Reference no: EM131703357

Medicare Part D Assignment - Health Care Delivery - All Sections

This assignment introduces you to the process of selecting an insurance plan using the on-line tool for comparing Medicare Part D plans sponsored by CMS. Your 65± patients are expected to navigate this web-site to determine which plan works the best for them.  The web-site requires patients to enter their prescription medication, and select dosing and network pharmacies.  In the next steps, patients receive results that compare patient cost-sharing and plan performance ratings.  Crucial information - whether the drug itself is part of the insurance formulary (drug list), requires prior authorization, or has quantity limits - can be buried in the detailed analysis.  While information about the coverage gap, including how it is calculated and when additional help is available, is covered in the Plan Finder, applying the results to a particular patient case takes practice. 

Additionally, it is important to remember that these drug costs are good-faith estimates and may not be the actual costs paid by a patient on the specified plan over the course of the 12-month insurance period. Insurance companies are allowed to reclassify a drug with 60 days' notice to its subscriber (e.g. a Tier 2 drug can be moved off-formulary), and patients have reason to ask about therapeutic equivalents.

It is well known that the costs of prescription drugs can be unaffordable for many. As you work through this exercise, you will fully appreciate the cost of prescription drugs as a portion of available income of the average Medicare beneficiary. Patients can neither comply with nor adhere to a drug regimen that they cannot afford.  As a pharmacist, you are expected to advise on drug use and therapeutic alternatives.

Pharmacists may provide limited advice on the selection of a drug insurance plan.  You must be careful to frame your advice within the permitted range. Federal law limits the information a pharmacist can provide on plans and providers; violations are subject to criminal sanctions.  Specifically, under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), "pharmacies cannot direct, urge or steer patients to a particular [Medicare Part D] plan.  They also may not compare different benefit plans unless created by CMS.  Pharmacies also may not collect or accept Medicare enrollment applications and may not accept compensation for conducting enrollment or marketing activities" .  In particular, "referring patients to the Part D plans with which the pharmacy contracts and offering patients gifts, coupons or cash for prescription transfers" is a violation of the Anti-Kickback Statute (AKS; found at 42 USC Sec 1320a-7b) . Pharmacies are allowed to "inform patients of the plans in which they participate and distribute marketing materials and enrollment applications...Pharmacies MAY DISTRIBUTE CMS-APPROVED PLAN FINDER

INFORMATION AND ANY INFORMATION FROM THE CMS WEBSITE AND THE MEDICARE WEBSITE".

In short, this research exercise will place you in the "patient's shoes", as you navigate the web-site, familiarize you with the information found there, allow you to compare costs and quality of service, and finally work with patients to achieve better compliance and adherence to drug regimens. This exercise introduces you to this important resource, demonstrates key concepts related to insurance coverage, and acts as a spring-board to effective medication therapy management, particularly drug evaluation and analysis of therapeutic equivalents.

You are completing this exercise to achieve specific learning objectives; they are as follows:

1. To understand the Medicare Part D prescription drug benefit and to learn how to use the Medicare tool called the "Prescription Drug Plan Finder".  Patients are expected to use the Finder to compare plans to select the one that provides the best coverage for the medications they will take over the coming 12 months and to enroll.

2. To learn to document all search results and organize the information to prepare for analysis.

3. To learn how to input information in the website calculator.  Particular attention is paid to correctly inputting the drug name, drug administration, and dosage form. Students are alerted to generic formulations and will evaluate the financial impact of generic interchange.  

a. In our drug list selection, we routinely include a brand or innovator drug without an interchangeable formulation, to demonstrate the high cost of brand drugs. This also highlights off-formulary prescriptions, since many insurance plans will not cover brand drugs when a generic equivalent exists, or place the brand on a much higher tier. Students are exposed to the financial impact of the brand-specific prescription, and then given an opportunity to discuss generic --and later, therapeutic -- alternatives.

