Transcript The Medicare D Utilization Management Spreadsheet Project

The Medicare D Utilization
Management Spreadsheet
Project
Benjamin Crocker, MD
[email protected]
Stevan Gressitt, MD
Edward Pontius, MD
Medicare D in Beta Version: 2006
• Many details still to be worked out
regarding what UM edits mean, criteria for
exceptions and appeals, etc.
• Unclear how much actual UM has
happened compared to published edits
• Business issues of PDP’s compared to,
and as stalking horses for MAP’s in an
environment of changing subsidies.
Supporting Beneficiary Choice
• For Dual Eligible and full-subsidy
beneficiaries, pricing and tier placement
do not matter
• Utilization management is the only plan
differentiator regarding medications in the
protected classes
• Formulary inclusion of non-protected class
medications (such as addiction
medications) may be important
CMS Tells Physicians not to advise
patients re plan selection
• Conflict of interest cited, physicians
encouraged to punt this to pharmacists
and other agencies.
• Pretense is made that consumers will get
information from internet sources
• Most physicians confused by Medicare D
• Formulary Finder little used by anyone
after early weeks
Physicians encouraged to use
commercial databases
• Epocrates, then Skyscape, offer desktop and
PDA formulary info for Medicare D
• This is convenient for early tech adaptors
• Some divergence between commercial
formulary redistributors and plan formularies, but
much less that divergence of CMS Formulary
Finder and plan formularies.
• Republishing of Epocrates or Skyscape
information by subscribers is forbidden.
• Patient access to these databases unlikely
So how can physicians help
patients understand their choices?
• Showing patients comparative UM edits
across plans protected by first amendment
• Graphic display of data, with color,
increases patient comprehension of
differences
• Politicians and doctoral level clinicians pay
attention to “pretty colors” as well
As Maine Goes, so goes the Nation
• The Government and Legislative Affairs
Committee of the Maine APA District Branch
took action to inform Maine clinicians and
patients about Medicare D UM in late December
2005.
• Spreadsheets for 7 Major classes of medication
(only 1 psychiatric) were posted at
www.mainepsych.org, and updated periodically.
Not much interest indicated from nonpsychiatric
clininicians.
March, 2006
• PA and QL vanish from Medicare Formula finder
for over 10 day, leaving STEP only UM edit.
• Almost nobody notices.
• CMS says it was a computer glitch, leaves the
inaccurate information up without comment until
it is eventually corrected.
• This was during a period that many special help
beneficiaries had a choice of plans, and the
deadline for non-subsidized beneficiaries was
starting to loom
July 2006
• PA’s that have been in place for all commonly used
atypical antipsychotics on Formulary Finder for Wellcare
Signature for most of they year vanish at the beginning
of July for about a month.
• Before and after this, Wellcare’s whole formulary
vanishes for several days from the formulary finder.
• CMS June 29 statement suggests that this is a form of
plan discipline.
• Wellcare denies that the PA’s have been removed, and
its website formulary continues to post the PA’s.
Eventually they re-appear on the Medicare Formulary
Finder. Of all national plans, this is the only one to put a
blanket PA on all atypicals except clozapine.
Advocacy Organizations Notice
Formulary Finder Problems
• APA letter from Dr. Scully to CMS regarding
Medicare D Manual dated September 26, 2006,
and Medicare Rights Center report of
September 2006 note inaccurate data posted
regarding UM on Medicare site.
• MAPP spreadsheet project abandons updates of
spreadsheets in midyear as intractable
confusion regarding UM data on CMS Formula
Finder makes it impossible to cite this source as
reliable information.
What next for the Spreadsheet
Project?
• Constructing and updating spreadsheets
will require mining data directly from plan
formularies.
• 2006 formularies vary in organization,
completeness and printability. ?2007?
• Because of increased work of data mining,
fewer medications can be tracked unless
volunteers or funding can be found
National Spreadsheets
• A few plans now dominate the Medicare D broad
market.
• National plans generally use the same formulary
and UM in various regions.
• Formulary UM data could be centralized for
national plans, leaving only a few regional plans
to be mined locally.
• Many hands make light work.
• AACP, Women Psychiatrists and AAPA post
spreadsheets for each PDP region on their
websites, May 2006