This guide does not apply if you have a hybrid medicaid-medicare plan through your state. Those folks know who they are, and if you have no idea what I'm talking about, you don't need to worry about it.

Before you begin you'll need three things:

1. A complete drug list of the person you're doing the research for. This means you'll need drug names, strengths, and quantities. Calculations are done for a 30-day supply, so if you take something 3 times a day, the quantity for 30 days will be 90.
2. About five minutes
3. An Internet connection (har har)

Here's a walk-through, so you'll want to open the link in a new window or tab…

Click on "Find & Compare Plans" which brings you to this:

Click "Begin Personalized Search" which will bring you to this next screen. You will want to click where it says "click here." Do NOT click the Continue button. This might trigger a browser prompt asking you if you want to continue sending this information over an unsecured connection. You're not actually sending any information about yourself, so click Continue.

That brings you to this page:

You'll want to mimic what I've done: put in the zip code of the person who you're doing the search for, ignore the age range and health status, and then select "No" for all three of the next questions. They have no bearing on choosing the Part D plan for the average person. Click "Continue" at the bottom.

That brings you to this. Click the "Continue" button. (Top or bottom doesn't matter.)

Get out that drug list that you put together. Click "Enter My Drugs" on this screen:

That brings you to this screen, where you can begin typing what drugs you take. I'll fill in a couple of examples that someone might take, and run you through a couple of screens that you might run into.

So here's my list for Bob Smith. Click "Continue" at the bottom when you are done filling in the drug names:

The next screen allows you to adjust the strength and monthly quantity. Go through the list of drugs on the left and change the strengths to reflect the drugs that you use before you start changing the quantities. Each time you select a strength other than the default, the page reloads, and you may lose any changes that you've made to the quantity. I learned this the hard way.

This next screenshot is the default, and the one after that reflects the changes I've made. Click Continue when you're finished.

The next step is optional. You can choose a Password Date that allows you to save your drug and location information and pharmacy preferences. That means that when 2009 rolls around, you can more quickly retrieve your drug list and make changes rather than having to enter all of the information from scratch. I recommend using the person's date of birth because it doesn't change. I will skip this step because I'm working with a dummy profile, but it is pretty self explanatory.

If you choose to save your drug information, be sure to write down the number that medicare.gov gives you, as well as the date that you chose.

Next you can choose a pharmacy based on zip code. This doesn't matter overmuch if you're going to use a chain or independent pharmacy. If you're working with a specialty pharmacy (for example, your doctor's office has its own dispensary, or you're a college student and use the university health office), then you may want to specify the pharmacy that you'll be going to. Again, I'm going to skip this step since it doesn't matter for most people.

At this point, all of the plans that cover the drugs you entered will show up. I like to display 10 on a page, but that would be a huge screenshot, so I'll stick with 5 for demo purposes.

You can compare up to 3 plans to see an in-depth breakdown of the plan information (monthly premium, what the copays will be on various drugs and so on. Tick the checkbox for the plans you're interested in and hit "Compare". (On every page thus far, there has been a "Printer Friendly" link in the upper left corner. This is particularly helpful if you want to print out the plan summaries and detailed breakdowns for offline viewing and annotating. I use it regularly.)

Plans I don't recommend

There's one company that I would avoid right now and that is WellCare. They are the cheapest (as you can see from my screenshots), but they have been in some substantial hot water lately, thanks to some VERY shady accounting practices. Their stock recently plummetted from $130 to $27 at its lowest thanks to being raided by the FBI. They also regularly screw over their customers. Please, stay away from the them.

Enrolling

Enrolling in a plan can be done online or on the phone. Some companies, like Humana, like to send a rep to your house to sign you up. Some people love this, and some people hate it. I find it a little weird, personally. I'd rather call a phone number and do the whole process from beginning to end without having someone come into my home.

[tags]Medicare Part D, How-To, prescription drugs[/tags]

I think this is bollocks. I think they're afraid.

It IS in your purview to make therapy recommendations. This is especially true for elderly people on Medicare Part D. For the first time (ever?) we have a system that indirectly rewards a large segment of the patient population for using fewer healthcare resources. (You don't hit the donut hole, so you save money.)

But what about those people who legitimately consume large amounts of healthcare dollars? They need an advocate. And that's YOU. The community pharmacist. When situations like this arise, you're the one that should go to bat for the person on the other side of the counter, because no one else can.

Interfacing with a doctor

Some pharmacists are hesitant to interface with a doctor's office. Maybe they're worried that they'll get stuck on the phone all day trying to make a change to a less expensive drug. But there are ways around this.

It's called asynchronous communication. And it's more efficient and less demanding on both your time and the doctor's time because it allows the both of you to communicate when you each have time rather than employing The Interrupter — AKA the telephone. This is the difference between urgency and importance. What you have to say is not usually urgent in this context. But it is important.

Last November and December, I made 25-30 suggestions for drug therapy change during the course of my Medicare consulting — all of them via fax — and all of them were accepted. This saved my patients an average of $500/year. This is serious money for someone on a fixed income.

Speak their language

Not all of these changes are silly little things like switching from one drug in a class to another. Or trying an ACEi instead of an ARB. Some of these changes were broad, tackling a given medical problem (or even multiple co-morbidities) from a different angle. Many of your elderly patients — particularly those with chronic illness — see multiple doctors, and lots of times there's no communication going on. In these instances you are the FOCAL POINT for their drug therapy. You are the gatekeeper, you see everything they take on your little computer screen. (Unless they're one of the relatively few people who enjoy playing Musical Pharmacies.)

