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 www.medicare.gov 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?

Drinking Coffee, Lower Mortality

Over the years, the consumption of coffee and its relationship to your health has been controversial.  In my medical school, internship, and training years in the late 1970‘s, it was thought that consuming more than five caffeinated beverages per day was associated with an increased risk of pancreatic cancer. That relationship has since been disproved.

The May 17th issue of the New England Journal of Medicine published a study on coffee drinking that will certainly make coffee drinkers more comfortable with a consuming a “cup of Joe.” They looked at a National Institute of Health – AARP study that began 1995 and includes almost 230,000 men and 173,000 women. They found that coffee drinking was associated with many negative behaviors including cigarette smoking, less exercise, eating more red meat, and eating less fresh fruits and vegetables.  Upon initially looking at the data, coffee drinking was associated with an increased mortality. However, when researches removed the negative behaviors from the data, and looked at the people who drank coffee but didn’t smoke and exercised; they found a significant drop in the mortality of coffee drinkers. Over 13 years, men who drank 4-5 cups of coffee per day had a risk reduction of 12% while women had a risk reduction of 16%.

The risk reduction was considered “modest” by Neal Freedman, PhD of the National Cancer Institute.  Lona Sandon, RD (registered dietitian) of the UT Southwestern Medical Center in Dallas said, “Based on this study alone I would not tell people to start drinking more coffee to lower their risk of death.”   She felt individuals should “stop smoking, be more physically active, and eat fruits, veggies, whole grains and healthy fats…. A little coffee doesn’t appear to hurt.”  Cheryl Williams, RD, of Emory Heart and Vascular Center in Atlanta commented that “if you are not a coffee drinker, this study is not a good enough reason to start.”

The study seemed to show that with consumption of 4-5 cups of coffee per day your risk of death due to cardiovascular disease, respiratory disease, injuries and accidents, diabetes and infections decreased. Coffee consumption did not appear to protect against cancer-related deaths. The design of the study does not allow us the luxury of saying drinking coffee is the “cause” of an “effect” of lowered overall mortality, but does certainly hint at it.

What is clear is that coffee drinking does not appear to have an adverse effect on already healthy lifestyles, but will not protect an individual from the detrimental effects of smoking, poor dietary choices and inactivity.