4. To identify the information generated by the website and check it for accuracy. Students must answer the following questions:

a. Are all the drugs included under coverage?

i. Verify that the itemized price list matches the original drug list.

ii. Check the drug list for name, dosing, prior authorizations and formulary limitations.

b. Are all the costs included? 

i. Independently add the costs of the premiums, deductibles, co-pays and full price drugs.  Then, determine if premiums are included in the total cost.  

ii. Can you itemize and calculate costs using the Plan Finder?

iii. Can you verify the information generated? In the columns noting what the government pays and the patient pays, are there any duplications/or omissions?  In particular, there is a column that notes what the government pays and then what the patient pays.  The explanation for the number that the government pays seems to include what the patient pays, so is the column correctly labeled?  Can you subtract the amount the patient pays and get a better understanding of what the government pays?  Are we close to the 75%/25% Medicare cost-sharing formula?  Does the "Patient Pays" amount include premiums?

5. To examine the differences in coverage by comparing the deductibles, premiums and drugs (brand or generic) in their assigned plans and categories.  This is the "drill down" where you see what difference the costs in your category make. How different are the total costs between the highest and the lowest?

6. To determine which drugs are on and off the formulary. Are the drugs covered?  If not, what is the impact on the patient?

a. Calculate the costs of the non-formulary medications.

b. Validate formulary coverage independently of the Plan Finder tool.

7. To calculate prescription costs for drugs that are not maintenance medications. Specifically, how does the plan handle prescriptions for under 12 months which are to be taken for shorter durations, or intermittently? EG Solvadi, and Wellbutrin.

8. To demonstrate that the plan finder can give disparate results.  Do the exercise for 1 pharmacy, then a combination of pharmacies and see if you get the same plans and same costs in the search results Students are to document any shortcomings they find with the Plan Finder with regard to ease of use, organization of information, and general accuracy.

9. To examine the impact of the "coverage gap" on the patient's access to prescriptions and become familiar with the options for extra help.

10. To select, based on the completed research, the plan which you determine is the most appropriate within your assigned plan category and support that decision. 

11. To compare the costs of Mail Order with traditional community pharmacies as described by the plan finder. How would you counsel a patient on mail order? Evaluate the appropriateness of using mail order for the patient in terms of cost and convenience.

Process:

Once the student has completed the individual exercises, the student will join a pre-assigned group. All students in this group will have the same drug list and zip code, but will have examined the plans using different comparators - e.g. lowest annual cost, lowest deductible, formulary coverage, best overall rating, and finally, plan name. Because the website is regularly updated, students must print out their search information, to allow validation and accurate comparisons.  This is a snapshot in time of benefits in a particular area.

The group activities are as follows:

1. The group meets and each student presents the results of the student's research and conclusions to the group. 

2. Using all the members' information, the group will evaluate all information and vote one plan as the "best," listing the reasons for the decision.  The group will document the vote and the support in its final report.

3. Students will analyze the business decisions made in creating Medicare Part D, such as including the total patient costs of the plan, and the total cost of the plan, combining patient, insurance, and government payments.  Evaluate what drugs and therapies are excluded or minimally covered and determine if the plan allows for sufficient therapeutic equivalents, newly approved and expensive therapeutics.  Can you determine if any of these drugs are in shortage or recalled due to manufacturing issues?  Are there a substantial number of PAs that you can attribute strictly to cost concerns rather than safety?

4. Of the five different methodologies for selecting a plan using Med D, which does the group think is the most effective - star rating?  Lowest overall cost? Etc.  How is this information used in patient counseling?

THE ASSIGNMENT: Key Points and Basic Rules:

There will be an instructional live demonstration one time in all classes in all sections. Before that demonstration, you should: 1. Read this entire Assignment and 2. Know your individual assignment.  To find your assignment, go to the Grade Columns in Blackboard. Next to your name, you will see a number and a letter.  Write down your group number and your letter and go to the document titled, Medicare Part D Key Code. The Key Code has your actual assignment. The number is your Group number, and shows the zip code for your group. The letter is your individual assignment, which is the criterion by which you will be sorting your results.  The list of drugs you will use in completing this assignment is also on the sheet. You should find your Group and Plan assignment from the Key Code, and have read these instructions before you come to the in-class demonstration.

