Why Medicare Part D is a Nightmare!
This is going to be a serious blog about how Medicare Part D has impacted people at my work. I was prompted to write this blog while listening to the state of the Union address last night. The quote that struck me was,
"And in all we do, we must remember that the best health care decisions are made not by government and insurance companies, but by patients and their doctors."
While I thought the speech was pretty good for the most part. I feel that Medicare Part D, which is exactly a uniting of our government and insurance companies, is a direct contradiction to this statement.
I am going to do my best to make this blog make sense to others who are not in my field. Please remember, I do not claim to know all there is to know about Medicare Part D. I am only going on what I have been told through my work. We are one of the three largest pharmacies in the country, so I believe that we have pretty up to date information on the topic.
When Medicare Part D was first introduced, I kept seeing commercials for pharmacies that would say things like "bring in a list of the medications you are on and we will tell you which Medicare D plan is right for you." I assumed that this was because there were some Medicare D plans for low end drugs and some for high end drugs. Maybe a plan for drugs that have no generic form yet and one for drugs that do. Maybe a plan that focuses specifically on cardio- pulmonary drugs and one that focuses on chemo treatments. I was wrong. What this actually meant is which insurance company that is already established will be providing your Medicare D benefit. For example: Humana got together a list of drugs that they will cover under Medicare Part D and provides this list to pharmacies. If more of your drugs are on Humana's list than Blue Cross Blue Shields list, then you should sign up with Humana.
The problem comes in when you look at these drug lists. We are going to use Vancomycin for our example. Vancomycin is a very strong antibiotic. It is generally (and maybe always) given in IV form. It is safe to say that if you are on Vancomycin then you are fighting off something that without treatment, would more than likely end your life. Vanomycin comes in many forms. I am going to list them here.
250 milligram vials
500 milligram vials
1 gram vials
10 gram vials
100 gram bulk vials
500 milligram Ad-Vantage vials
1 gram Ad-Vantage vials
It is not important that you know what all the differences in these vials are, it is only important that you know that there are many different forms. Now, for each of these vials, there are different manufactures. Each manufacture labels their vial with a unique identifier known as an NDC number. So for Vancomycin 10 gram vials you might have 5 manufactures with 5 different NDC numbers. Now back to our insurance companies.
When the insurance companies who were going to be providers for Medicare Part D made their drug list, they did not just write Vancomycin on the list. Instead they wrote something like Vancomycin 10 gram with NDC ###-###-####. Now each insurance company that created a list did the same thing. The problem is that they did not have any guidelines to use the same drug vial size or NDC number as any other insurance company. Now, why is this a problem?
1) Nobody is able to carry enough inventory to accept Medicare part D. Lets say a patient is getting released from the hospital and the doctor orders 100 mg of vancomycin every 8 hours. This is 300mg of the drug a day. If the patient has Humana (for exmaple) you must use 3 100mg vials, according to their list, or you will not get paid. If the patient has Blue Cross, you must use 1 1gram vial, or you will not get paid. Not only must you use this size vial, but you must have the same NDC number that the insurance company has authorized. So your inventory must now include every size vial from every specific manufacturer for every possible insurance that provides for Medicare Part D. Does that sound like a sensible way to provide healthcare?
2) A pharmacist gets word that patient needs to be placed on Vancomycin for a serious infection. The vial type that needs to be used is on backorder. The Pharmacy is supposed to use a 500mg vial but only has 1 gram vials in stock. If this pharmacy fills the order with 1 gram vials, THE INSURANCE COMPANY IS NOT GOING TO PAY. So guess what happens, they pharmacy turns the patient away. The MD calls round trying to find a pharmacy to provide the medication but guess what, nobody accepts Medicare part D because nobody can afford to. So if a pharmacist decides to dispense with the incorrect vial size (although there is absolutely no difference in the drug) this pharmacist has now commited a crime called fraud.
So does this sound like patient care is being left up to the MD and patient or up to our government and insurance companies?
"And in all we do, we must remember that the best health care decisions are made not by government and insurance companies, but by patients and their doctors."
While I thought the speech was pretty good for the most part. I feel that Medicare Part D, which is exactly a uniting of our government and insurance companies, is a direct contradiction to this statement.
I am going to do my best to make this blog make sense to others who are not in my field. Please remember, I do not claim to know all there is to know about Medicare Part D. I am only going on what I have been told through my work. We are one of the three largest pharmacies in the country, so I believe that we have pretty up to date information on the topic.
When Medicare Part D was first introduced, I kept seeing commercials for pharmacies that would say things like "bring in a list of the medications you are on and we will tell you which Medicare D plan is right for you." I assumed that this was because there were some Medicare D plans for low end drugs and some for high end drugs. Maybe a plan for drugs that have no generic form yet and one for drugs that do. Maybe a plan that focuses specifically on cardio- pulmonary drugs and one that focuses on chemo treatments. I was wrong. What this actually meant is which insurance company that is already established will be providing your Medicare D benefit. For example: Humana got together a list of drugs that they will cover under Medicare Part D and provides this list to pharmacies. If more of your drugs are on Humana's list than Blue Cross Blue Shields list, then you should sign up with Humana.
