Medicare drug benefit tips: 7 key things doctors need to know

Fall has arrived, and that means the Medicare prescription drug plans are off and running.

Starting now with the help of their families and the physicians that take care of them, beneficiaries will work to decide how -- or whether -- to sign up for what many are calling the biggest change to hit the health program since its inception. Seniors and people with disabilities face a variety of economic and practical considerations as they prepare to enter a new era of Medicare outpatient drugs.

Here are seven points that may help doctors determine what role they can -- or wish -- to play in this process. Still, no matter what level of involvement physicians decide to take, it's a given that all doctors should decide how they will handle patients' questions.

1. You're first on the list

In a recent Kaiser Family Foundation poll, most seniors said they first would ask for their physicians' counsel in deciding whether to enroll in a Medicare drug plan. Federal officials overseeing the rollout of the new benefit say doctors need to prepare accordingly.

The Centers for Medicare & Medicaid Services is asking doctors and their staffs to bone up on the basics of the benefit in advance of this fall's initial enrollment period. The more physicians know about what the government is offering seniors, the better off everybody will be when the inevitable first questions start coming up in the exam room, the agency said in a recent article to doctors.

"As a trusted source, your patients may turn to you for information about this new coverage," the agency said. "Because of this, we're looking to you and your staff to take advantage of this 'teachable moment' and help your Medicare patients."

Educational materials that the government has been offering physicians to distribute to colleagues and staff have stressed their role as the gatekeepers to enrollment information.

The main message that CMS is trying to impart: First learn, then teach.

2. Your audience is diverse

Every Medicare enrollee is eligible to sign up for drug coverage regardless of income and health status, but not every one will necessarily want to.

With doctors' help, federal officials say, most beneficiaries will decide early on whether the program is right for them. The Dept. of Health and Human Services recently estimated that as many as 30 million out of the 41 million eligible enrollees will sign up for drug coverage in the first year of the benefit's operation.

Legitimate reasons exist as to why certain patients might not be eager to sign up for the new benefit. Some already have coverage for their medications through a former employer and are not sure if they want to give it up in favor of a Medicare plan, beneficiary groups say. Yet others spend little on prescriptions right now and wonder if it makes sense to pay monthly premiums for unneeded drugs.

The situation becomes more complex with the addition to the mix of Medicaid, state pharmacy assistance programs and Medigap plans. Depending on how generous the existing coverage is, beneficiaries might be able to wrap the new Medicare benefits around holes in their current coverage rather than choose one program over another.

The moral of this particular story is that not all beneficiaries are facing the same set of circumstances, experts say.

3. Your patient's bottom line matters

The decision patients need to make in the coming months is essentially an economic one. For some low-income seniors, the government might be putting too much money on the table for beneficiaries to pass it up -- and for their doctors to let them.

Many people with low incomes already should have gotten wind of the federal subsidies for which they could be eligible. The Social Security Administration this summer mailed out millions of letters alerting seniors that they could qualify for extra help under the Medicare drug benefit.

Individuals who make less than $14,355 annually and couples who earn less than $19,245 are eligible for extra financial help, assuming that their assets do not exceed certain limits. Beneficiaries at the lowest end of the income spectrum would be required to pay only $1 to $5 for each of their prescriptions, with no premiums or deductibles.

The prospect of such federal assistance has prompted seniors' groups such as AARP to urge their members to fill out any application forms that they receive from Social Security -- or risk throwing away free money. Beneficiaries already receiving certain forms of government help won't need to bother; enrollment will be automatic for them.

Those who would receive the standard drug benefit would, after paying a monthly premium, then pay a $250 deductible to trigger the coverage. The government would bankroll 75% of the next $2,000 in drug costs, after which the initial subsidies would cease. A catastrophic benefit, under which Medicare pays for 95% of drugs, would kick in only after the beneficiary has spent $3,600 of his or her own money.

The bottom line, according to CMS -- know your patients' bottom line.

4. Tell patients to act quickly

Drug benefit open enrollment for 2006 launches on Nov. 15 and continues for six months, until May 15. Physicians should know that any of their Medicare patients who have not signed up by the spring will need to cool their heels before they can do so again -- after the beneficiaries contemplate a new set of fiduciary issues.

