The Congregation at Duke University Chapel

Medicare, Senior PharmAssist & Moving Forward


Medicare, Senior PharmAssist & Moving Forward

presentation at Adult Forum by
Gina Upchurch, RPh, MPH
19 February 2011

Major Public Health Concerns: Associated with Medication Use

  • Medicines don't work in people who don't take them.
  • Sometimes the best medicine is no medicine at all.

Major Public Health Concerns: Associated with Medication Use

  • Underuse:
    • cost
    • under-treatment or "sub-therapeutic"
    • non-adherence
  • Overuse or inappropriate use:
    • polypharmacy -multiple, sometimes unnecessary drug use
    • lack of attention to geriatric medicine and prevention options
    • uncoordinated care - including multiple providers, poor communication & harried environments
  • Health Literacy

Goal of Medication Therapy

  • Maximize Benefits
  • Minimize Risks

To improve health outcomes ... in the most cost-effective manner possible

Medication-related problems

  • Good News: Estimated that 2/3 of the deaths and injuries from medicines can be prevented
  • Bad News: Every $1 spent on medicines is matched by $1.36 dealing with a MRP (medication-related problem)

Pharmaceutical Care

We make assumptions:

  • medications prescribed correctly
  • medications dispensed correctly
  • medications administered correctly
  • medications monitored routinely

Medication Consumption

  • Drug Interactions
    • Drug - drug
    • Drug - disease
    • Drug - nutrient
  • Not all drug interactions are bad
  • Clinical trials and "post-marketing surveillance"

Adherence Considerations

  • Adherence as an "end" or a means to an end?
  • Seniors are no more or less adherent than other age groups if matched for complexity of drug regimen
  • When older adults are non-adherent, 90% of the time they underuse the medication
  • 73% of the underuse is INTENTIONAL
Source: Cooper JK, et al. JAGS, 30(5)1982.

Senior PharmAssist Elements

  • Medication therapy management
    • Monitor
    • Educate
    • Interdisciplinary Approach
  • Payment (supplement to Medicare or sole source)
  • Referral (medical and social)
  • Empowerment & Activation - medication records, geriatric formulary

Senior PharmAssist's Direct Financial Assistance

  • If 60 or older and Durham resident - offer supplemental coverage to Medicare D or if the person has no Rx coverage, we offer primary coverage to individuals with incomes up to 200% of the federal poverty level
    • Single = $1,805/month or $21,660/year
    • Couple = $ 2,428/month or $29,140/year
  • Participants pay no more than $2/generic or $5/brand-name - on our geriatric formulary
  • Eligible for one-on-one medication therapy management and tailored community referral
    • Transport or home visit

Safe and Effective Medication Use

Participants Prescribers and Pharmacists
  • Medication Therapy Management (MTM)
    • ChecKmeds NC
  • Medication record
  • Link pharmacy profiles
    • PBM – Catalyst Rx
  • Geriatric formulary
  • Medication record
  • Geriatric formulary
  • Direct feedback

Financial Assistance with Meds

We help anyone apply for the federal low income subsidy via SSA to lower their premiums, co-payments, and eliminate the coverage gap or "donut hole."

We help seniors apply for NCRx - the statewide program that helps people 65 and older with limited incomes pay up to $29/month on their Part D premiums

Senior PharmAssist: What Else?

  • Durham seniors 60 & older, at/under 200% FPL not eligible for our card program because of Full LIS, MQB, Medicaid or retiree coverage ARE ELIGIBLE for a free medication review every 6 months.
  • We help younger people without Rx coverage - assess eligibility for drug manufacturer patient assistance programs, & look for other ways to bring costs down.
  • We help ANY Medicare beneficiary in Durham sort through Medicare-approved drug plans.
    • Any age, any income.

Federal Medical Programs

Medicare Medicaid
  • administered federally
  • persons 65+ or disabled, ESRD, ALS
  • Rx medications – mostly not included until 2006
  • Part A - hospital care and what follows
  • Part B - outpatient benefits, including physician visits – covers 80% of "allowable"
  • administered by states; with federal matching funds
  • for the medically impoverished who are deemed "categorically" eligible
  • Rx medications - included - with "duals" now receiving benefit via Medicare-approved plans


  • Most Medicare beneficiaries have:
    • traditional Medicare Part A and B
    • have a secondary medical coverage or buy a supplement and
    • choose a "stand alone" Part D drug benefit.
  • Some Medicare beneficiaries trade all of this for a "Medicare Advantage" plan (Medicare Part C), which include HMOs, PPOs, and PFFS plans, and some plans specifically for special needs populations (e.g. nursing home patients). They can include Rx benefits (MA-PD), but are not required to.


Source: Kaiser Family Foundation Medicare Spending and Financing Fact Sheet, August 2010

Who? What?

