Medicare Part D Counseling: Just One More 'Unfunded Mandate'?


WASHINGTON — Physician obligation to help patients negotiate the upcoming Medicare Part D outpatient drug benefit will result in “another unfunded mandate” for Medicare providers, Ronald Castellanos, M.D., chairman of the Practicing Physicians Advisory Council said at the group's recent meeting.

Noting that patients are most likely to rely on their physicians for aid in choosing among the new drug plans, Dr. Castellanos said, “Basically what you're doing is putting the burden on physicians in their offices to really educate the Medicare recipient.”

PPAC members asked the Centers for Medicare and Medicaid Services to make educational materials as simple possible, including information on whether beneficiaries are eligible for the low-income portion of the program.

“I really want a lot of information, very digestible,” said PPAC member Geraldine O'Shea, D.O., an internist from Jackson, Calif. “Something very easy for them to understand, because I do not want to take time out of my time to do medicine with my patient to say, 'Well, let me see your tax return.'”

“We are trying to make the information available as simple as possible,” said Jeffrey Kelman, M.D., medical officer for the CMS Center for Beneficiary Choices.

Council member Barbara McAneny, M.D., an oncologist from Albuquerque, requested a computer program that would allow physicians to type in the drugs a patient is using and come up with the plan that would cover all of them. She also proposed that CMS be required to develop a reimbursement code for physician time spent on drug plan education, but it was voted down by the panel, with members saying it wasn't practical.

Dr. Kelman said CMS is getting “much more robust formularies” from drug plans than officials had anticipated. “They're looking like commercial formularies,” he said, adding that the formularies would be available on the Web site in October.

All drugs approved by the Food and Drug Administration must be on the formularies, Dr. Kelman said. If a drug is not included, a beneficiary can appeal, based on medical necessity, “preferably with a physician's help,” he said. “All medically necessary drugs that are approved by the FDA with certain exceptions … have to be available.” In a move important to rare drug organizations, Dr. Kelman said if there is only one drug to treat a disease, it must be included in the formulary.

Part D also will ensure drugs are available for chronic conditions by “favorably risk adjusting” those diseases, Dr. Kelman said. The plans also will “overadjust” for low-income individuals and nursing homes. “We went to a lot to trouble to ensure nobody was discriminated against on the formulary or based on the Part D benefit,” Dr. Kelman said. Dr. Kelman urged physicians to begin moving patients to the new formularies before the benefit is effective Jan. 1, 2006. “The last thing we want is 40 million exceptions and appeals in the first week,” he said. Beneficiaries can enroll in the program from November 15 through May 15.

In other issues, Dr. Kelman pointed out that by law, barbiturates and benzodiazepines will not be covered by the plans. He said the program was hoping states would continue to pay for these inexpensive drugs for dual-eligible beneficiaries (those receiving both Medicaid and Medicare benefits). Other drugs not covered include cosmetic agents and weight-loss and weight-gain products.

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