Medicare Part D prescription drug coverage could spark confusion

As the country rings in the New Year, dramatic changes will be taking place regarding Medicare and state drug programs administered through Medicaid. Medicare Part D, the program’s new prescription drug benefit, will take effect Jan. 1, 2006, requiring thousands of Texas Medicare beneficiaries to choose from a selection of private drug plans. As this transition approaches, physicians will be called on to field questions from concerned patients.

Medicare Part D initiation won’t just affect Medicare beneficiaries. Major changes are also in store for some of the country’s most vulnerable populations — the poor and disabled.

People who are eligible for both Medicare and Medicaid, sometimes called “dual eligibles,” will no longer receive pharmaceutical benefits through the Medicaid program after Jan. 1. They will receive drug coverage under Medicare Part D, which means they will either enroll in their choice of drug plans or they will be randomly assigned to plans. The Texas Health and Human Services Commission is particularly concerned with this population since the commission currently administers the Medicaid Vendor Drug program.

What follows is a message that HHSC has provided the Academy:

What Medicare Part D means for Medicare beneficiaries

On Jan. 1, 2006, Medicare’s new Part D plan will roll out. It is considered to be one of the single largest changes to Medicare since its creation in 1965. Part D provides optional prescription drug coverage to all Medicare beneficiaries. This coverage will be provided through private drug plans that contract with Medicare. The client’s drug coverage will be limited to the drugs listed on the private plan’s formulary. In September 2005, the Centers for Medicare and Medicaid will award bids to Prescription Drug Plans. The premium for Medicare Part D for Medicare beneficiaries will vary from plan to plan, based on the arrangements each plan makes with Medicare. The expected average premium for 2006 is estimated at $35 a month.

What it means for beneficiaries of both Medicare and Medicaid

Medicare Part D coverage changes prescription coverage for individuals who are dual eligibles (those receiving both Medicare and Medicaid). Currently dual eligibles in Texas receive their drug coverage through the state’s Medicaid Vendor Drug program. That Medicaid drug coverage will end as of Dec. 31, 2005, and change to Medicare Part D prescription coverage, beginning Jan. 1, 2006. Dual eligible clients will be assigned to a Medicare prescription drug plan in October of this year for coverage that begins Jan. 1, 2006. If dual eligible clients do not like the plan that the CMS assigned to them, they can change plans. Some dual eligible clients will be expected to pay co-pays ranging from $1 to $5 (this does not apply to institutionalized individuals). Covered drugs will be limited to each plan’s formulary. Dual eligible clients and other low-income Medicare beneficiaries will be eligible for assistance with Part D premiums and cost sharing, through Part D’s low-income subsidy. Dual eligibles will automatically get the low-income subsidy. They will not have to apply for it.

Important Dates

• September 2005 — CMS awards bids to Prescription Drug Plans participating in Medicare Part D.
• October 2005 — CMS auto-assigns dual eligible clients to a Part D plan. If they do nothing, their drug coverage will be with the plan auto-assigned to them by CMS. Dual eligible clients can change plans if they don’t like the plan they were assigned.
• Dec. 31, 2005 — Medicaid prescription drug coverage, the Vendor Drug program, for dual eligible clients ends in Texas.
• Jan. 1, 2006 — Medicare Part D coverage begins.

This summer watch for more information and communications materials from TAFP, the Texas Medical Association, Health and Human Services Commission, Medicare and other sources. Use these materials to inform your patients. Identify the new Medicare Part D plans — stand alone drug plans and Medicare HMOs. Review their formularies and contact information for patient coverage problems.

Liability carrier introduces scholarship for med students

The Texas Medical Liability Trust is currently accepting applications for the TMLT Memorial Scholarship, according to a company press release. TMLT will award eight $5,000 scholarships to one student at each Texas medical school beginning in September 2005.

Scholarship recipients will be chosen based on a point system that weighs each student’s academic achievement, financial need and written essay.

“By creating these scholarships, we hope to assist medical students in financing their education and to create awareness among these students — these future physicians — about the issues surrounding patient safety and medical liability,” says Tom Cotten, president and CEO of TMLT.

The scholarships recognize academically gifted Texas medical students who express interest in finding creative ways to enhance patient safety.

“Students have a unique perspective and we want to hear their ideas. We want them to think about what they could do in their own careers to help reduce medical liability risks,” Cotten says.

