JAMA Study: Give Doctors Info on Most Widely Covered Medicare Drugs

Adams Dudley

While millions of elderly Americans are skipping medications because they can't afford them, a new study in the Journal of the American Medical Association offers a solution: Tell doctors upfront which drugs are most widely covered by Medicare so that patients can get their medications faster and more cheaply. R. Adams Dudley, MD, MBA, of UCSF, is senior author of the study, which offers a unique analysis of drug coverage under Medicare Part D formularies, lists of drugs that are paid for or covered under a drug plan. Because formularies vary so widely among Medicare Part D plans and because many states have 50 or more such plans, it is difficult for clinicians to know which drugs are covered for their patients. As a result, significant numbers of elderly patients find out from their pharmacists that the drug they've been prescribed is not covered or has a very high co-payment, making them unaffordable, even though similar but less expensive medications could have been prescribed. Dudley is UCSF associate professor of medicine and health policy associate director for research. His co-author is Chien-Wen Tseng, MD, a Robert Wood Johnson Foundation generalist physician faculty scholar at the University of Hawaii and a physician investigator at the Pacific Health Research Institute. For the study, they evaluated more than 100 Medicare Part D formularies in California and Hawaii. They took into account co-payments and requirements for prior authorization and targeted coverage for 75 drugs in eight treatment classes, including those for treating high blood pressure and cholesterol. The key insight was that doctors think of drugs in classes of similar medications, which can be substituted for each other to help reduce patients' costs, but only if the doctors know which drugs are covered, according to Dudley. In the study, coverage of individual drugs varied among plans, but nearly all plans covered at least one drug in seven of the eight treatment classes. Generic drugs were most widely covered, but not all generics were well covered and some brand-name drugs were very well covered. Dudley noted, "Despite all the controversy and confusion about which drugs are covered in the new Medicare plans, it turns out that this is more an information problem than a coverage problem. We found that there is almost always a way that doctors can help their patients afford their medicines, but only if they have the information about what is covered. This is a good thing, because information problems are much easier to fix than coverage problems." In the current system, where coverage information is not easily available, variation among plans in coverage of individual drugs contributes to widespread confusion about Medicare Part D among physicians, pharmacists and patients alike. Nearly 1,900 plans offer a drug benefit, and although some cover as much as 95 percent of commonly used prescription drugs, others cover less than 65 percent. "As a practicing doctor, I see this regularly," said Dudley. "After I write out a prescription for a patient, the patient or the pharmacy will call me back, asking for a prescription that is covered. If doctors had this information in advance, we could talk with our patients about their medication choices and determine which option makes the best sense for them before writing a prescription."
Identifying Widely Covered Drugs and Drug Coverage Variation Among Medicare Part D Formularies Chien-Wen Tseng, MD, MPH; Carol M. Mangione, MD, MSPH; Robert H. Brook, MD, ScD; Emmett Keeler, PhD; R. Adams Dudley, MD, MBA JAMA 2007;297:2596-2602 Full Text | Full Text (PDF)
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