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?