All application materials are available on the TMLT Web site, www.tmlt.org. The application deadline is June 1, 2005.

To apply for the scholarship, students must submit the following:

• an application (available at www.tmlt.org);
• a medical school transcript;
• a brief statement of personal financial need; and
• a 1,000-word essay answering the question: “What can individual physicians do to ensure patient safety and minimize the risk of medical malpractice suits?”

Death rates lower in areas with more primary care physicians, but not specialists, Health Affairs article says

Inappropriate tests and procedures, inadequate volume cited as possible reasons why higher specialist ratio does not lower death rates

According to a Health Affairs press release, counties with a greater number of primary care physicians have a lower mortality rate, but having a greater number of specialists does not appear to lower the mortality rate, according to an article published on the journal’s Web site.

Federal data on physician supply in more than 3,000 U.S. counties indicate that a higher ratio of primary care physicians to population results in lower mortality rates overall as well as for heart disease and cancer, according to the analysis by Barbara Starfield, M.D., M.P.H., a professor at the Johns Hopkins Bloomberg School of Public Health, and three colleagues. A higher ratio of specialists to population did not improve mortality rates, she says.

Starfield’s findings of the analysis could help guide lawmakers developing health care workforce policy.

“In view of the strong evidence that having more specialists, or higher specialist-to-population ratios, confers no advantage in meeting population health needs and may have ill effects when specialist care is unnecessary, increasing the specialist supply is not justifiable,” she says.

The analysis affirms an existing body of work that has documented no improvement in population health when the ratio of specialists is increased.

Starfield suggests several possible explanations for her findings:

• Patients may be receiving care from specialists outside their area of expertise, putting them at higher risk for mortality from community-acquired pneumonia, heart attacks, congestive heart failure and upper gastrointestinal hemorrhage.
• Because higher volume is associated with better outcomes in surgery and other specialty procedures, a higher specialist-to-population ratio may mean that specialists are seeing fewer patients and thus are less proficient.
• Because specialists have a higher likelihood of suspecting serious disease as a result of their training, a higher specialist-to-population ratio may mean more unnecessary diagnostic workups, which puts patients at risk of medical errors.

Starfield’s co-authors are Leiyu Shi, an associate professor at the Hopkins School of Public Health; Atul Grover, an instructor there; and James Macinko, an assistant professor of public health at New York University.

The research was supported in part by a grant from the federal Bureau of Primary Health Care. To access the article, go to http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97 or go to www.healthaffairs.org and perform an author search for “Barbara Starfield.”

FPs crucial to closing black-white mortality gap

If the black-white mortality gap were eliminated, an estimated 83,570 deaths among blacks could be prevented each year. “Family medicine is the right discipline to deal with this kind of [mortality gap] problem,” said FP David Satcher, M.D., Ph.D., former surgeon general and principal investigator for a new study on disparities in care.

“Obviously, there are situations in which people need subspecialists, but only the family physician takes the kind of responsibility for his or her patients and their families that’s going to be needed in dealing with this problem,” Satcher said. “Primary care providers in general, but especially family physicians, have a critical role to play.”

He shared this assessment after the March 9, 2005 release of the report, “What If We Were Equal? A Comparison of The Black-White Mortality Gap in 1960 and 2000,” published in the March/April Health Affairs.

“We’ve made tremendous progress in the health of all people in this country” from 1960 to 2000, said Satcher. “However, the progress has not been equal.”

He zeroed in on the dramatic decline in mortality rates for children younger than 1 year old. (See chart.) The rates for blacks and whites plummeted between 1960 and 2000, but the gap between black and white rates actually grew.

“Do you get the picture here?” asked Satcher, director of the National Center for Primary Care at Morehouse School of Medicine, Atlanta. “There’s been progress for both blacks and whites, but for blacks relative to whites, the gap has not narrowed.”

The study, reported on by Reuters and Associated Press, included among its co-authors staff members of AAFP’s Robert Graham Center in Washington. To read the study abstract, go to http://content.healthaffairs.org/cgi/content/abstract/24/2/459.

Some study highlights:

• The gap in mortality rates worsened for black men 45 and older between the years 1960 and 2000, but there was less disparity among black males overall between 1990 and 2000.
• The gap narrowed from 1960 to 2000 for black females ages 1 to 74.
• “The United States has made progress in decreasing the black-white gap in civil rights, housing, education and income since 1960, but health inequities persist,” the authors said.

