Medicare Part D – A Beacon or a Warning Light?

NPC President Dan Leonard says the Medicare Part D prescription drug program has by nearly every measure been a success, but there is room for improvement, particularly when it comes to managing chronic conditions.

The Medicare Part D prescription drug program has by nearly every measure been a success, but there is room for improvement, particularly when it comes to managing chronic conditions, according to health care policy experts who joined a panel discussion hosted by the National Association of Social Insurance (NASI) on June 10.

“One of the most important challenges that older Americans face—and that Medicare needs to deal with—is managing the treatment of chronic conditions. These people have different goals—they want to be able to stay active, spend time with their grandkids, enjoy retirement, or just maintain their current level of health,” said NPC President Dan Leonard, who moderated the discussion.

Today, more than two-thirds of Medicare-aged beneficiaries have two or more chronic conditions; 15 percent have six or more. Eighty-one percent of older persons use at least one medication, and 29 percent use five or more medications, Leonard pointed out.

Given those statistics, Leonard posed a series of questions to the panelists: “How can we improve their medication adherence and health outcomes so that they can achieve their goals? How can we best manage benefits to ensure access to the right care? Are there new delivery system models that we should consider?”

“If there were an obvious solution, I don’t think we’d be having this conversation,” responded PhRMA Senior Vice President for Policy and Research Jenny Bryant. “There are big burdens on patients with multiple chronic conditions. Cost sharing and utilization management have grown. We need to think about how we manage incentives for health plans, and also medication therapy management and access to care.”

According to Bruce Stuart, professor, University of Maryland School of Pharmacy, Medicare’s medication therapy management (MTM)—in which pharmacists work to optimize drug therapy and improve therapeutic outcomes for patients—is not working well. It can be difficult to ensure that patients have access to the right medicines because “the plans have established mechanisms to exclude, rather than to include. We also don’t have the information from [the Centers for Medicare and Medicaid Services] to know whether MTM works. We really should be looking at other alternatives,” Stuart said.

There are a lot of opportunities to improve MTM, such as more efficiently resolving drug therapy problems and recognizing that health plans’ “one-size-fits-all” approach to MTM will not work for everyone, pointed out Kim Swiger, vice president, clinical product marketing, Mirixa Corporation. “It’s about care coordination,” she said.

Another challenge panelists noted is that there isn’t always alignment between the doctors, quality measures and payers. Physicians often have financial incentives for meeting quality measures for patient care, but they can’t meet those quality measures if patients don’t have access to the right treatments.

“As a doctor, I’m under orders to have my patient manage their conditions, but then they are denied access to the treatments,” said A. Mark Fendrick, MD, professor of internal medicine in the School of Medicine and of Health Management in the School of Public Health, University of Michigan.

Regarding access issues, Fendrick suggested that payers requiring step-edit therapy should consider a “good soldier” approach. In other words, patients who diligently follow all of the steps required by their health plans, such as trying the first line of therapy for their conditions until they reach the optimal treatment option, should not be required to pay a higher copay for that treatment. It’s not the patients’ fault if their biological makeup means that they need a treatment with a higher copay, explained Fendrick, so these patients should not be further penalized by higher costs.

Bryant agreed that this could be a good approach, but cautioned that patients might be required to “jump through the hoops” again if they change health plans during open enrollment. “You want to make sure that they don’t have to repeat step therapy. You need to think about what this means for patients,” said Bryant.

Leigh Purvis, director of health services research at AARP’s Public Policy Institute, emphasized that when it comes to improving medication adherence in Medicare, cost-sharing may be short-sighted. “It will be spread out throughout the health care system, whether it’s through taxes or other costs increasing. We need to get value into the system. We need to ask if there is [comparative effectiveness research] if a new drug is entering a crowded category. That’s where we need to be headed—we want to make sure that we have the resources to pay for new advances.”

Fendrick concurred. “We need to change the conversation from how much we spend to how well we spend,” he said. “We need to discuss the waste in the system, which for drugs is incredibly low compared to hospitals and other areas. If we could cut the waste in Medicare, we could afford spending in the right places.”

And while Medicare could be improved, Purvis reminded panelists and the audience not to lose sight of the bigger picture. “When we think about Medicare, there are millions of people who didn’t have coverage before, and that is a huge success,” said Purvis.

The panel discussion was part of a half-day event, Medicare Part D – A Beacon or a Warning Light?, one in a series of symposia hosted by NASI marking the 50th anniversary of Medicare and Medicaid.