by Bob Roehr
Medicare Part D, the prescription drug benefit created by Congress in 2003, is failing people with HIV/AIDS, according to a detailed online survey of their members conducted by the American Academy of HIV Medicine and the HIV Medicine Association.
“Bureaucratic roadblocks, exorbitant co-pays, and plans that fail to cover key drugs mean that this new program is failing an especially vulnerable population,” the groups concluded in the survey that was released April 5.
Medicare is the second largest source of federal funding for people living with HIV, covering an estimated 100,000 PWA beneficiaries.
The Centers for Medicare and Medicaid Services, which regulates the programs, made antiretroviral drugs one of only six categories where Part D health insurance providers must cover “all or substantially all” drugs that are available in that class. It allowed “prior authorization,” approval of a doctor’s prescription by the insurance provider before it can be filled, only for Fuzeon, the most expensive therapy.
But that regulatory mandate has not stopped problems from arising. Some 83 percent of the responding physicians said their patients had problems getting prescriptions filled since joining a Part D drug plan, and 75 percent of those with a problem had gone without medications.
“For many of my patients, Medicare Part D has been a huge barrier to treatment,” said Aimee Wilkins, a physician at Wake Forest University Health Sciences. Gaps in therapy can contribute to the development of resistance to those drugs. Prior authorization is a significant factor in allowing those gaps to occur.
“We’re currently processing at least 25 prior authorizations per week. That consumes more than half a nurse’s time,” said Michael Saag, director of the HIV clinic at the University of Alabama at Birmingham. Four out of five providers surveyed said prior authorization was a problem in getting prescriptions filled.
“The net effect of prior authorization is that it makes providers think twice about each prescription they write, even if it is genuinely the best medicine for the patient,” said Saag. “That is not the proper way to practice medicine. The only ones who benefit are the insurance companies.”
A portion of patients are “dual eligible” for both Medicare and Medicaid and were served by a variety of programs, including the AIDS Drug Assistance Program. The 2003 law requires that all eligible ADAP patients automatically be enrolled in Part D as of January 2006. That raised another series of issues of co-payments for the generally low income patients.
The survey reported that 48 percent of these dual eligible patients were worse off under Part D in terms of the drugs covered, while only 9 percent were better off, and the balance remained about the same.
When it came to co-payments, 58 percent had to pay more out of their own pocket, 34 percent reported that costs stayed about the same, and only 5 percent were better off in terms of lower co-pays.
HIVMA and AAHIVM are calling for federal regulators to aggressively enforce the prohibitions on prior authorization that already are on the books. It is asking Congress to pass legislation that will ensure that Part D plans cover all drugs, and addresses prohibitive levels of co-payments.