Know many confused 65-year-olds? Probably not. But confusion is the reason CMS gives for reducing the number of prescription drug plan choices from many to few. A Kaiser Health News interview with CQ Roll Call's Emily Ethridge explains this and other changes to Medicare's Part D prescription drug program for people 65 and over.
MARY AGNES CAREY: Now CMS currently -- that’s the Centers for Medicare & Medicaid Services, which oversees the Medicare part D program -- they currently require that Part D plans cover the vast majority of drugs in six specific classes. And they’re proposing to drop two of these categories next year, and another might be dropped in 2015. What are these drugs that could lose this "protected status," as they call it, and why are people so concerned about it?
EMILY ETHRIDGE: The drugs that CMS is proposing to remove from this requirement to offer are anti-depressants and immunosuppressant drugs, and the one that they’re thinking about doing later are anti-psychotic drugs. So we’ve had a lot of outcry from patient groups for the communities that take these medications saying we’ve been able to have access to all these drugs before on all our Medicare plan formularies, now we’re really worried this is going to reduce our access and reduce our ability to get the drugs we need. They really make the point that these drugs aren’t all the same. So it’s important to have a wide range of availability.
MARY AGNES CAREY: What’s CMS’s response? What’s the rationale for doing this?
EMILY ETHRIDGE: The CMS administrators have said, "We don’t have any problems with the other drugs that aren’t in these protective classes," as they call them.
There are about 140 classes of drugs that Medicare has on its formulary plan. And there are only six that are in the special categories. They’re saying "If you don’t have a problem with the other 134, we shouldn’t have any problems with a couple of these."
MARY AGNES CAREY: Did they also suggest that plans have some issue in that they can’t really leverage a discount with a drug maker if they have to offer a wide array?
EMILY ETHRIDGE: Right. If you have to offer, on your plan, every single anti-depressant that’s available for purchase, it makes it really hard for you to negotiate because the drug maker knows you’re required to offer that drug so they can sell it to you at a higher price.
MARY AGNES CAREY: Are there any protections in the law for someone who says -- let’s say they offer some choices that don’t work for a particular patient. What does that patient or their physician do if the drug that is covered doesn’t work for them?
EMILY ETHRIDGE: You’re supposed to be able to go to Medicare and say "This is the drug I need, here’s the medical proof for why I need it, it needs to be covered," and that was it. [Now,] it’s awfully time-consuming, you’re negotiating with the government and your plan, and your doctor. It’s just a really complicated prospect.
MARY AGNES CAREY: Currently, Medicare beneficiaries who are in Part D have something like three-dozen plans, in a particular region, to choose from. CMS is proposing some limits to those number of plan offerings. Why are they doing that?
EMILY ETHRIDGE: It’s a really big limit. They would actually limit it down to two plans in each service area and CMS says that’s because, right now, there are just too many plans. Seniors are confused. Do they have such an overwhelming amount of information on all these plans, that it’s really hard to make a good choice? They’re not going to sit down and compare 36 plans to pick the right one. They say seniors really don’t even move plans that much, even though they have this wide array of options. They tend to stick with one and stay with it not take advantage of these different options they have.
MARY AGNES CAREY: So the idea is that these plans are somewhat duplicative and if you narrowed the choices, then people might do more comparison shopping? Is that the thought?
EMILY ETHRIDGE: Right, it's can you make a smarter, better decision? Can you make this decision process easier for a senior? If you’re comparing plan one to plan two, that should be a lot simpler. It’s easier to see the differences than if you’re comparing plans one through 36.
MARY AGNES CAREY: We’ve talked about two of the proposals in this regulation. It’s a pretty big regulation. What are some of the areas that are causing some concern on the Hill?
EMILY ETHRIDGE: There is another area that is really important, which is about preferred pharmacy networks. The rule says that a plan would have to allow any pharmacy that’s willing to meet its price to participate in its preferred network. Right now plans sort of negotiate with -- and they have a certain particular pharmacy. They say you get a better deal if you go to this pharmacy. They offer better prices, because they negotiated something together.
CMS would say: If any pharmacy comes to you and offers to meet the terms of that deal, you must accept it.
MARY AGNES CAREY: Emily, one thing I’ve been wondering about this is: We know that the administration is currently embroiled in a big battle on Capitol Hill over the Affordable Care Act and its implementation. Now this particular proposal is also causing a lot of concern -- not only with Republicans but Democrats, as well.
Why do you think CMS made this proposal at this time?
EMILY ETHRIDGE: It is confusing, because it is a lot of change at a time when the Medicare situation is already changing. We heard a lot from the CMS officials about price and the cost of Medicare Part D, which covers prescription drugs. It’s increasing much higher than the rest of Medicare. They say this proposed rule would actually save money over ten years. And they say it would make things simpler for seniors.
They say that because of the law, in some cases, we don’t need, maybe, this many plans. The health care law is reducing that prescription drug doughnut hole, that coverage gap that we’ve all heard so much about. If that’s being made smaller, then we don’t need all these plans to fill that in -- we don’t need all these choices, and we don’t need spend money on all of these options. It’s just not necessary.
MARY AGNES CAREY: Thanks for bringing us up to date, Emily Ethridge of CQ Roll Call.