Medicare Part D often prevents patients from accessing the drugs they need
by Chael Needle
LifeGuide [Treatment Horizons]
Increasing treatment options” is a popular phrase in the interconnected worlds of researchers, physicians, patients, advocates, and pharmaceutical companies, who more often than not make good on their commitments to sustaining the lives of people living with HIV/AIDS. Yet this reality of expanded options is arguably being hampered by Medicare Part D, the new drug-prescription arm of the federal health insurance program for people over sixty-five, and people under sixty-five with certain disabilities, among others.
The HIV Medicine Association (HIVMA) and the American Academy of HIV Medicine, whose combined membership represents nearly all the nation’s HIV medical providers, surveyed their members about their experiences and their patients’ experiences with Part D. Eighty-three percent of respondents said their patients had experienced problems having prescriptions filled—including ones for antiretrovirals, as well as for medications for OIs, the management of drug side effects, and mental health, among other conditions—since joining a Part D drug plan. Seventy-five percent of those respondents had patients who went without medications, among other findings.
Medicare Part D, launched in January 2006, offers forty-plus approved insurance plans, each of which has created its own formulary, a list of preferred drugs. A patient’s best bet is to choose the plan that has a majority of the drugs they need. While the plan may sound good on paper, putting it into practice has revealed its limitations for patients.
Part D was meant to capitalize on the “free market” ideal—consumer choice would encourage competition among insurance companies to lower costs for patient benefit. But, says Dr. Michael S. Saag, MD, that free-market ideal has not been realized. The options, especially for those on Medicaid who had to switch-over to Medicare for prescriptions, were curtailed from the get-go by a series of assumptions: that patients had access to a computer, were computer literate, and savvy enough to figure out which plan was best for them. As the deadline approached, they ended up choosing a plan at random, says Dr. Saag, or let the government assign a plan to them. Part D, he theorizes, does more good perhaps for insurance companies, who cut deals with pharmaceutical companies to buy brand-name-only drugs at heavily discounted rates to create their preferred lists, and more good for pharmaceutical companies, who can close their free compassionate-use programs now that patients can afford drugs through the government assistance of Part D, than it does for patients.
Dr. Saag, a clinician and lab researcher who helped create the 1917 Clinic, an AIDS outpatient clinic started in the late eighties at the University of Alabama at Birmingham, reports that physicians have become aware of another limitation in the form of the process of prior authorization. If you need a drug that is not on your plan’s preferred list, you need what is called “prior authorization.” Four out of five surveyed providers whose patients had problems getting prescriptions filled pointed to prior authorization as the cause.
As Dr. Saag, an HIVMA board member, describes it, the process almost needs to be mapped out on a flow chart to be understood: If your new prescription isn’t covered, someone at your doctor’s office, typically a degreed healthcare professional, must figure out which plan you are on; then find the correct 1-800 number and call to request a review form be faxed; then wait for the fax; then fill out the form, explaining why the review is warranted and have it signed by a physician; fax it back; wait; if the review is approved, a prior authorization application is faxed over, on which you have to justify through medical-chart documentation why the needed drug is better than the one on the preferred list; get it signed by a physician; fax it back; wait for approval. Also, all approved prior authorizations need to be renewed, and each prescription is on a different renewal schedule. Fuzeon, the only HIV medication that does require prior authorization, needs to be reauthorized every three months, for example. (Despite an exemption for antiretrovirals, nearly half of those with Part D problems said they have had to request prior authorizations for these drugs.)
If all steps are done right and as working relationships develop between clinics and insurance companies, says Dr. Saag, drugs are almost always approved, but what is “disturbing” is that a doctor’s best advice for treatment is often put on hold while he or she watches an untried but preferred-list drug fail in a patient before he or she is allowed to request their original choice. So, a patient’s condition might progress and worsen in the time lag.
Processing several prior authorizations a week also creates an unnecessary workload and stress on healthcare professionals and patients, points out Dr. Saag, whose clinic has begun tracking prior authorizations and their turnaround times in the context of clinical outcomes and plans to publish its results soon. HIV clinics, many of which struggle with the threat of bankruptcy, are not reimbursed by the insurance companies or the federal government for these extra hours of work, says Dr. Saag, who predicts that universal opt-out testing will bring more HIVers into treatment and increase the need for accessible healthcare even more. Treatment options have increased since the arrival of HAART, but so has the wait time for treatment—at least for those on Medicare Part D.
Chael Needle wrote about CCR5 antagonist maraviroc in the March 2007 issue.
April 2007 |
