Covering prescriptions: Look for a smooth path
Last month, I outlined my philosophy for treating not just dry eye disease, or DED, but pretty much everything there is to be treated in eye care.
This philosophy, known here and elsewhere as the minimal effective dose, expounds on the value of using just enough, and not one teeny tiny bit more, to achieve a particular outcome or goal. I hopped in the “wayback machine” to my days as a CrossFit trainer* and developer to offer a non-DED analogy: You want the fewest gym visits lasting the shortest amount of time moving the lowest amount of weight as infrequently and slowly as possible without injuring yourself in the process.
And you want to pay the least amount of money for your gym access.
If you are a patient, your health insurance premium can be thought of as your gym membership. However, we all know that health insurance does not cover the entirety of the cost to “use the gym.” Patients face the financial challenges of co-pays, co-insurance and deductibles — minimum outlays that must be made before meaningful payments are forthcoming from insurance — kind of like paying for classes on top of your monthly dues. Unlike doctors and their staff members, your CrossFit trainer is not helping you find someone to pay for your deadlifts and burpees.
We really should be doing just that. Yes, there are doctors who fervently believe that the entire ecosystem that has grown around begging an insurance company to pay for a medicine that “should be covered” is wrong on its face. I admit to a deep philosophical agreement with this line of thought. It is not possible to estimate how many doctors have this opinion and escalate to a policy in which they decline to participate in the prior authorization process, but the fervor with which they make these declarations online sure makes it feel like there are a lot of them.
Much more quietly and insidiously, large medical organizations known as accountable care organizations (ACOs) typically have in place policies and protocols that effectively do the same thing. Stuff like prohibiting sample use, barring drug rep visits or declining to use specialty pharmacies designed to provide coverage for expensive medications. The insidious part is the failure to provide clerical assistance to doctors who wish to prescribe branded medications that almost always result in the need to participate in a prior authorization; I have yet to meet the doctor, already under the time gun due to onerous electronic medical record and regulatory burdens, who could possibly invest even 15 minutes of production time on the phone with a willfully obtuse insurance functionary.
And yet, both of these situations, the doc who “stands on principle” and the obstructive ACO, eventually result in harm to your patient. Both of them are inherently wrong. Both of them keep us from our duty to care for the patient before us. One may eventually fail at the effort to help a patient obtain payment for an insurance-covered treatment; that happens all too often. Still, not to try, via deeply felt abhorrence for the process or system-wide efforts to avoid the process, to order a treatment and send your patient off with a hearty “you’re on your own” seems, well, wrong.
How should we go about the business of getting our prescriptions into the hands of our patients? Let me step down from my soapbox and offer some suggestions. First, it is important to understand the basics of prescription “coverage” in the United States. Once upon a time this was a simple proposition: Your insurance company negotiated a discounted price from the manufacturer and paid part of that negotiated wholesale price, and you paid the pharmacy for the rest. Kinda like buying last year’s Tommy Bahama shirt at Marshalls.
That turned out to be altogether too logical, rational and straightforward. Enter pharmacy benefit managers, voracious profit-generators for their owners. How? In simplest terms, by requiring manufacturers to give them a “rebate” on their price for a spot on the formulary. This, as much as anything else, has driven up the list prices of branded medications in the U.S.: A 60% rebate on a $100 medication is $60, while that same 60% on $1,000 is $600. Your poor patient pays the same 20% co-pay on the full, not the discounted, price — in this case $20 and $200, respectively.
Math is brutal.
To make matters worse, just when we all get the hang of a system, no matter how honorable or onerous it may be, they go ahead and change the rules on us. We can still use coupons or CoverMyMeds types of programs for patients who have commercial insurance. The manufacturers elect to accept a smaller payment for their product by literally “buying down” the cost of a drug. If all coverage is denied, even after a prior authorization, some companies offer a cash pay option through a specialty pharmacy (note that this amount will not count toward deductibles). Pharma reps provide a huge service to you and your patients by providing coupons, access to cash pay and education on how to use them. This is why you should welcome reps into your office (and one more stain on the souls of ACO administrations that don’t).
Medicare continues to be the bane of our existence in the DED world, though, even when the new rules look like a pretty good deal. Why? Because CMS expects us to explain them. As if it isn’t a big enough time sink to explain the January deductible reset to every Medicare patient. Take the new $2,000 annual cap on medication expenses included in the Inflation Reduction Act last year. Sounds great, right? Unless your patient’s monthly immunomodulator expense went from $100 to $500. Do they have to pay that $500 on top of whatever their other medications cost? Take out a loan for $2,000 or put it on a card and get it all out of the way in January?
That would be too easy to explain. Nope, they can do what is called “smoothing,” paying a fraction of each prescription cost where the denominator is the number of remaining months in the year (eg, 1/11 for a script purchased in February). The health insurance company is supposed to keep track of all this and alert every pharmacy involved that the cost becomes $0 once they have spent $2,000. Yup, your patient must trust the same people who denied the prior authorization to do the math.
Try ’splaining that.
It took me 30 minutes to explain this to my sophisticated staff. Imagine doing this with all of your 65+ DED patients. It is impossible. Do yourself and your staff a favor: Go to https://www.medicare.gov/search/medicare?keys=smoothing+of+payments+for+medicare+part+d&searchPage=en. Print out the link and a few of the highlights, and hand the whole shebang to your Medicare patients with instructions to call their Part D insurance company and apply for “smoothing.”
Even I have a limit as to how far I can be forced to go when I am helping my patients get their DED medications covered.
*Take a walk over to drdarrellwhite.com and search for “minimal effective dose.”
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
Collapse
Read more about