Physicians complain Medicare Part D decisions threaten patient care

The AMA urges physicians who are encountering problems with Medicare drug plans to report them to CMS and the Association.

By David Glendinning, AMNews staff. June 5, 2006.

Washington -- Elizabeth Delesante, MD, says she had to endure a more than four-month administrative nightmare to convince a Medicare drug plan to do what she thinks it should have done in the first place.

Dr. Delesante, a psychiatrist in Brainerd, Minn., had a patient with schizophrenia who had been stable for 18 months on a 320 mg daily dose of Geodon (ziprasidone). As a low-income beneficiary eligible for both Medicare and Medicaid, the patient had been automatically enrolled in a MedCo Health Solutions plan. The insurer would only pay for a 160 mg dose, based on the manufacturer's package insert and Food and Drug Administration guidelines.

MedCo, and then an independent contractor, rejected the physician's explanation that the patient needed an off-label exception to the dosage limits and that it was this higher dosage that enabled the beneficiary to move out of a nursing home and hold down a part-time job. With no way to afford the extra pills, the patient was in danger of a catastrophic relapse.

"She was terrified," Dr. Delesante said. Late last month, a mere hour before the appeal was to go before an administrative law judge, MedCo decided to start covering the requested dosage. The psychiatrist estimates she and the assistant who helps run her solo practice spent 200 uncompensated hours trying to resolve the problem, while sustaining the patient with free drug samples.

Dr. Delesante is not the only physician who has run into coverage problems under the new drug benefit. The American Psychiatric Assn. alone has collected more than 1,000 complaints from doctors and patients about how Medicare Part D plans are operating, said Karen Sanders, APA's assistant director of publicly directed services.