Physician Part D Education Efforts: An '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, noting that he would bring educational material to the council's next meeting.

Council member Barbara McAneny, M.D., an oncologist from Albuquerque, requested the agency to develop a computer program that would allow physicians to type in the drugs a patient is using and come up with a plan to cover all of them.

She also proposed a draft recommendation that would require CMS 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.

Walking through the benefit, 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. He added 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, but “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.” However, off-label prescriptions will be covered, Dr. Kelman said.

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. He said formularies would be compared to others in their region and to commercial plans.

Council member Laura Powers, M.D., a neurologist from Knoxville, Tenn., said she was relieved by Dr. Kelman's comments. “We were so worried that our patients with very expensive drugs were going to be eliminated from all the formularies.”

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 Nov. 15 through May 15.

Dr. Kelman also noted that by law, barbiturates and benzodiazepines will not be covered. Those medications are inexpensive and the program was hoping states would continue to pay for them for beneficiaries receiving both Medicaid and Medicare benefits. Cosmetic agents and weight-management products also will not be covered.

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