Practice Manager Insider

New ACS Analysis: Which Part D Plan is Right for Your Patients?

The Medicare Part D plan that patients choose greatly affects their out-of-pocket cost for cancer therapy, but not always as one might expect. Figures from a recent analysis by the American Cancer Society (ACS) and Avalere Health reveal, for example, that a patient receiving standard first-line treatment for lung cancer (non-small-cell type) could pay more than four-fold more in out-of-pocket costs depending upon the Part D plan chosen.

The information is timely, as open enrollment for Part D 2007 plans begins on November 15. ACS intends to use the data to update its primer about Part D coverage of cancer therapies. The report includes specific cost data and comparative bar graphs.

ACS and Avalere calculated and compared Medicare beneficiary out-of-pocket drug therapy costs for each of 7 standard, first-line regimens for certain cancers: breast cancer, metastatic breast cancer, metastatic colon cancer (2 different regimens), high-grade lymphoma, low-grade lymphoma, and non-small-cell lung cancer. The study considered patient costs in 12 Medicare drug plans, including 4 Medicare Advantage options. Analysts considered premiums, copays, coinsurance, and other elements of patient cost (eg, the gap in coverage referred to as the “donut hole”). It also examined Part B coverage for the same regimens.

Part D plans studied covered nearly all agents that are elements of the regimens examined. Patient cost sharing varied widely, however. Findings include the following:

• Part D plans with copays can be more costly than those using coinsurance.
• Patients reached the aforementioned coverage gap (ie, $2250 total medication spending) in only 3 protocols—those for breast cancer, metastatic breast cancer, and non-small-cell lung cancer.
• A Part D plan that offers medication coverage during the “donut hole” period usually, but not always, would substantially lower beneficiary costs for persons using the 3 aforementioned protocols that would reach the coverage gap. Examples of cases where gap coverage did not yield lower out-of-pocket costs include plans that charge relatively high copays before the gap threshold is reached, and those that exclude brand-name agents from their formularies.
• Higher-premium plans do not always result in lower out-of-pocket costs for the cases examined. Patients receiving protocols with fewer Part D drugs (eg, those for colon cancer and lymphoma) were most likely to incur higher costs with higher-premium coverage.

A key finding regarding Part B coverage is that supplemental insurance is crucial for patients receiving the treatment protocols examined in this study. Premiums for the most popular so-called Medigap plan examined varied by locality but were thousands of dollars less than the patient’s Part B liability without the insurance. 

http://www.avalerehealth.net/research/docs/ACS_Cost_Sharing_For_Cancer_Patients.pdf

http://www.kaisernetwork.org/Daily_reports/rep_hpolicy.cfm#40639

How Fast Are Your Peers Adopting IT for Clinical Uses?

Physicians have been slower to use email to communicate with patients about clinical issues compared to the speed with which they have adopted other clinical applications of information technology. This finding comes from the Center for Studying Health System Change (HSC) Community Tracking Study Physician Survey, a nationally representative telephone survey of continental US physicians. It was reported in last month’s HSC Data Bulletin.

About 24% of respondents reported using email to communicate with patients about clinical issues in the 2004-2005 survey, compared to 20% in 2000-2001. In contrast, reported use of IT to access patient notes and write prescriptions increased by 38% (36.6% to 50.4%) and nearly 100% (11.4% to 21.9%), respectively, according to an earlier Data Bulletin. Physicians in staff or group HMO practices reported the highest rates of email use for to communicate clinically with patients, with 47% using email in this way. Practices for who Medicare constitutes at least 50% of revenue were less likely to report using email for patient clinical communications compared to those with less revenue from Medicare (18% vs 26%, respectively). About 22% of medical specialists responded that they use email in this way, compared to 28% of surgical specialists and 24% of primary care physicians.

HSC cites several possible reasons for the lag in adoption of email for patient clinical communication. These include the cost of implementing a secure messaging system, concern that email will add to workload rather than substitute for phone or in-person consultation, and lack of reimbursement for email consultations.

http://www.hschange.org/CONTENT/875/875.pdf

http://www.hschange.org/CONTENT/848/848.pdf

Obtaining Reimbursement for Preventive Counseling Services

An article in the most recent issue of the Journal of Oncology Practice discusses Medicare and private payer coverage of cancer prevention counseling for persons in certain risk categories. Authors, including Practice Manager Insider’s own Elaine Towle, surveyed medical directors for 6 private payers and 4 Medicare carriers about coverage of cancer prevention counseling. Following are some of the other findings:

• Few formal Medicare coverage policies on cancer prevention counseling exist at either national or local levels. The exception is national coverage for a smoking cessation counseling benefit under two conditions: if the beneficiary has an illness caused or complicated by tobacco use, or if the effectiveness of the beneficiary’s medication(s) is complicated by tobacco use.
• Medicare carrier medical directors interviewed believed that cancer prevention counseling would be covered for a patient with an established cancer diagnosis, a precancerous condition, or a high risk of familial cancer.
• Most private payers do not have formal coverage for preventive counseling but do pay for cancer preventive counseling delivered to a patient with a precancerous condition or a personal or family history of cancer.
• Cancer prevention counseling by a medical oncologist generally will be billed using established evaluation and management (E/M) codes, said both Medicare and private payer medical directors. The exception for Medicare carriers would be that intermediate and intensive smoking cessation counseling should use the new codes provided for those services.
• Neither Medicare nor private payer medical directors require specific documentation in the patient medical record for cancer prevention counseling. Both referred to the CPT guidelines for reporting E/M services, which must justify the level of service billed. Medicare’s policy states that time is the key determinant of E/M level of service when >50% of the face-to-face patient/family-physician encounter is dedicated to counseling.

http://jop.stateaffiliates-asco.org/September06Issue/214.pdf

Part D Plans Cover 75% of Cancer Treatments, Health Affairs Study Reports

Medicare prescription plans cover 75% of agents used to treat cancer, according to an analysis published in the current issue of Health Affairs. The study, by Bowman and colleagues of Avalere Health, reviewed cancer drug coverage offered by nearly 3,000 Medicare Part D plans’ formularies in January and February. The Washington-based health care advisory group self-funded the study. It did not examine data for infused chemotherapy drugs, agents used primarily in supportive care, or oral cancer drugs covered by Medicare Part B. It also did not evaluate beneficiaries’ access to drugs during the so-called “doughnut hole” gap in coverage.

Coverage differs significantly, however, and people with cancer should review prior authorization and other policies when choosing a plan, researchers cautioned.

Under a 2003 Medicare statute, Part D plans must cover “all or substantially all” antineoplastic agents. The study reported that plans cover 75% of anticancer treatments—99% to 100% of generics and about 70% of brand name offerings. Other findings include the following:

• The 20 most commonly prescribed anticancer agents were covered almost universally.
  
• About 10% of agents require prior authorization.
  
• Less than 5% of plans limit the amount of drug that a patient can obtain at one time.
  
• No plans require step therapy, in which patients must try lower-priced drugs before receiving coverage for more expensive options.
  
• Copays of $5 to $40 are more common than coinsurance. When coinsurance is applied, the most common proportion is 25%. Erlotinib is an example of an agent with a median copay of $40.

http://content.healthaffairs.org/cgi/content/abstract/25/5/1240

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=39925

http://www.avalerehealth.net/wm/show.php?c=1&id=724