TUESDAY, June 19, 2007 (HealthDay News) -- Medicare's new Part D drug benefit is widening patients' access to drugs, a new study says. The real problem, experts say, lies in finding out if your particular plan covers the medication you need.
That's because more than 1,800 different private health plans across the United States now participate in Part D -- each carrying its own formularies, or drug-coverage charts.
"Technically, it is possible for physicians to look up every drug for every patient, but in practicality, this study says they aren't doing it because it's just too hard," said lead researcher Dr. Chien-Wen Tseng, a generalist physician faculty scholar at the University of Hawaii School of Medicine.
The result from a previous study, Tseng said, is that "12 percent of patients said that they had left the pharmacy empty-handed, because the drug was either too expensive or was not covered."
And a recent survey of U.S. doctors found that 59 percent said their Medicare patients had encountered trouble getting prescriptions filled under Part D, which took effect last year, Tseng said.
"The whole point of Part D is to expand access," she added. "But if people can't figure out which drug is actually paid for in Part D, then we're back to where we were before the drug benefit."
The study, which was funded by the nonprofit Robert Wood Johnson Foundation, is published in the June 20 issue of the Journal of the American Medical Association.
Despite encountering some bumps along the way, Medicare's new drug benefit is widening access to medications for the average older American, most experts now agree.
"Part D benefits provide a lot of coverage for people who didn't have it before," said Tseng, who is also affiliated with the Pacific Health Research Institute in Honolulu.
In their study, Tseng and the study's senior author, Dr. R. Adams Dudley, of the University of California, San Francisco, used data from Medicare's Web site to track the availability of 75 widely used medications for older patients in California and Hawaii. The drugs were drawn from eight classes, including ACE inhibitors, beta-blockers, calcium channel blockers, diuretics, SSRI antidepressants and statins.
The good news was that, in the vast majority of cases, patients could expect to find at least one drug from each of the eight classes that would be covered by their plan, with the exception of heart drugs called angiotensin II receptor blockers.
The real problem came in figuring out -- in the short amount of time allowed by most doctor's office visits -- whether a particular drug was or was not covered by a patient's participating health plan.
"In California, for example, we looked at people who were potentially faced with over 70 plans" to sort through, Tseng said. "That means that you'd have to have hard copies [of each plan's formulary] and look that up each time, or have Internet access and navigate through the Medicare Web site."
Unfortunately, the study found that, in most doctor-patient encounters, that's just not happening. "This information is not currently easily available to physicians, and physicians don't have the time to look up every drug for every patient," Tseng said.
There were some helpful -- but not foolproof -- rules of thumb, however, the study found. For example, about three-quarters (73 percent) of generic drugs were widely available across plans. "So, physicians might think 'Great, that gives me a shortcut -- just prescribe the generic,' " Tseng said.
However, since one-quarter of generic medications aren't widely covered by plans, that could leave a large minority of patients frustrated as they run into roadblocks at their local drug store.
And those frustrations aren't just an inconvenience, Tseng said.
"These things have real consequences for patients," she noted. In fact, 17 percent of doctors who said their patients had failed to get a prescription filled explained that those bureaucratic mix-ups had led to "a serious medical consequence" for the patient involved.
Robert Hayes is president of the Medicare Rights Center in New York City, a consumer watchdog group. He said these types of incidents are still all too common for Part D participants.
"The key message here is that the variety of plans confounds people's ability to get the drugs that they need," Hayes said. "Very often, people leave the doctor's office with a prescription that they cannot and do not fill."
The solution, he said, lies in a renewed commitment by Medicare to streamline drug-coverage information for both doctors and patients.
"In three words: Simplify, simplify, simplify," Hayes said. "With the amount of money that we are putting into this program, people in Medicare and the American taxpayer should be getting far better health care. That's the frustration."
Tseng agreed. "Ideally, we should be making this all very easily accessible," she said. "Part D benefits provide a lot of coverage for people who didn't have it before. We're just saying, let's find a way to help providers find out what's actually covered and paid for by Part D."
More information
There's much more on navigating Part D at Medicare.
