Prescription Drug Benefit Off to Bumpy Start

By Rebecca Vesely, STAFF WRITER

A WEEK AFTER Medicare’s new prescription drug benefit took effect, pharmacists and physicians are finding themselves on the front lines of a massive government program, playing the roles of counselor and customer service representative to elderly and disabled patients.

Meanwhile, millions of Medicare beneficiaries are trying to sort out the details of their coverage and decide whether they should sign up for the benefit.

“There’s been quite a few glitches,” said Mike Negrete, vice president of clinical affairs for the California Association of Pharmacists.

Some pharmacists report computer problems, delays getting new drug cards, confusion about drug coverage and requests from patients seeking extensive help choosing from the 47 available drug plans in the Bay Area.

Yet others say the transition is going relatively smoothly so far, considering the scope of the program.

Medicare Part D, as the drug benefit is known, began on Jan. 1, and pharmacists said a long, rainy holiday weekend kept many patients away until Tuesday, when pharmacies started getting busy.

A computer program that drugstores rely on to check customers’ insurance eligibility was down from last Sunday afternoon until at least Tuesday. And hot lines to insurers and to Medicare have been busy or have had long wait times.

“Pharmacists are spending up to two hours per patient trying to sort this out,” Negrete said. “It’s crippling.”

Some pharmacies are faring better than others. Teddy Jackson, pharmacy manager at Wal-Mart in Pleasanton, said Wal-Mart’s national computer database has allowed her to quickly locate changes to patients’ insurance.

“I don’t feel swamped yet,” she said.

Jackson said she’s got “lots and lots” of requests for help in understanding the drug benefit.

“It’s a little hard to know what’s the right decision for them,” she said. “A lot of times I just refer them to other sources.”

Other pharmacists are reporting extensive problems.

Michael Lee is a pharmacist at San Francisco’s BioScrip Pharmacy, which specializes in drugs for organ transplant and HIV/AIDS patients. Lee said many of his patients have enrolled in Part D but haven’t received their drug cards yet. This means pharmacists have to use other, often busy channels to track down federal officials and insurers to verify the patients’ enrollment.

“It’s rough,” Lee said. “The system gets bogged down. The pharmacist can’t dispense the drug, and the patient is standing in front of you.”

Many of Lee’s customers require medications to preventinfections and treat diabetes and hypertension. Fortunately, medications required by transplant recipients so their bodies don’t reject the organs are covered under a separate Medicare program, Lee said.

“For patients we know, we can help them,” he said — for example, by holding a customer’s personal check until the pharmacy receives payment from the insurer and then ripping up the check.

“But we can’t take out a tab on all our patients,” he said. “If it’s a patient new to us, it’s very difficult to provide the drugs.”

Delays ‘causing a lag’

Enrollees in the new drug plans typically won’t get their drug cards in the mail until three to five weeks after they sign up, said Larry Kocot, senior policy adviser at the Centers for Medicare and Medicaid Services, CMS, which oversees Part D.

“This kind of administrative delay is causing a lag at the prescription counter,” Kocot said last week in a conference call with reporters.

At the BioScrip Pharmacy, only one or two affected customers out of 20 have their new insurance locked down or have received their cards, Lee said.

“We still have a large group of patients who were not aware this was happening,” he said.

More than half of the 43 million Medicare beneficiaries nationwide are sitting on the sidelines, and most have until May 15 to enroll before facing penalties.

One million seniors and disabled patients who previously had no drug coverage have signed up for Part D, according to government figures released Dec. 22. Another 20 million seniors have enrolled through their Medicare HMOs or retirement plans. In the final week of December, thousands more signed up, Kocot said.

The 6.2 million low-income people nationwide who are on Medicare and Medicaid, which is known in California as Medi-Cal, have been automatically enrolled in the new drug program. Called dual eligibles, these patients were assigned to one of 10 drug insurance plans and saw their coverage change over from Medicaid on Jan. 1.

Pharmacists in California are finding that these dual eligibles often are unsure which program they have been assigned to or haven’t received their drug card yet from their new insurer. There are 1 million dual eligibles in the state.

“I’m confused as hell over this whole thing,” said Johnie Mills, a dual eligible from Oakland.

Mills attended two events on the drug program this fall, including one hosted by her Congress member, Rep. Barbara Lee, D- Oakland.

“I commend her for doing it, but it didn’t help much,” she said.

Mills received individual counseling at the San Antonio Senior Center in Oakland’s Fruitvale District and found that the plan she had been auto-assigned to, Sierra Rx, didn’t cover two of her prescriptions. If she stayed with that plan, she would have paid $100 a month for the drugs. A counselor instead found her another plan that brought her drug costs down to co-pays between $1and $3.

