New Year, New Medicare Plan

For physicians and pharmacists, the day after the New Year’s holiday is often the busiest. This year they are bracing for even longer lines as baffled patients try to use Medicare’s new drug benefit.

Much has been made about confusion among seniors over choices presented by Medicare Part D, which adds prescription discounts to the federal health insurance plan for the elderly. Doctors and pharmacists will find out just how confused they are when patients -- some of whom may not know they were automatically signed up for the program -- start arriving next week.

This comes on top of a surge of business that traditionally follows the New Year’s holiday as patients seek help with colds and the flu and new employer-sponsored health plans take effect.

John Cronin, senior vice president of the California Pharmacists Assn., described it as a “sort of a triple witching hour for pharmacists.”

“There’s going to be an awful lot of confusion,” said Cronin, a pharmacist who owns two drugstores in San Diego County. “Is it going to be mass confusion that’s overwhelming or is it going to be a trickle? We really don’t know.”

The drug benefit is meant to lighten the load of high drug prices for elderly patients. But because it is not a one-size-fits-all program, pharmacies and physicians will have to figure out which of the hundreds of plans their patients are on -- and untangle myriad different premiums, co-payments, approved drug lists and coverage areas.

Some pharmacists and physicians have spent weeks trying to help patients get ahead of the problem.

At Rancho Santa Fe Pharmacy, Jason Kim has spent much of his time since Thanksgiving helping customers figure out which drug plan is right for them. For a fee, the pharmacist considers what drugs they are using, what they might take in the future and what plans would best meet their needs.

“Pharmacists are taking this seriously,” said Bob Graul, a pharmacist and owner of the store, who expects the demand for that service to continue.

“I expect we’re going to have an outcry even though everybody’s done a lot to prepare for it,” said Jack Lewin, chief executive of the California Medical Assn.

Seniors have until May 15 to enroll in one of several Medicare-approved drug plans without penalty. If they sign up after that, they face higher premiums.

Almost half of the 43 million people on Medicare already have been enrolled. The vast majority of them were signed up automatically by virtue of participation in a Medicare Advantage managed health plan that already includes drug benefits, in a retiree benefit program with drug coverage, or in Medicaid insurance programs for the poor.

Jeff Flick, the regional administrator for the federal agency that runs Medicare, said it was doing everything possible to help pharmacists, physicians and patients make the most of what he called a worthwhile benefit.

“An awful lot of people are going to have access to prescription drugs this year [who] didn’t have it before,” Flick said. “Obviously [pharmacists] like it when customers are in their stores. They know it’s coming. They are ready for it. They’ve planned.”

Flick acknowledged, however, that the transition could be bumpier for doctors.

“We’re doing a lot of things to help the physician,” he said. “But that will be, in some ways, a slightly more interesting challenge.”

Indeed, several physicians said they were concerned because they had not received formularies -- lists of covered drugs -- for the new plans.

Although the lists are generally available on the Internet, physicians say they don’t have time to run to a computer every time they write a prescription to make sure the drug they have in mind is covered by the patient’s plan.

Flick said the agency spent months educating pharmacies and physicians on what to expect. The agency’s website is so user-friendly, he said, that it should take a physician no more than a few minutes to check whether a drug is covered on a patient’s plan and, if not, to look up a suitable alternative.

In addition, the agency made the formulary data available to Epocrates Inc., a San Mateo, Calif.-based medical information service for physicians that soon will provide the drug lists free for downloading to computers and hand-held personal digital devices. The California Medical Assn., in collaboration with the California Healthcare Foundation, is working to make free or low-cost PDAs available to physicians in the state.

Insurers also are trying to distribute formularies. PacifiCare Health Systems, for instance, mailed drug lists to affected members. It also gave the complete formulary to physician groups and will mail physicians pocket cards listing the drugs they cover in the most commonly prescribed therapeutic classes.

Nevertheless, UC Davis medical professor Richard Kravitz and Sophia Chang of the California HealthCare Foundation, writing in the current issue of the New England Journal of Medicine, questioned whether physicians were ready for the challenge because surveys showed most of them had little interest in helping patients deal with drug costs and navigate formularies that could change as often as once a month.

Some physician groups are encouraging their Medicare patients, particularly new ones, to visit their doctor as soon as possible to go over their new drug plans and make sure they have the right prescriptions. That’s the message Monarch Healthcare, an independent practice association in Orange County, is sending to an estimated 8,000 new Medicare members it is set to pick up next week.

“This is a big deal to us,” said Monarch Chief Executive Bart Asner. “It’s going to be a very busy January for our physicians.”

The transition will be more difficult for some patients than others. Seniors who were in Medicare Advantage managed-care plans that already offered drug coverage should find the transition almost seamless. For those who had traditional Medicare coverage and are adding a stand-alone drug plan or joining an Advantage plan for the first time, the transition will be a bit more challenging.

The most complex cases doctors and pharmacists probably will see are the so-called dual eligibles -- low-income seniors and disabled people enrolled in both Medicare and Medicaid programs. Those who haven’t enrolled on their own will find that Medicare automatically signed them up.

“The question is, will they realize they have been enrolled and are being covered under a different plan now?” said Michael Polzin, a spokesman for Walgreen Co., which has conducted special employee training to help people in this group.

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Times staff writer Ricardo Alonso-Zaldivar in Washington contributed to this report.