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
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
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
"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
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. ▪