The problem comes in when you look at these drug lists. We are going to use Vancomycin for our example. Vancomycin is a very strong antibiotic. It is generally (and maybe always) given in IV form. It is safe to say that if you are on Vancomycin then you are fighting off something that without treatment, would more than likely end your life. Vanomycin comes in many forms. I am going to list them here.
250 milligram vials
500 milligram vials
1 gram vials
10 gram vials
100 gram bulk vials
500 milligram Ad-Vantage vials
1 gram Ad-Vantage vials
It is not important that you know what all the differences in these vials are, it is only important that you know that there are many different forms. Now, for each of these vials, there are different manufactures. Each manufacture labels their vial with a unique identifier known as an NDC number. So for Vancomycin 10 gram vials you might have 5 manufactures with 5 different NDC numbers. Now back to our insurance companies.
When the insurance companies who were going to be providers for Medicare Part D made their drug list, they did not just write Vancomycin on the list. Instead they wrote something like Vancomycin 10 gram with NDC ###-###-####. Now each insurance company that created a list did the same thing. The problem is that they did not have any guidelines to use the same drug vial size or NDC number as any other insurance company. Now, why is this a problem?
1) Nobody is able to carry enough inventory to accept Medicare part D. Lets say a patient is getting released from the hospital and the doctor orders 100 mg of vancomycin every 8 hours. This is 300mg of the drug a day. If the patient has Humana (for exmaple) you must use 3 100mg vials, according to their list, or you will not get paid. If the patient has Blue Cross, you must use 1 1gram vial, or you will not get paid. Not only must you use this size vial, but you must have the same NDC number that the insurance company has authorized. So your inventory must now include every size vial from every specific manufacturer for every possible insurance that provides for Medicare Part D. Does that sound like a sensible way to provide healthcare?
2) A pharmacist gets word that patient needs to be placed on Vancomycin for a serious infection. The vial type that needs to be used is on backorder. The Pharmacy is supposed to use a 500mg vial but only has 1 gram vials in stock. If this pharmacy fills the order with 1 gram vials, THE INSURANCE COMPANY IS NOT GOING TO PAY. So guess what happens, they pharmacy turns the patient away. The MD calls round trying to find a pharmacy to provide the medication but guess what, nobody accepts Medicare part D because nobody can afford to. So if a pharmacist decides to dispense with the incorrect vial size (although there is absolutely no difference in the drug) this pharmacist has now commited a crime called fraud.
So does this sound like patient care is being left up to the MD and patient or up to our government and insurance companies?
posted by Bleach at 6:13 PM
14 Comments:
Sounds like crap to me. I hate dealing with health insurance. I have at least 7 emails from my company's benenfit person that I haven't taken care of yet. We switch providers back and forth every year so I have to roll my HSA account back and forth. It's a pain in the ass so I haven't done anything about it yet.
I guess if I was unhealthy I would have cared more by now.
that was a good explanation. thanks for laying it out.
anyway, THAT IS BULLSHIT. what a nightmare. this sounds like it is going to favor big companies that have the invetory to carry all these diffrent dose types and put further pressure on mom-and-pops.
i favor a free market economy and all, but that seems unfair.
in bush's defense, i think he was saying "[... doctors and patients make their own decisions...]" as a segway into his statement about health care reform.
im bet thats just the tip of the ice burg
I recommend that you send a copy of this blog and any other concerns you may have to Senator Grassley. He is very interested in this area (as are many other senators), and would probably like to hear from you.
Are you able to split vials? If not, do you ever have to waste portions of vials to fill a prescription?
You may also want to to let CMS and the HHS Inspector General (Dan Levinson) know how Part D is impacting pharmacies.
In response to a Congressional request, we are currently performing over 100 audits of rural pharmacies and the adequacy of Part D reimbursement. Based on your remarks, I'm not sure that this objective necessarily gets at the problem.
I might indeed write a letter.
I am glad to see you commented...I was anxious to hear your feedback.
As for the splitting vials. In the past. If a patient's order called for the use of half a vial, and we had to use the entire vial, then the insurance company was billed for the entire thing. I wouldn't swear to that but I am pretty sure. I am pretty sure that this set up worked out in favor of the pharmacies since they could then used the remaining portion to fill another order if need be.
There is a definite role of greed on the part of the pharmacies that has led to the health care crisis we are in today. The above is one of the examples.
I think that this may have been a reason that Medicare D decided to lay this out the way the did. The problem is that they went too far and patient care is being sacrificed.
Good luck with your audits. I am sure they will prove beneficial.
