The Rest of the Story

A lot of blogging has been done regarding the Medicare prescription drug benefit, so much so, that there is no point in rehashing it.  You may recall the allegations that the budget projections were falsified, that unseemly political arm-twisting was done to get the votes in the House, and that the plan is a giveaway to pharmaceutical companies because it prohibits negotiation for better prices.  Now, the big theme is the complexity of the Plan.  It is turning out to be difficult for people to figure out exactly what they should do and how they should do it.  Headlines on the subject (as aggregated by Google News) include: US "greatest advance" in health care puzzles elderly, Medicare Prescription Plan Confuses Elderly, Medicare drug plan confusing seniors, CONFUSED BY COVERAGE CHOICES, New drug plan is prescription for confusion, the Medicare maze, Drug plan's side effects: Confused seniors, and Medicare's Part D as Plan B.  Just looking at the headlines, you get the impression that a lot of people are having trouble figuring this out.

The one point that I have not seen covered in all of this is the problem that will occur after everyone gets signed up for one of the plans.  People think that the real problem is figuring out what plan to choose, but that is just the start.  

In order to understand the problem fully, it is necessary to look at this from the doctor's point of view.  All of these plans have one thing in common: they provide good coverage for some drugs, and no coverage for others.  As a result, the patient's doctor will, in many cases, be unsure what prescription would be best for the patient.  

Most patients are expected to choose the plan that provides the best coverage for the drugs that they are taking when they first sign up.  That would make sense, as that strategy will result in the lowest out-of-pocket cost -- as long as the prescriptions do not change.  However, when a change is necessary, the doctor often will be in the position of trying to help the patient figure out whether to stay on a given drug, which is no longer doing a good job, or change to something that might work better, but that might not be covered by the plan.  There are so many different plans, that it will not be possible for anyone to keep track of what plans cover what drugs.  Sure, lists will be available, but those lists are not always accurate; they sometimes are incomplete, or misleading, or just plain wrong.  

If these new plans work the way that existing insurance formularies work, it will be possible for the doctor to file an appeal, in those cases that an uncovered drug is needed.  But this is time-consuming, generates a profusion of paperwork, and it increases the risk of lapses in treatment.  Furthermore, by complicating the process of writing and filling prescriptions, it increases the risk of medication errors.  Also, the appeals usually are processed by clerks who use checklists to see if certain pre-established criteria are met.  They are not able to make independent, professionally-informed medical decisions.  In order to get an actual pharmacist or physician to review the case, you have to get to the second level of the appeal process.  And those people often do not listen to reason.

To illustrate, here is an example: a patient is stable, on an established regimen of medication.  The patient, for whatever reason, changes from one plan to another.  The coverage is different, so now one of the medications is not covered.  The doctor can either expose the patient to a high out-of-pocket cost, or risk having the patient become unstable by changing the drug.  Naturally, an appeal would be appropriate.  I've done this many times, always arguing that it would not make any sense to change the drug and expose the patient to that risk.  Some companies go along with it, but others do not.  

There would be little point in complaining about all of this, without offering a suggestion for improvement.  If one accepts that something has to be done to control the costs of prescription medication, then clearly some kind of restriction is necessary.  Now, the idea that is said to underlie the profusion of Part D plans, is the notion that having many different companies competing will somehow result in the evolution of a more efficient way to get the job done.  The problem is, that the more complex the system is, the more duplication of effort there will be, and the more time it will take for doctors, patients, and pharmacists to figure out what they should do.  Thus, in the pursuit of efficiency, the system actually creates more inefficiencies.  

The solution is to find a way to use an existing system, one that is already up and running fairly well, then try to improve it.  One of the most perplexing things about Part D is that the government chose to ignore this obvious point.  

I can't speak for all 50 states, but I can say that most if not all states already have a managed prescription drug plan, in Medicaid.  Those plans already exist, the doctors and pharmacists have figured out how to work with them, and the plans have been in operation long enough, that many of the bugs have been worked out.  There is no reason to have dozens of companies go out and duplicate all the effort that already has gone into the establishment and debugging of the Medicaid plans.  The solution is to have each state simply extend the existing Medicaid plans to cover Medicare recipients.