Medicare Part D – Who Is Watching the Henhouse?

Medicare MontageOctober through December 7th is the time of year when patients should be re-evaluating their Medicare Part D Drug Plan and their private insurance options.  Medicare patients are encouraged to log on to and access prescription drug plans. They are asked to enter their Medicare identification number, zip code, name and then their prescription medications. The computer will then find them the most cost effective drug plan in their area for their medication needs. 

This process is so important that I always remind my patients about it in our practice quarterly newsletter and offer to perform the service for those patients who are not computer literate or who just do not get it. It is additionally the time of year when patients begin to receive notification that some of the medications covered on their Medicare Part D Prescription Plan formulary, or on their private plans, will not be covered the next year and they will need to change. 

This is not a particularly difficult action for younger healthier patients taking few prescription drugs but it does become challenging for the elderly on multiple medications for many chronic diseases and problems. There is no organization or government office supervising or monitoring this process and it can lead to problems. Take the example of TJ, an 84 year old woman with long term sleep problems, coronary artery disease, intermittent congestive heart failure, chronic kidney disease, high blood pressure , elevated cholesterol, spinal stenosis, diffuse osteoarthritis and age appropriate short term memory loss. After seeing a neurologist she has been placed on temazepam 15 mg one half tablet at bedtime as needed for sleep. She purchased a Medicare Part D Prescription Drug Plan through AARP because of her trust in that organization.  They contract with United Healthcare to provide the Medicare Part D Drug Insurance Plan. 

In 2013 a 30 day supply of temazepam cost the patient $10 per month. The notice says that in 2014 that same medication will cost the patient $85/month if she buys the generic version or $95 per month if she wishes to purchase the brand name version. Her AARP United Healthcare is suggesting that in 2014 she switch from temazepam to trazodone.  Trazodone will only cost her $7 per month for the generic version. Trazodone is an antidepressant drug which was found to be sedating and has now obtained permission to be used for insomnia.  In my humble opinion comparing one half of a 15 mg temazepam to 50 mg of trazodone for sleep is like comparing a small ceremonial glass of wine consumed at a religious service to snorting a few lines of cocaine (a stimulant), and then taking a few shots of vodka to slow the shakes of your hands before you go out and drive carpool.

Our small office caught this error in judgment and prevented the change. We wonder who exactly at the drug plan considered the difference in medications in this senior citizen and approved this?  How much money, favors or gifts exchanged hands at the purchasing and corporate level to negotiate this change in formulary.  If this patient was in a larger practice with little oversight would this change in medications been handled and approved by non-medical staff with no questions asked? 

Patients who put their trust and faith in AARP deserve better oversight and regulation.  This is one case but how many thousands more are slipping through in the name of greed and corporate profits?

Customer Satisfaction and the Quality of Your Health Care

CMSThe Center for Medicare Services (CMS) has issued edicts and guidelines to hospitals that their customer satisfaction survey ratings must improve or else they will be fined and penalized.  One of the areas where they want improvement is in the emergency room or department.  They now require ER’s to make a disposition and either treat you and send you on your way or admit you to stay within three hours (180 minutes). On the surface anyone who has spent time in an emergency room cannot possibly object to speedier more efficient service so why am I objecting to this new regulation?

For decades emergency rooms have practiced the art of triage. Triage means they treat the sickest but most salvageable patients first.  Those with simple non-life-threatening issues and those with severe issues but no hope of survival get placed at the back of the line in deference to sicker individuals with problems that require immediate attention if the patient is to survive. Emergency Rooms have become everyone’s after hours and weekend primary care office for many reasons. They are jammed with minor health problems and social issues that in an earlier less litigious era would have been treated at home by family and friends or seen by the family doctor in the office or in the past in their homes. Many of the reasons for these visits would have been treated with guidelines and instructions available in any Cub Scout or Brownie First Aid instructional manual but today clog the ERs.  Should an abrasion from a fall to the arm of a 12 year old receive the same immediate attention as a change in mental status and collapse of a previously healthy 45 year old father of three?

CMS has not differentiated between University Hospital Centers with fulltime on-site interns, residents and fellows and community hospitals where few if any of the treating physicians are on location full time.  In order to stay in compliance with these draconian rules, community hospitals are diverting doctors and nurses from caring for patients in the facility to the emergency department to “move patients along.”   Our community hospital initially imposed a “thirty minute rule” which said that when a community based physician received a phone call from the ER that a patient required admission they had 30 minutes to admit that patient.   Admitting a patient without seeing them, taking a history and doing an appropriate examination is not in the patient’s best interest. When the medical staff was asked to approve this rule as part of the Medical Staff bylaws, they overwhelmingly rejected it.

Everyone wants prompt, efficient, courteous attention and service especially when ill. CMS and this administration are trying to implement it by decree without true consideration of how their actions will impact patient care. One size does not fit all.  Without citizen outcry to their elected officials, poorly thought-out policy in the name of cost savings will impact you and your loved ones unless you speak up.