Unless seniors have drug coverage from another source that is at least as generous as what Medicare is offering, they will pay a premium penalty for signing up late. For every month beyond May that a beneficiary delays enrolling in a drug plan, his or her monthly premium offer will permanently increase by 1% of the national average premium.

With that economic sword of Damocles hanging over seniors' heads, AARP and other groups are urging every Medicare beneficiary to strongly consider joining a drug plan before mid-May. Even the healthiest of patients likely will need more expensive drug regimens later in life, and some could develop sudden illnesses during the vulnerable interim months when they have no access to catastrophic protections, the groups say.

Part of a physician's medical advice to elderly and disabled patients therefore may be that they should make a reasoned decision -- but within a reasonable amount of time.

5. Patients' choices will abound

Regardless of how complex their physicians' advice ends up being, those who embrace the Medicare drug benefit in the coming months will find no shortage of plan options.

Before releasing the full list of private plans Medicare approved to participate in the program, CMS announced that beneficiaries in every region of the country would be able to choose from a list of more than 10 stand-alone prescription drug plans, with the tally exceeding 20 in some areas. Those figures do not even include any Medicare Advantage managed care plans that have applied to administer drug benefits.

Federal officials treated the news as evidence that private plans have a great interest in getting into the nascent Medicare drug market. Healthy competition among insurers will translate into robust health benefits and lowered costs for both beneficiaries and the government, they said.

At the beginning of the year, CMS estimated that average monthly premiums would run seniors close to $40 per month. But the plethora of competitive bids allowed the agency to lower its estimate closer to $30 per month.

Seniors and the physicians who treat them also are bound to hear a great deal from insurers themselves. Some of the larger firms that are offering national drug plans are each planning to spend tens of millions of dollars on marketing their benefits directly to beneficiaries, industry experts said.

So doctors helping their patients navigate the drug benefit decision process should be aware that the choices will not end just because the beneficiaries decide to go for it.

6. You may be asked to fight

Many seniors will want to research which plans will cover most or all of the drugs that they are likely to need over the course of the year. To that end, CMS offers reference forms to doctors that their patients can use to record their medication regimens for side-by-side comparison to plan offerings.

For many seniors, the drugs that they need will be somewhere on the formularies of drug plans in their area, according to CMS.

For those who don't find their particular drug listed, in many cases a comparable alternative within the same clinical category will be available, agency officials said.

But even those who are the new program's fiercest supporters concede that cases will arise in which a needed drug has no covered alternatives and cannot be found on the approved lists of any plan in the area. In those cases, doctors could find themselves recruited into action during the enrollment period.

Physicians knowledgeable and weary of long, protracted battles with managed care companies might not relish the thought of taking on yet another insurer. But some patient advocates say medical professionals would play a vital role in prompting reversals of formulary decisions -- in some cases even before a beneficiary has taken advantage of any drug benefit.

Drug plans must have an appeals process in place from the start that is designed to take expert clinical assessments into account when drug formularies receive a challenge based on medical necessity.

Some patients might find that the process of getting the drugs they need is not simply a matter of signing up. It's a matter of getting their doctors to help them fight to ensure that the plans they sign up for cover the drugs they need.

7. You can pass the baton

If these details sound overwhelming to some practices, they very well might be. CMS and physician groups such as the American Medical Association are working to make sure that doctors don't get distracted from what they do best by getting bogged down in minutia.

In one flyer the agency and the AMA produced for doctors, the groups urge physicians to keep their "teachable moment" minimal if need be.

"We understand the pressure on your clinical time with your patients, which is why we would just ask that you inform your patients who have Medicare that the new prescription drug coverage could be valuable to them and worth exploring," the document states.

Passing beneficiaries off to experts who have more time and resources to walk them through the more all-consuming details of the drug benefit enrollment process may be as simple as knowing a phone number or Web site. Assistance from Medicare itself can cover everything from determining low-income subsidy eligibility to comparing drug offerings of competing plans. Regional organizations known as Senior Health Insurance Assistance Programs, or SHIPs, and Area Agencies on Aging also will provide assistance and counseling that physicians may not have the time to offer.

Above all else, physicians need to be available to diagnose medical conditions and prescribe the necessary drugs to treat them, CMS said. Just because doctors are the first stop for help in figuring out what happens in the meantime doesn't necessarily mean that they need to be the last stop.