastination in signing up. Where patients used to get some medications for free, now they have to pay.”

He said there has been some national pushback on this particular issue, and CMS is taking a second look, but when or if the agency will allow these plans for enrollees has yet to be decided.

The bright side

Sobelson credits nursing homes for tackling issues with Part D head-on. “Nursing homes really did well, especially for the dual-eligibles, and kept the drugs flowing,” he said.
And for the most part, Bret Lennerton, administrator of Hackett Hill Healthcare Center in Manchester, would agree.

“We took it upon ourselves and became very knowledgeable about the regulations and reviewed the plans that would work best for our residents,” Lennerton said.

For residents who already had Medicare or private insurance, the facility helped them work through the information and served as a resource. Lennerton’s biggest concern, however, was for the dual-eligible residents, who make up 45 percent of his patient population.

“You would think that the plans would have all the same formularies, but there is actually a huge difference,” he said. Many of his residents chose AARP’s Medicare Rx plan, administered by United Healthcare, because, according to Lennerton, it has the largest formulary.

The biggest problem Lennerton has run into at his 68-bed facility has been CMS’s timeline of the Part D rollout, particularly as it pertains to those with Medicare and Medicaid.

“If you were already on Medicare and had not chosen a plan, Medicare was supposed to arbitrarily choose a plan for you by a certain date (Dec. 31, 2005). That didn’t happen. We structured our whole process around that. Because residents in a nursing home facility are waived from the one-year restriction on changing plans, we were waiting until everyone was supposed to have been signed up, and those that were not assigned the AARP plan, we would switch them to it. Since that time, Medicare is still switching patients back to other plans, but not notifying us. When we find out, we have to switch them back to the ARRP plan again,” said Lennerton.

He said his pharmacy “has been very diligent” at keeping track of plan changes and notifying him.

On the bright side, Lennerton has not had much difficulty with getting approval for medications not on a Plan D formulary. “The approval process is not overly difficult; it’s just an extra step. It’s not like they’re denying everything, they’re just looking for the reasoning behind why a patient is not on a comparable, less-expensive drug,” he said.

Lennerton said none of his patients has been denied non-formulary prescriptions, and they have received most approvals within 24 hours. Also, he has not experienced any issues with his residents who qualify for free drug programs not receiving their medication.

“We have the medications; the only problem is who’s going to pay for them. My only concern is that Medicare should have stayed on their time lines,” said Lennerton. – CINDY KIBBE