Article: The Doctor Is Crucial Missing Link In The Medicare Debate

By ROBERT E. DAVIDSON, PH.D. Published on 12/4/2005

From Suddenly Senior

The Day has printed a series of articles on the details of Medicare Part D, the new prescription drug benefit for older people and those with disabilities. You have read about the gaps in coverage, the "doughnut hole," and the incredibly complicated procedures and choices that threaten the beneficiaries. Many people say that they won't participate, though if they change their minds later they will have to pay a 1 percent monthly penalty for each month that they could have signed up and didn't.

However, two groups caught in the middle have been overlooked: pharmacists and doctors. Pharmacists will have to collect co-pays from poor people. Unlike the Medicaid co-pays of recent years, these are not optional. The patient must pay or leave empty-handed.

The pharmacist also must get prior approval for many drugs under most plans. She must call the doctor, who must write or call the insurance company, which must authorize the purchase. This, too, is not likely to happen while someone waits. The way most doctors operate, it will take at least 24 hours. Patients should understand that filling a prescription may take several days, several calls and visits, and possibly aggravated advocacy. Doctors must prepare to do some of that advocacy. Patients and family members must do the rest.

All 44 plans in Connecticut have different rules. Even those from the same company differ on the requirements for getting or paying for a specific drug. Some demand that you pay the difference in cost between a preferred drug and the one prescribed. Others require that you try and fail on one or two other drugs before you can get the one that your doctor prescribed. The doctor can write a letter claiming that you have already tried and failed on the others so that you may be "grandfathered" in on January 1, but later prescriptions may have different procedures.

Prior authorization is not new. Doctors got used to it in the early days of managed care and made their peace with it. They learned the rules and standards for each plan and built the necessary letter writing into their computers and schedules. Every year at renewal time, my doctor advises me as to which plans are easiest to deal with.

This will be harder, because it affects so many people all at once. The phone lines will be jammed. The clerks and the nurses behind them will be overwhelmed just as they are learning the rules. Tempers will fray, prescriptions will be unfilled, and people will suffer. Many will go home and not try again.

Doctors have a special responsibility here because they are the professionals. Patients are amateurs, with limited knowledge of medicine, medications, and insurance procedures. Doctors know whether medications that are nominally in the same class really do work as well. They know which ones to prescribe or avoid for overweight patients, how they interact with other pills a patient takes, or have side effects that patients won't tolerate. They must use this knowledge proactively to assure continuity of care.

What can doctors do? They can put a Part D option on their phone triage systems. They can talk to their patients individually when they come in and write to them as a group to warn of pitfalls and procedures and delays. They can prepare prior authorization letters in advance. Most of all, they can allocate time and staff to answer pharmacists' calls promptly so that patients know what will happen, even if they can't resolve the situation immediately.

Doctors should not simply say that this is someone else's problem. They should not leave it to pharmacists to explain everything while a person waits in a long line of angry people. They should not blame all of it on the government because the procedures are the work of the insurance companies that created the plans and formularies.

Doctors don't like Part D any more than anyone else. However, they cannot wait for the program to collapse like a levee in New Orleans because too many people will drown. The chaos may generate hearings in Congress next spring, but there will not be a quick fix. Like the rest of us, doctors will have to cope.

But unlike the rest of us, they can make it easier for their patients by minimizing the disruption and delay and by being as nice to pharmacists and angry patients as they can. Here is their chance to be old-fashioned healers, to treat the bureaugenic condition of anxiety as their grandfathers did before we had today's medical miracles. It is a different kind of medical work. They won't get paid for it and maybe they shouldn't have to do it, but in Medicare Part D, they do. I hope they will.

Robert E. Davidson, Ph.D. is the director of the Eastern Regional Mental Health Board, a non-profit planning and evaluation agency for mental health programs. He may be reached at 886-0030 or ermhb@downcity.net.

© The Day Publishing Co., 2005