Experts from healthcare policy organizations and advocacy groups that cater to Medicare enrollees exchanged best practices and proposed policies to help alleviate access issues during the Cost-Sharing Roundtable, co-hosted by the Patient Access Network Foundation and The American Journal of Managed Care®, on February 23, 2018, at the Barbara Jordan Conference Center in Washington, DC.
What are the current and future needs of the Medicare population to ensure continued access to care? Panelists grappled with this question at the Cost-Sharing Roundtable, co-hosted by the Patient Access Network (PAN) Foundation and The American Journal of Managed Care®, on February 23, 2018, at the Barbara Jordan Conference Center in Washington, DC. The experts weighing in to the discussion were Leigh Purvis, director, Health Services Research, AARP Public Policy Institute; Julie Carter, federal policy associate, Medicare Rights Center; Leslie Fried, JD, senior director, Center for Benefits Access, National Council on Aging; and Paul Billings, national senior vice president, Advocacy, American Lung Association.
Moderator Cliff Goodman, PhD, senior vice president and director, Center for Comparative Effectiveness Research, The Lewin Group, asked how the change in the administration had affected healthcare trends and what indicators were in use by organizations to monitor the impact on the ground.
Carter said that increased drug prices and challenges with navigating the healthcare system, among others, seemed to be on the rise. These, she added, are more practical indicators of trend. “The last 12 months have been very disruptive for patients, especially those enrolled in Medicare. This can potentially lead to a healthcare paralysis as patients struggle to make decisions.”
Coinsurance tiers increase the out-of-pocket (OOP) costs for enrollees, Fried said. “We see a significant increase in cost of drugs through the year, which results in having greater OOP at the point of sale. However, Medicare beneficiaries don’t really get the benefit at point of sale,” which results in unaffordable OOP costs, she added.
Purvis underscored the significant cost burden of growing OOP costs on Medicare beneficiaries, who have a median income of $26,000, and one-fourth of these idividuals have an average income of $15,000.
“Our members are increasingly falling through the cracks,” Purvis said. “It’s harder for me to point them in a direction and also provide help.”
Billings explained that his organization is seeing patients hit the Medicare Part D donut hole and they didn't even know it existed. He narrated the story of a patient whose $42 co-pay in the pharmacy went up to $137 when she hit the donut hole. That was a significant and unaffordable jump in her cost share, which needed additional co-pay assistance.
Organizations are trying to structure their systems so they can counsel and navigate these patients in the right direction. “We receive calls on our helpline, where we have counselors to navigate appeals and complaints, in parallel with educational programs. Often, we have a patient who may not be eligible for a program. We don’t have a mechanism to help patients who may be making just a little more than the level set for eligibility. They aren’t making a lot of money, but don’t qualify for Medicaid,” Carter explained.
She said that the Medicare Rights Center helps such patients with their appeals process and also ask them to speak to their provider about formulary tiers.
For Fried and her team, a majority of calls are from community-based organizations, primarily about OOP costs. “Eligibility is a major issue … we need to liberalize financial eligibility with these programs,” she said.
Purvis emphasized the need to educating enrollees to get more in the weeds. “Enrollees are sticky and they don’t look at formularies year to year,” she said, adding that beneficiaries should consider whether their tiers have changed and how that may affect coverage for their drugs.
“Do you feel the strain of the changes?” Goodman asked, to which Purvis replied, “Based on the way prescription drug prices are going, we know a lot more needs to be done.”
Billings agreed. “New drugs are good news, but costs are a concern, within and outside the Medicare population,” he said. “It’s terrifying for patients who are doing well on these drugs to lose their coverage. We are helping patients find tools so they have financial support, but they have run out of options in some cases.”
“As rules changes, patients find themselves starting from scratch to ensure stable financial support for their treatment,” Billings added.
Patient coinsurance, according to Purvis, is directly proportional to the rising drug prices.
Explaining the imbalance in the system, Fried said that 9% of Medicare Part D enrollees—responsible for 57% of Part D spending—are entering the catastrophic phase. “Which is a small group of people with very high costs. And even in the catastrophic phase, they are responsible for 5% of the drug cost … 5% of a high-cost drug is still very high!”
Billings explained that he is pro-innovation, which is necessary if he wants to see a treatment and cure for lung disease, but patients still have to be able to afford the price of innovative drugs.
“What support do Medicare patients need now?” Goodman asked.
“Education to understand the different parts of the program is vital,” Carter said, explaining that the annual reboot, with constant changes, is difficult. She drew attention to the State Health Insurance Assistance Programs, which she said are an amazing resource for Medicare enrollees and their families. She also indicated that the CMS Medicare Plan Finder could be helpful, but that it has its flaws.
Also, simplifying things for people is extremely important, Carter indicated. “More choice is not necessarily good. A lot of people will simply not choose—rather, they just decide to stick to their existing plan,” which Carter described as “paralysis.” Lack of awareness may lead to patients discovering formulary restrictions or provider restrictions within their plan.
“Only 13% of Medicare patients are shopping,” Fried said. “If people are not shopping for a better deal, why offer them a better deal?"
Fried agreed with Goodman’s comment that the Medicare payment structure cannot afford today’s healthcare market. “That’s something we all have to be concerned about,” she added, “and that folks at CMS and MedPAC [Medicare Payment Advisory Committee] are concerned about.”
“If we eliminated the asset test, as done with Medicaid expansion, more people would be eligible … that would significantly assist a certain population [of beneficiaries],” Fried said. Enrollees, she added, do not enjoy the price protection that insurers benefit from, due their price contracts with manufacturers.
“MedPAC and CMS have been toying with Part D benefits changes to stem the bleeding. But this is just shifting the costs around … the cost usually ends up back with the enrollees,” Purvis said, in the form of higher premiums, higher deductibles, etc. “Prescription drug prices is the root of the problem,” she added.