Government News
Part D Hassles Driving Treatment Decisions
Psychiatric News
Volume 42 Number 24 page 9-9

Prior-authorization requirements and preferred drug formularies under the Medicare Part D prescription drug program are associated with significant increases in administrative burden for psychiatrists and their staffs.

To psychiatrists treating enrollees who are "dual eligibles"—that is, people eligible for both Medicare and Medicaid—that likely comes as no surprise. But a report to appear in next month's Psychiatric Services provides statistical evidence confirming anecdotal impressions: drug-plan features and medication-access problems related to Part D implementation are associated with increases in administrative burden that may result in less time for direct patient care.

Moreover, it also appears that the significant administrative hurdles encountered in some plans are causing clinicians to alter treatment plans and switch medications, according to a nationwide survey of psychiatrists.

"Nearly 20 percent of psychiatrists say, 'Forget it. I'm going to switch or discontinue clinically indicated medications rather than go through appeals or exceptions processes,'" said study author Josh Wilk, Ph.D." They can't spend the time going through the hassle of trying to get the medication they want to prescribe.

"CMS has allowed drug plans to use a broad range of management strategies," Wilk told Psychiatric News. "The agency needs to examine how several of these strategies are being implemented and their possible effects on patient care. These plan policies have a real effect on administrative burden and patient care." (see Part D Helpful Hints for New Plan Year.)

At the time of the study, Wilk was a researcher with the American Psychiatric Institute for Research and Education (APIRE) and is now supervisory clinical psychologist in the Division of Psychiatry and Neuroscience at Walter Reed Army Institute of Research.

In the study, 5,833 psychiatrists were randomly selected from the AMA's Physicians Masterfile and sent a mailed survey in the first four months of Medicare Part D implementation (January to April 2006) using practice-based survey research methods. Responses were obtained from 3,247, or 64 percent, and 1,183 psychiatrists met eligibility requirements for the study.

The researchers found that psychiatrists and their staffs spent on average 45 minutes in administrative tasks for every one hour of direct patient care for dually eligible patients.

Some plan features proved to be especially time consuming for psychiatrists and their staffs. For instance, patients in plans that require step therapy—in which they must be shown to fail on particular medications before they can access another—required on average 71.4 minutes of administrative time per hour of direct patient care, compared with 37 minutes for patients in plans that did not have that feature.

Patients in plans that had mandated dosing limits required on average 60.9 minutes of administrative time per hour of direct patient care, compared with 36 minutes for patients in plans that did not have dosing limits. Patients in plans requiring prior authorization required on average 57 minutes of administrative time per hour of direct patient care, compared with 32 minutes for patients in plans without that feature.

The researchers also found that patients in plans with preferred drug lists required 53 minutes of administrative time per hour of direct patient care, compared with 31 minutes for those in plans without lists.

Patients who had problems filling prescriptions, for whom appeals had to be filed, or who had experienced copayment problems required significantly greater administrative time compared with patients who did not, according to the study.

Perhaps most alarmingly, 19 percent of psychiatrists surveyed reported changing or discontinuing clinically indicated medications rather than pursuing appeals or exceptions processes for their patients.

"Not surprising at all," is how Irvin (Sam) Muszynski, J.D., director of APA's Office of Healthcare Systems and Financing (OHSF), characterized the study findings. OHSF voiced numerous concerns about the Part D program during its development and has been monitoring problems with it since it went into effect.

"Where there is a problem with a drug plan, there is almost always a significant time component involved in addressing the problem," he told Psychiatric News. "Clearly, one way clinicians end up avoiding these problems is by avoiding prescribing the drugs that are needed. The plans are creating incentives for clinicians to avoid using drugs their patients need.

"What it shows broadly is that these prior-authorization requirements for drugs add significantly to the cost of medical practice," he said." The time spent doing this is uncompensated, and the amount of time is significant."

Muszynski added that switching patients to another medication can require substantial time in counseling patients and families.

He noted that complaints from clinicians have dropped off since the early days of the Part D program—when the transition from Medicaid drug coverage caused widespread problems for dual eligibles—but added that when OHSF staff make specific inquiries of clinicians, many of the same problems revealed by the APIRE study turn up. He urged clinicians to contact OHSF about problems associated with the prescription drug program.

"The study provides important data that we are using to work with CMS to determine which prior-authorization strategies are really necessary and which aren't," Muszynski said.

"Medicare Part D Prescription Drug Benefits and Administrative Burden in the Care of Dually Eligible Psychiatric Patients" is posted at<http://psychservices.psychiatryonline.org/> under the January issue.

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