Co-payments can be hardship

Previously, dual eligibles in California paid nothing for their drugs, and for very low-income recipients, those extra dollars aren’t easily parted with.

“I’ve had a couple of dual eligibles who have balked at the co- pays,” Jackson, of the Wal-Mart pharmacy in Pleasanton, said.

Finding the right drug program for each customer takes time — at least 30 minutes — and patience.

La Clinica de la Raza, a community clinic in Oakland, has about 750 Medicare patients, of whom all but 100 are dual eligibles. The clinic has trained a pharmacy technician to shepherd these patients through the drug benefit enrollment process.

La Clinica’s pharmacy director, Dolly Davar, said staff spent the last few weeks of December phoning all Medicare patients and urging them to come in for Part D counseling.

“It’s been hard to get in touch with people,” Davar said. “Making sure no one is going without their medications is the basic priority. Doctors are checking that they will have their supply.”

Glicerio Contreras is one of the lucky ones. The 85-year-old from Oakland takes a variety of medications for his heart and other conditions. He was automatically enrolled in a plan offered by UnitedHealth Group. After spending about 20 minutes imputing his medications into the computer, pharmacy technician Olga Rubalcaba found that the plan does cover all of Contreras’ medications. The only exceptions are aspirin and vitamins, which still will be covered by Medi-Cal free of charge.

For many Medicare beneficiaries and counselors, a call to Medicare or to a specific insurer is necessary. But getting through can be difficult.

Insurers say they are being inundated with calls.

UnitedHealth Group, Contreras’ new insurer, is handling between 6,000 and 8,000 calls per hour, or three to five calls per second, during peak hours.

About 60 percent to 70 percent of those calls are from people seeking to enroll in a plan. Thousands more are from people who already have enrolled in a UnitedHealth plan and have questions about getting their prescriptions filled, said Dominick Washington, spokesman for UnitedHealth.

Other Medicare beneficiaries are trying to decide whether to sign up for the benefit.

Ernest Nowak of Castro Valley sought out help from Phil Epstein shortly before the Christmas holiday. Epstein is a counselor with the Health Insurance Counseling and Advocacy Program, known as HICAP, which offers free and unbiased help with Part D.

Nowak met Epstein in an office at the Castro Valley Senior Center and wanted to know whether he and his wife should stick with coverage through the Federal Employment Health Benefits Program (FEHB) from years working at the Alameda Naval Station, or switch to Part D.

Nowak brought in a slew of paperwork, but when Epstein asked for a letter from FEHB that is supposed to tell beneficiaries whether their coverage is better than Part D, Nowak could recall no such letter.

“I wish my wife were here,” Nowak lamented. “She usually handles this stuff.”

After reviewing the couple’s current benefits and comparing them with Part D plans, Epstein said they were better off staying with FEHB.

All-important paperwork

But if Nowak wanted to switch to Part D, he needed the missing letter from FEHB informing him of his benefits, or he would risk paying Part D enrollment penalties later. Epstein called FEHB to check on the letter. After several tries, he got through to an agent and verified that the letter had been sent.

“Don’t ever lose that letter,” Epstein told Nowak.

Getting adequate help is requiring involvement from already busy doctors and pharmacists, many of whom are reluctant, wrote two California physicians recently in the New England Medical Journal.

Dr. Richard Kravitz, director of the Center for Health Services Research in Primary Care at the University of California, Davis, and Dr. Sophia Chang of the California HealthCare Foundation in Oakland, said physicians should be prepared to advocate for their patients.

If a patient’s new drug plan won’t cover a certain drug, physicians can request coverage and are expected to get a response within 72 hours. Appeals are permitted, but these can be time- consuming, the authors noted.

“The capacity of many front-line physicians to deliver on these new responsibilities is uncertain, especially given the harried pace and poor reimbursement that are associated with primary care practice,” Kravitz and Chang wrote in the article.

To help physicians better understand their patients’ rights under Part D, the Alameda Contra Costa Medical Association developed a five-page information checklist.

“We’re trying to find some efficient ways to educate our members,” said William Guertin, executive director of the association. “All this is falling to pharmacists and doctors, and there’s a tremendous amount of confusion.”

Physicians may not be equipped to advise patients about the right drug plan for them, however, because they may not be aware of every medication the patient takes, Guertin said.

“In any case, doctors should be dealing with patients’ medical conditions, not … this bureaucratic mess,” he said.

Kocot, of CMS, said there have been some successes and that pharmacists have filled millions of prescriptions nationwide for people newly enrolled in Part D.

“We’re not saying there haven’t been issues that have come up, but we’re addressing those issues and moving forward,” Kocot said.

Pharmacists expect that it will take several months to sort out the details.

“The advantage is that it’s nationwide,” Davar said. “Everyone is dealing with it.”

Contact Rebecca Vesely at rvesely@angnewspapers.com.