Pharmacy & Therapeutics - April 2008 - (Page 200) LETTERS TO THE EDITOR Medicare Part D: Still More Failures I read with great interest the opinion piece by Walter Way and Fred Mayer in the March 2008 issue of P&T (“Failures of Medicare Part D Delivery and Recommendations for Improvement”). A great set of ideas, but I feel that the failure can be investigated even further as you delve into the subspecialties of pharmacy. In the world of long-term care (LTC), the delivery of medications is complicated by the use of boxes for emergency drugs and regular changes of medications like warfarin [Coumadin] to address residents’ needs. Interestingly enough, all prescription drug programs (PDPs) have required, as part of their contracts with LTC pharmacies, that “emergency drug boxes” be provided in LTC facilities. Imagine the patient’s surprise at the pharmacy when a PDP allows payment for an emergency drug box item, then rejects payment for the remainder of the prescription amount because of a “refill too soon.” You can also imagine the patient’s disbelief that a PDP would deny payment for a change in a warfarin dose because of a “refill too soon” restriction. Finally, imagine how perplexed the LTC pharmacy would be to call a PDP for an override on payment and to have the PDP technician refuse to grant a prior authorization because it has taken over two weeks (1) to contact the physician and for the LTC facility to send all appropriate information to the physician and (2) for the facility to submit the exact form that the PDP requires for approval. When a “low-income subsidy” status or when a “long-term care resident” status is not properly assigned to an individual, there is no centrally organized clearinghouse to process and correct the error. The frail, elderly resident is expected to coordinate this action. If a third party attempts to resolve the error, the submission of what the Centers for Medicare and Medicaid Services (CMS) calls “best available evidence” is directed back to an amorphous telephone or fax number at the PDP. The receipt of any of this information is hardly ever reported back to the pharmacy for resolution. The need for a “transition period” to allow for medication delivery was a central tenet of the Medicare Modernization Act (MMA) Part D effort; however, the transition period allows drugs to be provided when they are dispensed but does not allow the pharmacy to be notified that the prescription was refilled during this period. Therefore, particularly in the LTC world, the pharmacy first becomes aware of the problem only at the end of the transition period, when the refill is rejected. Now I ask you: what good is a transition period if the pharmacy doesn’t know about it to act on the need? In the world of long-term care, the residents, for the most part, do not have the chance to read, comprehend, or act on any letter that CMS requires them to receive. Even if such a letter were to be sent to these patients, there is no reason to believe that the address on file at CMS would be that of the current LTC facility. It will take years to make improvements before all parties involved in Medicare Part D can derive the plan’s intended benefits. My concern is that the items I have addressed here have been reported consistently since the inception of the Part D benefit—and they are still unresolved. Sincerely, Jacob Hutti, PharmD PCA Pharmacy Louisville, Kentucky Committees Should Include Informatics; P&T Should Publish More about It I have been the medical informatics officer for a threehospital, not-for-profit medical system in central New Jersey for three years. My responsibilities include developing the computerized physician order entry (CPOE) for our hospital system. As such, I voluntarily became a member of our hospital’s P&T committee because I felt the committee’s expertise was critical for CPOE success, which by its very nature attempts to influence physician behavior by offering clinical decision support when the physician orders medications electronically. I thought that the pharmacists, P&T physician members, and hospital senior management would be keenly interested in a new tool that would enable them to help achieve cost savings and effectuate their quality initiatives. Eager to improve our CPOE’s clinical content, I was surprised that my presence on the P&T committee was greeted with a huge yawn, followed by persistent apathy. The clinical pharmacists seemed threatened by my presence, and the committee seemed quite content with the status quo. I am not one of those geeks who believe that informational systems are the only path to improved quality. I am old enough to remember walking to the library, and I share the frustrations of current end-users as we travel down the new information superhighway. I understand that current medical software and hardware are products in evolution and will never replace an experienced professional. However, I am a true believer that clinical decision support during the drug-ordering process is a remarkable improvement in a physician’s workflow. Embedded in a typical commercially available CPOE application are clinical decision-support programs. There are vendors who specialize in medications. Typically, they screen for allergies, drug duplication, drug interactions, pregnancy precautions, food interactions, and so on. Because these databases are electronic, they are easily modified and updated. Even within the CPOE application per se, methods are usually available to educate physicians and clinicians. These include so-called processing instructions and pop-ups. These systems are well suited to enforcing a hospital’s formulary and educating physicians about costeffective and evidence-based medications. There is a discipline entrenched in electronic ordering continued on page 248 200 P&T® • April 2008 • Vol. 33 No. 4
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