INDIVIDUAL PORTION: These are the individual questions you must answer for your project:

1. Identify the plans in your Letter assignment and document that you found the correct plan. To satisfy this requirement, you must include: 1) a screen shot of the drug list you saved; and 2) a screen shot of the webpage where you have identified all of the plans in your category, and 3) a screen shot that shows that you have selected the first and the last ranked in your category (that you have expanded the number of available plans beyond 10).

2. What are the full year costs for each of your plans FOR ALL OF THE PRESCRIBED DRUGS?  List any/all premiums, deductibles and co-pays, plus loss of coverage, costs of drugs not covered, and any costs in the coverage gap. You print out the information from the web-site and then, verify that the calculations on the webpage reflect all the costs the patient will pay.  In your answer, document where you get these numbers from your print-outs.  Use footnotes and mark the chart.

Each of the months expands, so you can see the actual drug costs.

Examine the charts that you get from the Medicare Part D Finder - and make sure you are looking at the full year costs, not partial costs. The difference is significant, because it changes when the patient enters the coverage gap and when the patient/if the patient qualifies for catastrophic coverage. 

There is one chart we have found that calculates full annual costs, and that is the chart that shows how much the plan pays and how much the government pays. 

To answer these questions, you will have to adjust the plan comparators, but you MUST use your original plans.

3. Which of your plans has the lowest annual cost? (or lowest costs for the remainder of the year).

4. Which of your plans has the lowest drug deductible?

5. Which of your plans has the lowest monthly premium?

6. Which of your plans has the best overall plan rating?

7. Do any of your plans offer coverage during the "coverage gap" or "donut hole?"

8. Are all of your drugs covered in the formulary?  List the ones that are NOT covered.

9. How much money in each plan is paid by the government?  List the answer for each plan in the chart.  Now, total the amount of money, for each plan, paid by the patient, paid by the plan and paid by the government.  Compare the totals across plans.

10. Compare the price differences between all the retail and mail order pharmacies available as preferred providers under your plan; support this information. This information is contained within the month-by-month costs chart.

11. Identify when your patient goes into the donut hole.

12. Can you determine what a monthly prescription fill costs the patient using this chart? 

13. Do any of your plans have "Drug Restrictions"?  Discuss what these are and how these impact costs.

14. Compare the monthly drug costs in the coverage gap/donut hole.

15. Compare the monthly drug costs in the catastrophic coverage stage.

16. How many drug tiers does each of your plans have?  What is the purpose of drug tiers?

17. What plan of these  do you recommend, and why?

Finally, you are asked to select the overall best rated Medicare Health Plan in your zipcode.

18. Document the plan selected by the Finder tool.

19. Compare the drug costs of your lowest cost PDP plan with the costs of the Medicare Health Plan.  Print out the results for the Medicare Health Plan.

20. Which type of plan do you recommend - the best PDP or the Medicare Health Plan with drug coverage and why?

Additional Activities:

21. Perform the Plan Finder search with two pharmacies selected. Pick the same as before and pick another, lesser known community pharmacy. Run the plan finder for each pharmacy separately. Are the first and last plans in the results the same as your original search?

22. What input do you have on Ronald's ability to pay for these medications? What do you suggest he do? What can we do?

23. For the Plan you selected as the best, please do a quick search to determine if the formulary coverage can be independently validated? Are there any resources to find this information apart from the Plan Finder?

24. Discuss the utility of the Plan Finder and its accessibility to the average patient.

a. Answer the question, "how readily available is this information for patients before they enroll in plans?"

These are the questions your group must answer for your project when you bring all of your material to class:

1. Review all member's individual work and determine if everyone has interpreted the questions/data in the same way. Record any differences which you cannot resolve.

2. Compare the annual cost of one plan from each individual which that person determined to be the best, and document the range of prices. 

3. Determine the "best" plan for Ronald from all plans, and support that decision.

4. Identify any areas where money can be saved.

5. What is your group's opinion of the Medicare Plan Finder? Refer to your notes above. Is there anything you'd like to add to that?

Assignment Files -

https://www.dropbox.com/s/2tj083tov8pdzn1/Assignment%20Files%20-%20Medicare%20Part%20D.rar?dl=0