Medicare Compliance & Reimbursement

One organization offers tips on how your patients can save on drugs.

Approximately 48 percent of all Medicare Part D beneficiaries will be left without drug coverage this year when they reach the infamous "doughnut hole" in their prescription drug plans, according to a new study.

Only 4 percent of the 22.5 million Part D benes are in plans with doughnut-hole coverage for both generic and brand-name prescription drugs, Kaiser Family Foundation's principal policy analyst Juliette Cubanski and vice president Patricia Neuman said in their report. The Kaiser report appeared on the Health Affairs Web site shortly after the Nov. 15 commencement of the Part D Open Enrollment Period, which will last until Dec. 31.

"Another 8 percent of enrollees have coverage in the doughnut hole for generics only," according to the Nov. 21 Health Affairs release. Subtracting the low-income benes who have subsidized gap coverage leaves nearly half of all Part D enrollees without doughnut-hole coverage.

Enrollment Choices May Be More Difficult For Seniors To Make This Time Around

With so many seniors left without gap coverage this year, the question is whether benes will have the know-how to pick the right plan (preferably one with adequate doughnut-hole coverage) for 2007.

The federal government believes that seniors will have the help they need during the open enrollment to choose appropriate plans, but industry leaders and researchers are skeptical.

"Building on last year's successes and experiences, beneficiaries and those who are assisting them have access to a variety of consumer tested tools and resources which have been enhanced to help them make confident, well-informed decisions about their health and prescription coverage in 2007," the Centers for Medicare & Medicaid Services' (CMS) acting administrator Leslie V. Norwalk said in a recent statement.

MS is touting its new online tools that it put in place to help enrollees choose the right Part D plan for them, including information on Part D plan performance, which the agency posted on its Plan Finder Web site. Benes can "see how plans are rated along with specific data on how they performed on the following areas of customer service, including: telephone customer service, complaints, appeals and sharing information with pharmacists," CMS explains.

But benes may still have a hard time choosing a prescription drug plan (PDP), simply because there will be 31 percent more stand-alone PDPs available in 2007 than in 2006, and those that offer full gap coverage are still few, the Kaiser report authors note. Indeed, more PDPs will offer gap coverage in 2007 than this year, but most are offering generic-only coverage.
 
For instance, "Humana PDP Complete, which had the highest enrollment among plans offering full gap coverage in 2006, will cover only generics in the gap in 2007," Neuman and Cubanski say. And whether the higher cost for plans with generic-only doughnut-hole coverage will be a smart purchase for those benes who reach the gap is still in question, they add.

Easing Drug Costs Is In Benes' Own Hands, Group Claims

So, what should a Part D enrollee do when he doesn't know if paying extra for a PDP with gap coverage will actually off-set his costs later on when (or if) he falls into the doughnut hole? The National Center for Policy Analysis (NCPA) has some suggestions for seniors.

Under the new Democratic Congress, we might see a push for Medicare to negotiate lower drug prices with pharmaceutical companies, much like the Veterans Administration (VA) and Medicaid, but NCPA claims it has a better way to combat high drug prices under Part D. "The most effective way to lower drug prices is for seniors to become smarter shoppers," the NCPA said in its new study, "Shopping for Drugs: 2007."

In most cases, benes can lower their drug costs significantly by buying medications in large quantities and pill-splitting, comparison shopping or purchasing generic and other low-cost substitutes, the NCPA says.

"Seniors can save a lot of money if they shop for drugs the way they shop for bread," NCPA senior fellow and report author Devon Herrick said in a statement. "Savvy shoppers can most often do better than Medicaid, the VA or by shopping in Canada," he claims.

Shopping around, pill-splitting and buying generics can save seniors more than 90 percent in costs for many drugs, the NCPA maintains. And smart shopping is good not only for buying prescription medications, but also for choosing a Part D plan, the center says.

"Consumers have never had more opportunities to obtain pricing information about their drugs or the ability to turn that knowledge into savings," Herrick notes. "As we've seen with Wal-Mart's $4 generic drugs, when pharmacists have to compete for individual consumers' business in the information age, costs go down and quality goes up."

To view the abstract of the Kaiser article, go to http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.1.w1.

To read the NCPA's study, go to www.ncpa.org/pub/st/st293/st293.pdf.