In these cases you've got to speak their language. Don't even bother making a suggestion unless you are familiar with the latest treatment paradigms. If you want to change someone's insulin from a hojillion-dollar version to something more reasonable, be sure you're aware of the pharmacokinetic differences between the two. In your note to their endocrinologist, mention that you ARE aware of these differences but that you've spoken to Mrs. X and she is willing to try something new, and that this something new will save her $2000/year if it works.

Doctors listen, and they're usually willing to experiment if the patient is.

There are two types of "best drug"

You bring knowledge to the table that doctors don't have: how much things really cost. Most doctors have access to formularies if they want them, and they can relatively easily found out what kind of copay a patient will have if they prescribe X.

That used to be enough, but not anymore.

For Medicare Part D patients, the backend cost that the doctor does not have access to is a significant factor. Something might be a $28 copay, but UHC might be kicking in $250 behind the scenes that will quickly eat through someone's drug benefit.

There are two types of "best drug": the drug that is best from a therapeutic standpoint, and the drug that is best from a hybrid therapeutic-financial standpoint. This is the most pertinent concept of "best drug" for the person reaching for their wallet. Why reach for the Norvasc when you haven't tried felodipine?

Make it easy for yourself

You're a pharmacist. You're busy. You're machine-gunning prescriptions as fast as you can. The phone's ringing and one of your techs called out. Today is not the day to be making therapy suggestions. (If you find yourself in this situation often, you need to attend the RJS School of Pharmacy Management.)

But even bad pharmacies have good days. Make a template with your pharmacy name, fax and telephone numbers, with a section for the patient's information, and your notes. Personalize it with your name and titles. If you've got a system where you can type a note to the doctor, great. If not, don't insult insult them with bad handwriting, even though they may not return the favor. Be the bigger person and have someone else write it if you have to — bad handwriting does nobody any favors.

Take out as much of the repetition as you can. You have better things to spend your time on than redundancy.

Battles

There's this misconception that many pharmacists have that they're going to have to have a battle with the doctor to make XYZ changes. First of all, this rarely happens. Second of all, if YOU are battling THE DOCTOR, there is a problem, and it's not with you, if you are speaking on behalf of the patient as their advocate. No battles should occur; it should be a discussion. You know something the doctor doesn't, and maybe he knows something you don't about why s/he chose X drug instead of Y drug.

If you do end up having a battle, stick to your guns, but only if you know for a certainty that the patient will benefit if you do. Compliance issues due to money, dosing, etc. These are legitimate. Having a pet drug that you prefer is not. Conflict is not necessarily bad. Good relationships and mutual respect have been known to grow out of past conflicts.

Closing thoughts

These are the basics in effecting change as a community pharmacist. It is possible to take many of these ideas further, if you choose. Stepping on toes is never wise: step in when you see a patient is having difficulty with money, or if you can see they're otherwise unhappy. Many patients will come right out and ask if there's something else they can use. Some are unhappy with their doctor for any number of reasons, even though they've been seeing him for years. You may have an opportunity to save this patient-doctor relationship, and we all know how important good relationships are when it comes to healthcare, and how long they can take to build from scratch. They're not something to be thrown away lightly.

[tags]Medicine, pharmacy, MTM, community pharmacy, pharmacy practice[/tags]

Furfaro, a disabled heart-transplant patient, hit the doughnut hole last month when he tried to fill a prescription for two medications. Instead of two $25 co-pays, the pharmacist charged him $661 and $329 for the prescriptions.

"I threw a fit," he said. "What am I supposed to do? I don’t have $661 in my pocket."

Stuff like this comes down to personal responsibility. As the person in charge of Medicare consultation at my place of employment, we killed ourselves educating people about the plan. We did everything humanly possible to 1) educate people and 2) help them pick the plan that was right for them based on their current drug therapy. From the perspective of my pharmacy, there was nothing more that we could have done to educate people and help them make the right decision. Nothing.

Millions of people and millions more family members are going to be experiencing this shocking and crushing problem,” Hayes said.

The Medicare doughnut hole is a strange compromise between lawmakers who wanted to limit the cost of the program and those who wanted it to cover as many people as possible.

While it is an "advocacy" group's job to push for more, more, more — there are limits, and these limits were advertised, and most importantly, there were and are plans which do not have a doughnut hole. A pharmacist cannot help it if someone didn't pick a plan that would suit their needs better. At some point, it must be the patient's responsibility to take care of themselves. It is not that pharmacist's issue that this patient happened to be on Prograf and that Prograf costs a lot of money, however that pharmacist does end up looking like the bad guy, even though he or she was just bearing the bad news.

The fact that plans exist without a doughnut hole is conveniently conflated with the basic plan that the federal government outlined about a year and a half ago, before the private sector finalized their plans. Perhaps it is because the journalist doesn't know, but more probably, it is because leaving this fact out tugs on the heartstrings that much more.

If his health deteriorates further, Furfaro said, he’ll just get admitted to a hospital and receive his medicine that way, as Medicare will pay all bills if he is hospitalized.

In Mr. Furfaro's shoes, I would do the same thing, and it is something that will be addressed as in a year or two. With the doughnut hole, some people will always run out of coverage through poor planning, catastrophic occurrences, or what have you, and they will go to the hospital to continue getting their medications. However it is in the government's best interest to keep people out of the hospital when they are picking up the tab, because it is more expensive to keep someone in a hospital bed than it is to pay for their medications at a retail pharmacy.

In the meantime, the current Part D plan has worked out astoundingly well, and it is certainly off to a very good start. Where the money will come from in the future to continue its funding is anyone's guess, though.

Update 12.26am: I forgot to mention that Part D providers are required to send monthly notices to their subscribers telling them how much of their benefit they have used up, so if Mr. Furfaro had been doing his due diligence, he wouldn't have been blindsided by the doughnut hole.

[tags]Medicine, pharmacy, Part D, doughnut hole, Medicare Part D[/tags]