Among black men, Satcher explained, “homicide increased dramatically between 1983 and 1995, and the AIDS epidemic took off and started causing death.” As the 1990s progressed, homicides decreased and antiretroviral agents were developed, he said, leading to fewer black male deaths between 1990 and 2000.

“African-American women have improved educationally and earn 89 cents for every dollar earned by white women, and they’ve also made progress in terms of their health,” he noted. “On the other hand, African-American men earn only 78 cents for every dollar earned by white men, and that same kind of gap is reflected in the mortality rates.”

The article notes corrective actions needed: “universal health insurance coverage, a primary care medical home for each American, proportionate representation of African-Americans in the health professions, and the elimination of bias in the delivery of diagnostic and therapeutic interventions.” The article also calls for improvements related to the health of communities: “from nonviolent and exercise-friendly neighborhoods to more nutritious food outlets, educational equality, career opportunities, parity in income and wealth, home ownership, and ultimately hope.”

Satcher advised, “We’ve got to get more involved with changing the environment. We can do that by providing comprehensive care and getting social service involved. We’ve got to help patients improve their lifestyles, especially since obesity now threatens to undo a lot of the progress that we’ve made. Family physicians are especially important because we are the ones who get involved with all aspects of the patient’s and the family’s life. It’s going to take that to narrow the gap.”

Source: News from the AAFP, March 2005, © American Academy of Family Physicians

AHRQ: Preventing diabetes complications could save $2.5 billion annually

HHS’ Agency for Healthcare Research and Quality reported in a February press release the completion of a research synthesis estimating that the nation could save nearly $2.5 billion a year by preventing hospitalizations due to severe diabetes complications.

Diabetes, an increasingly common chronic disease, currently affects 18 million Americans, or about 6 percent of the population. Complications from the disease that may require hospitalization include heart disease, stroke, kidney failure, blindness, as well as nerve and blood circulation problems that can lead to lower limb amputations.

Complications can often be prevented or delayed with good primary care and compliance with the advice from providers:

• Reducing hospital admissions for diabetes complications could save the Medicare program $1.3 billion annually and Medicaid $386 million a year.
• Nearly one-third of patients with diabetes were hospitalized two or more times in 2001 for diabetes or related conditions, and their costs averaged three times higher than those for patients with single hospital stays — $23,100 versus $8,500.
• The risk of hospitalization for cardiovascular disease was two to four times higher in women with diabetes than in those who did not have diabetes.
• African-American, other minority and poor patients regardless of race or ethnicity were more likely to be hospitalized multiple times for diabetes complications than non-Hispanic white and higher income patients.

“These findings highlight the importance of carefully monitoring people with diabetes who have a prior admission for the disease to prevent repeat hospitalizations, improving the care of diabetic patients who also suffer from cardiovascular disease and enhancing treatment for minorities and low-income patients,” said AHRQ Director Carolyn M. Clancy, M.D., in the AHRQ release.

“Economic and Health Costs of Diabetes” summarizes findings of studies that were based on 2001 data from AHRQ’s Healthcare Cost and Utilization Project. To access a copy online, go to www.ahrq.gov/data/hcup/highlight1/high1.htm. For a printed copy, call the AHRQ Publications Clearinghouse at (800) 358-9295 or send an e-mail to ahrqpubs@ahrq.gov.

Educate your local media about family medicine

Do you get frustrated when the media don’t mention family physicians when reporting on maternity and pediatric health care? Next time that happens — instead of muttering, “Hey, how about me?” — go to the AAFP Web site at www.tafp.org. You can download letters tailored to educate your local media about family physicians’ scope of practice.

The letters were developed in response to a substitute resolution from the New Physician Constituency adopted at the 2004 National Conference of Special Constituencies. “More then 360,000 babies are delivered by family physicians each year,” says one letter. “In 2002, 16.6 percent of all office visits to physicians by patients under 18 years of age were to family physicians,” says the other. Both letters ask editors to keep family medicine in mind when producing future health care stories.

Go to http://www.aafp.org/x30963.xml and click on “Media Response Letters.” Then log in with your member ID and name, and select the sample media letter you’d like to use.

Source: AAFP This Week, March 22, 2005, © American Academy of Family Physicians