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The Medicare D Utilization Management Spreadsheet Project

The Medicare D Utilization Management Spreadsheet Project. Benjamin Crocker, MD Benjamin.Crocker2@att.net Stevan Gressitt, MD Edward Pontius, MD. Medicare D in Beta Version: 2006. Many details still to be worked out regarding what UM edits mean, criteria for exceptions and appeals, etc.

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The Medicare D Utilization Management Spreadsheet Project

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  1. The Medicare D Utilization Management Spreadsheet Project Benjamin Crocker, MD Benjamin.Crocker2@att.net Stevan Gressitt, MD Edward Pontius, MD

  2. Medicare D in Beta Version: 2006 • Many details still to be worked out regarding what UM edits mean, criteria for exceptions and appeals, etc. • Unclear how much actual UM has happened compared to published edits • Business issues of PDP’s compared to, and as stalking horses for MAP’s in an environment of changing subsidies.

  3. Supporting Beneficiary Choice • For Dual Eligible and full-subsidy beneficiaries, pricing and tier placement do not matter • Utilization management is the only plan differentiator regarding medications in the protected classes • Formulary inclusion of non-protected class medications (such as addiction medications) may be important

  4. CMS Tells Physicians not to advise patients re plan selection • Conflict of interest cited, physicians encouraged to punt this to pharmacists and other agencies. • Pretense is made that consumers will get information from internet sources • Most physicians confused by Medicare D • Formulary Finder little used by anyone after early weeks

  5. Physicians encouraged to use commercial databases • Epocrates, then Skyscape, offer desktop and PDA formulary info for Medicare D • This is convenient for early tech adaptors • Some divergence between commercial formulary redistributors and plan formularies, but much less that divergence of CMS Formulary Finder and plan formularies. • Republishing of Epocrates or Skyscape information by subscribers is forbidden. • Patient access to these databases unlikely

  6. So how can physicians help patients understand their choices? • Showing patients comparative UM edits across plans protected by first amendment • Graphic display of data, with color, increases patient comprehension of differences • Politicians and doctoral level clinicians pay attention to “pretty colors” as well

  7. As Maine Goes, so goes the Nation • The Government and Legislative Affairs Committee of the Maine APA District Branch took action to inform Maine clinicians and patients about Medicare D UM in late December 2005. • Spreadsheets for 7 Major classes of medication (only 1 psychiatric) were posted at www.mainepsych.org, and updated periodically. Not much interest indicated from nonpsychiatric clininicians.

  8. March, 2006 • PA and QL vanish from Medicare Formula finder for over 10 day, leaving STEP only UM edit. • Almost nobody notices. • CMS says it was a computer glitch, leaves the inaccurate information up without comment until it is eventually corrected. • This was during a period that many special help beneficiaries had a choice of plans, and the deadline for non-subsidized beneficiaries was starting to loom

  9. July 2006 • PA’s that have been in place for all commonly used atypical antipsychotics on Formulary Finder for Wellcare Signature for most of they year vanish at the beginning of July for about a month. • Before and after this, Wellcare’s whole formulary vanishes for several days from the formulary finder. • CMS June 29 statement suggests that this is a form of plan discipline. • Wellcare denies that the PA’s have been removed, and its website formulary continues to post the PA’s. Eventually they re-appear on the Medicare Formulary Finder. Of all national plans, this is the only one to put a blanket PA on all atypicals except clozapine.

  10. Advocacy Organizations Notice Formulary Finder Problems • APA letter from Dr. Scully to CMS regarding Medicare D Manual dated September 26, 2006, and Medicare Rights Center report of September 2006 note inaccurate data posted regarding UM on Medicare site. • MAPP spreadsheet project abandons updates of spreadsheets in midyear as intractable confusion regarding UM data on CMS Formula Finder makes it impossible to cite this source as reliable information.

  11. What next for the Spreadsheet Project? • Constructing and updating spreadsheets will require mining data directly from plan formularies. • 2006 formularies vary in organization, completeness and printability. ?2007? • Because of increased work of data mining, fewer medications can be tracked unless volunteers or funding can be found

  12. National Spreadsheets • A few plans now dominate the Medicare D broad market. • National plans generally use the same formulary and UM in various regions. • Formulary UM data could be centralized for national plans, leaving only a few regional plans to be mined locally. • Many hands make light work. • AACP, Women Psychiatrists and AAPA post spreadsheets for each PDP region on their websites, May 2006

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