Alleviating Confusion and Preventing Fraud
INTRODUCTION
Now that the Medicare Part D program has begun, attention is being focused on maintaining the integrity of this complex program. Because the Medicare Modernization Act (MMA) of 2003 represents the largest expansion of Medicare since the program’s inception approximately 40 years ago, it is inevitable that not everyone involved with Medicare Part D will have a positive experience adapting to the changes.
The Centers for Medicare and Medicaid Services (CMS) and the public are now primarily concerned about how Medicare beneficiaries will select a Prescription Drug Plan (PDP) while coping with ambiguous or incorrect information and about the possibility of fraud involving Medicare Part D.
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CONFUSION OVER PLAN ENROLLMENT
Medicare beneficiaries have stated that their confusion is largely the result of a seemingly limitless number of plan options, each with variations regarding not only premiums but also formulary designs, services, and pharmacy networks. Beneficiaries have, on average, 40 different prescription plans to consider, and comparing these plans is not a simple task.
Even though competition is intended to improve choices and to allow beneficiaries to select a plan that best meets their individual needs, this ability to choose appropriately is dependent on a knowledgeable consumer. Unfortunately, most Americans—particularly older people with some level of dementia—will be unable to make the necessary evaluation without assistance.
Those health care providers who are most ready and able to assist older patients are confused about the extent of involvement that the CMS will allow. The CMS marketing guidelines seem to indicate that health care providers are not supposed to help in this process directly, even though a recent Kaiser Family Foundation study pointed out that these were the exact sources to whom seniors would turn.
These marketing guidelines have caused confusion among health care providers because they seem to imply that these clinicians should not be steering patients to a specific plan. As a result, health care providers are under the impression that the only role they may play is to direct their patients to the CMS or other sources of general information. In fact, this is actually contrary to the CMS guidelines, which state that physicians may encourage patients to make the appropriate decisions. Unfortunately, this ambiguity leaves senior citizens alone to sort through the many complex benefit designs and plan options and increases the likelihood of their making ill-advised decisions.
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Physicians—whom elderly patients identified, in the Kaiser study, as being their preferred choice for education about Part D—are poorly equipped for this task. The physicians who could theoretically help Medicare beneficiaries in choosing plans have been so overwhelmed by the CMS rules that they are having difficulty guiding their patients into specific plans. In addition, the federal government has provided only a few educational materials and resources to physicians and other health care professionals. Private companies are attempting to fill the void with educational resources and training sessions for health care providers.
The experiences of beneficiaries who joined the Medicare discount card program underscore the need for help with enrollment in Medicare Part D, according to a report by the Department of Health and Human Services, Office of the Inspector General (OIG). The survey found that most beneficiaries relied on news media or direct mail for information; only 20% of them contacted an information source directly. It was concluded that promotion of Medicare Part D should make more use of the media and the mail. buy prescription drugs online
Despite these deficiencies, the focus thus far has been on the Medicare Web site and a toll-free call-in telephone line. A test by the Government Accountability Office (GAO) on the accuracy of Medicare’s toll-free hotline found that 29% of callers obtained inaccurate answers and 10% received no answer at all. Although the goal of the CMS is to bring about continued improvement and increased participation in the program, it may actually have a limited effect, because more than 75% of beneficiaries have never gone online and only 8% have ever used the toll-free phone number.