I also see that I didn't answer your question in regards to Medicare D. I will find out and post it later.
bleach, as far as the half vials are concerned, Specialized Clinician has a field that allows you to designate a drug as a "dose" or "unit". if the drug is designated a "dose", then if you dispense 1 gram of a 10 gram vial, the claim is sent for 1/10 the cost of the 10 gram vial. if the drug is designated "dose". i.e. Cubicin, Synagis, Procrit, then the claim is sent for the entire cost of the vial, whether 1/2 is used or the entire vial is used.
I’m no expert on the specifics, but I am surprised to hear/see that many pharmacies do not accept Part D. I know that Walgreen does. As does CVS, Rite-Aid, and Wal-Mart. I would guess that these 4 provide a majority, or at least a major portion of the nation’s retail drugs.
I was never a big fan of yet another government entitlement program. Hearing this makes me even more scared of a good number of the crazy ideals of many in congress regarding national healthcare. There are very few things that the US government does that it does well. Do you think that people in the US realize that the Canadian government is desperately trying to figure out how to get out of the healthcare business….with no success? It is a dangerous, one-way road.
For what it’s worth, while I think Bush should not have given in on the Part D plan, I do believe that he decided to do this vs. what most democrats wanted to do – which was much, much larger and more expensive. In essence, throwing them a bone.
Lastly, how many revolutionary drugs to you hear about being developed outside of the US. Not many. Why, because the US system enables this to occur. What do you suppose would happen if we went with national healthcare?
i have a question. how are the antiobotics that are being discarded being discarded?
are they destroyed or flushed down the drain with no treatment? just curious.
are they shot into outer space?
seriously, this is pretty interesting topic. tony has some good points. I am on his side when it comes to universal healthcare. and the cost of healthcare/drugs.
i do know that it takes a remarkable amound of money to make new drugs (research, i mean) and that is a huge part of our costs as consumers. you get what you pay for, after all.
if you want a tasty bit of controversy (which I know you love bleach), you should look into how many nations in Africa are getting free AIDS/HIV treatment when more are dying from malaria and other communable diseases that are much cheaper to treat. but, treating AIDS is hot, and that is where the money is going.
pretty interesting. I'll give you an article about it next time you are around my love shack.
?
First of all to T Schy. I should clarify that I was speaking about Infusion pharmacies accepting Part D.
And Fooie:
Antibiotics are being flushed down the drain not only by pharmacies and hospitals but by people who don't take all of their prescriptions. I have a friend who's wife works for the EPA in New York and they are extremely concerned about this. Think of all the nice bacteria that are forming in our rivers that are automatically resistant to our antibiotics because of this. That is an entire nuther blog.
that is what i was wondering. I know individuals do this, but if pharmacies do this it is much worse. Policies can enforce this with pharmacies whereas they cannot in individuals.
this is truly bad news. Pretty soon, the bugs will win. then we will be screwed.
Let me give you an example how Humana screws its subscribers who pay a monthly fee for the reight to be screwed! I received 90 days supply of a non generic medication before leaving for an extended vacation. I misplaced the medication and was informed by Humana that I could not purchase under the plan even a small supply to hold me untill I could locate the drug. I was not even able to use their negotiated price. I therefore ended up not only paying the $90 co payment but was forced to pay over $300 to buy a drug I needed to control my diabetes. Furthermore, I was treated like a criminal who was somehow stealing from them even though I was paying a considerabe monthly fee! I have three degrees and volunteer advising senior citizens about Medicare issues.
You can be sure I will never recommend Humama!!!
I am a pharmacist, and I know the public is not aware of how the insurance companies and drug companies are controlling medicare part d, but prescriptions medication in general. I might mention to you, that all of the insurance companies are receiving "rebates" (kickbacks) from the pharaceutical companies to have there product on the insurance formularies. The amount is a well kept "trade secret" but all indications are it is astronomical.
The Medicare Prescription Modernization act (Medicare Part d) was planned by the Pharmaceutical companies, the insurance companies, and Medicare. Retail pharmacy organizations we not allowed in any planning session.
Prescription drug prices rose immiediately, after the passage of this bill, and have been rising at a very hefty rate for name brand drugs.
Retail pharmacy profits have declined since the introduction the plan d even though script volume has incresed dramatically. The insurance industry is taking it from the retail pharmacist and putting it into there own pockets, and referring business to their own mail order facilities, you know, where you are able to get a 90 day supply.
gotta run I am pretty busy
I Believe Baltimore meant to write:
Specialized Clinician has a field that allows you to designate a drug as a "dose" or "unit". if the drug is designated a "UNIT", then if you dispense 1 gram of a 10 gram vial, the claim is sent for 1/10 the cost of the 10 gram vial. if the drug is designated "dose". i.e. Cubicin, Synagis, Procrit, then the claim is sent for the entire cost of the vial, whether 1/2 is used or the entire vial is used.
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