Everyone who has Medicare Part A or B (regardless of income) can choose a Medicare prescription drug plan

  • It is a choice, a voluntary Medicare benefit
  • It is administered by private companies as "insurance model" with cost-sharing requirements overseen by CMS (Centers for Medicare & Medicaid Services)
  • Medicare beneficiaries with limited incomes and resources may qualify for "extra help" or a low income subsidy via the Social Security Administration

Medicare Beneficiaries' Out-of-Pocket Drug Spending Under Medicare Rx Benefit, 2011


Medicare Prescription Drug Insurance

People with Medicare Part A or B can choose a Medicare drug plan.

  • Medicaid recipients who also have Medicare MUST get their drug benefits through a Medicare Drug Plan!
  • For most, it's a choice - a voluntary Medicare benefit that helps pay for prescription drugs.
  • Those with "creditable coverage" likely won’t participate but may.

Medicare Rx Benefit Options: 2010 & 2011


Warning in Durham County !!!

  • While Medicare Advantage plans include A and B benefits (and sometimes "extras") - may not be accepted by all providers in Durham.
  • DUHS limited plans accepted "in network":
    • BCBS - Blue Medicare (Partners HMOs and PPOs)
    • Sterling (PFFS and PPO's)
    • Coventry/Advantra (PPO's)
  • Out of network - Humana, AARP/United/Secure Horizon's, America's 1st Choice, Universal American - Today's Options

Medicare Beneficiary with Drug Coverage from a Past Employer or a Medigap Plan

  • Determine if coverage is "as good as" the standard Medicare benefit ("creditable"): Letters should arrive every year before November 15th.
  • If later dropped from "creditable" coverage, have 63 days to enroll in a Medicare-approved drug plan without having to pay 1% penalty

Past Employer Coverage

  • If "creditable" and past employer still contributes to the plan - likely want to stay put
  • However, if "creditable" but individual is contributing a significant amount - will want to compare
  • Considerations before dropping employer Rx coverage:
    • Is s/he also losing the medical coverage?
    • Can s/he get employer plan back later?

Medicare Beneficiaries Without Prescription Drug Insurance or "Creditable" Coverage

  • Will likely want to join a plan:
    • Pay a monthly premium in addition to a percentage of total drug costs (via deductibles and co-payments or co-insurance).
    • IT PAYS TO COMPARE PLANS because plans cover different drugs at different prices, which change EVERY YEAR.
    • Penalty clock for not having “creditable coverage” began June 2006 - (Penalty of $17.73/mo. more in premium if living under a rock since June 06)

Annual Lock In

  • Most Medicare beneficiaries will only be able to switch plans during the annual open enrollment period (November 15 - December 31 of each year).
    • This is why it is critical that folks choose plans that cover all or most of their medications
  • All folks eligible for the federal "low income subsidy" can change plans once a month
  • In addition, all enrollees of qualified SPAPs (NCRx or ADAP in NC) can change plans once during the plan year.

PDP Plans: "Considerable Discretion"

  • Formularies; TrOOP - "true" out-of-pocket Medicare beneficiaries who need a drug that is not covered will pay the entire cost of the drug, without a limit on expenditures, unless they can successfully appeal to have it covered
  • Utilization Management policies (i.e. prior authorization, step therapy, quantity limits, tiered cost sharing)
  • Exceptions and appeals processes
  • Transition fill policy

Medicare Changes - 2011+

  • Regulation of MA plans (currently paid 12-14% more) - postulated savings for larger healthcare reform; potential bidding process
  • Push for more standardization of the Part D plans and fewer choices
  • Annual election period – expanded and earlier - moving to October 15 - December 7 so we have 7 weeks to help review options and gives some time before benefit has to be in place January 1.

Medicare Changes - 2011+

  • 2011 - will not require cost-sharing on preventive services: ANNUAL wellness visit & disease screenings; cover many immunizations with no cost-sharing
  • Increased focus on waste, fraud, and abuse
  • ARRA funding – focus on shared personal health record - rewards to participate for physicians and hospitals and if not - penalties over time
  • Provider payment reforms and delivery system reforms

Medicare Changes - 2011+

  • Accountable Care Organizations
  • Patient-centered medical homes
  • Carrots: 42 quality indicators for hospitals - tied to reimbursement (including tracking hospital-acquired infections)
  • Sticks: Begin to reimburse providers less if Medicare beneficiaries are re-admitted to the hospital within 30-days of soon after discharge - strong incentive on hospitals to improve the quality of care (heart attack, heart failure, and pneumonia)

Medicare Changes - 2011+

  • Independent Payment Advisory Board: beginning in 2014 - recommend ways to reduce Medicare spending if annual rates exceed benchmarks
  • Center for Medicare and Medicaid Innovation
  • Medication reconciliation
  • Medicare therapy management
  • In 2013, will end tax deductibility for employers who receive Medicare Part D retiree drug subsidy (28%)

Medicare Changes - 2011+

  • Higher payroll taxes (0.9% more) for those earning >$200,000/single or $250,000/couple - pays for Medicare A
  • Medicare D premium - now income related (like Part B) if >$85,000/single or $170,000/couple
  • Savings assumes abiding by the "sustainable growth rate" formula that determines physician payments, which was put into law several years ago to control Medicare's annual growth