Clinical Geriatrics

As physicians, we have been taught that our job is to make the correct diagnosis and then write the right prescription, assuming that our prescription would be filled. Enter Medicare Part D with its aim to increase access to medications for seniors. But has this actually occurred? A recently completed survey showed that 94% of physicians are confused about Medicare Part D, especially with regard to accessing specific prescriptions.1 This difficulty has resulted in 70% of physicians spending at least 20% more time on administrative tasks related to Medicare Part D.1 Clearly, Medicare Part D has not produced an easier path to access medications for prescribers.

Medicare Part D has placed several different players in the process of obtaining prescription medications for our senior patients. These players include prescribers, patients, pharmacy providers, prescription plans, and the federal government, which includes the Centers for Medicare & Medicaid Services (CMS). Each player has different incentives and motivating factors that are important to understand. In addition, the environment is changing in such a way that the strength of each party in ensuring that the prescription gets filled is shifting.

PRESCRIBERS
Historically, prescribers have had the final word in what gets dispensed to patients. Decisions are based on the practice of medicine dictating the best medication on a clinical basis, but are also based, to some degree, on personal preference. Physicians would write a prescription and assume that it would be filled. As a direct result of Medicare Part D, this has shifted to other groups having a much greater say in what medication gets dispensed. In fact, the role of the physician in directing the specific medication that is dispensed has been decreasing, and is likely to continue to decrease in prominence.

PATIENTS
The patient or responsible party makes decisions on which medications are dispensed on the basis of value judgments. This means that when a patient or responsible party is faced with a coverage decision for a specific medication, the decision is between that medication and a less expensive equivalent medication, if available within the formulary. If the patient or responsible party does not see the value in paying for the branded prescription over the less expensive alternative, then the medication is changed from what the physician had ordered. In long-term care (LTC) facilities, the patient is oftentimes unable to pay for certain ordered medications, so it then falls upon the facility to act as the responsible party to cover the cost of the medication to assure that an ordered medication is made available in a timely manner. This situation became more prevalent as a result of Medicare taking the place of Medicaid for the dually eligible. As a result of the more restrictive Medicare Part D formularies, these issues will arise much more than they had in the past under Medicaid.

PHARMACY PROVIDERS
Over the years, pharmacy providers have increased in power, having Pharmacy and Therapeutics (P&T) Committees that develop their own formularies. These formularies tend to include those medications felt to be most appropriate for a drug or health plan or for a health facility. Now with the introduction of Medicare Part D, prescription drug plans have power over the pharmacy providers to ensure that their formularies are all-controlling. The CMS has been pushing down the ability of pharmacy providers, and especially LTC pharmacy providers, to direct which products are preferred within a formulary and therefore are subsequently dispensed. By calling into question rebates provided by pharmaceutical companies, and thus mandating that all rebates be reported to and taken into account by prescription plans so that said rebates reach the Medicare beneficiary, CMS has shifted the market power to some degree away from LTC pharmacy providers.