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Beware the Doughnut Hole

Policy Recommendations

Medicare critics have been outspoken about the complexity of the government’s prescription drug benefit for seniors ever since its January 2006 launch. Here are a few ideas for improvement:

  • Require insurers to offer just two or three Part D plans to reduce the number of choices available;
  • Require insurers to establish yearly contracts with drug companies to prevent unexpected mid-year jumps in drug costs after beneficiaries are locked into a plan;
  • Establish quality measures plans must meet to participate in Part D;
  • Create a list of drugs that should be covered, no matter the formulary, to help doctors and patients sort out those that could be prescribed for many ailments;
  • Seek rebates from Part D plans that have an insufficient percentage of drugs that can be substituted for lower-cost alternatives;
  • Speed up incentives for e-prescribing and a comprehensive electronic database to improve efficiency and reduce medication errors;
  • Allow drug reimportation to reduce healthcare costs; and
  • Create a pathway for FDA approval of generic biologics.—BN

Two-Way Conversation

Hospitalists generally don’t have the benefit of a longstanding relationship with their patients, says Ashley Beard, MD, PhD, a pharmaceutical policy research fellow in the Department of Ambulatory Care and Prevention at Harvard University. “And they’re dealing with people who are at their most vulnerable and least able to communicate effectively about what is going on in their lives.”

The virtual impossibility of knowing Part D formularies for every patient, she says, only increases the importance of effective bedside discussions and open-ended questions. “I think that communicating about costs really has been, and continues to be, a taboo subject in direct patient encounters, even though it is widely talked about in the research and popular press,” she says.

Likewise, hospitalists can intervene during transition planning, Dr. Beard says, when “the goal of the hospitalist is to stabilize the patient to be able to go out into the community and then have community follow-up care, preferably by a primary-care physician.” For people who don’t seek care regularly, she says, part of that stabilization can be a medication review that eliminates nonessential or harmful drugs and alleviates a patient’s financial burden.

Christine Lum Lung, MD, medical director of the independent Northern Colorado Hospitalists group, says a proactive discharge-planning department can be a huge help in coordinating such transitions of care. Her privately run group, affiliated with two private nonprofit hospitals in Loveland and Fort Collins, works closely with a “very active and involved” department that regularly meets with patients to assess financial issues. “Then they will approach us oftentimes with any concerns or issues with the discharge plan and medication,” she says.

Technology to the Rescue?

  •—Produced by Consumer Reports, the free Best Buy Drugs program translates scientific reports from the Drug Effectiveness Review Project into consumer-friendly guides that compare name-brand drugs with their generic counterparts.
  •—Epocrates—free medical software that can be downloaded onto a PDA—allows doctors to input a patient’s Part D formulary and determine the coverage or restrictions of specific medications, as well as other pertinent information. Note that not all formularies participate.
  •—The nonprofit organization Families USA has compiled a number of primers, links, resources, and background information for its online Medicare Drug Coverage Center.

Real-Time Solutions

Patient advocates have proposed a combination of other incentives to encourage better coordination among healthcare providers, including penalties for preventable rehospitalizations and a faster rollout of e-prescribing and electronic databases. Many hospitalists are particularly enthusiastic about the potential of electronic health records to assist them and their patients, though researchers like Soumerai are far less convinced about the merits of such a billion-dollar investment.

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