Drug Coverage Lacking in ACA and Part D – Story

I was optimistic about health care reform and voted for Obama both times! However, I’m more disgusted everyday. I should have known that seeing what a debacle Medicare part D is that ACA wouldn’t help either.

I am a physician in internal medicine in Peoria IL. Luckily my practice has lower than average medicare participants because finding a way for them to get medications they need is not working. At least before part D, most elderly qualified for drug assistance programs. My mom for instance could get Forteo, a $300/month or more drug, straight from Eli Lilly for $12. If she still needed that drug today it would be a much different story.

What really confuses me is that I have read that Medicare Advantage plans get paid more for sicker patients. Isn’t that the opposite for pay for performance? Today I had a patient with Diabetes that hasn’t tolerated any of the generic medications and brand name drugs would cost her $325 towards her deductible and we estimate $75 per month as a copay per drug. So her A1c was 12.9 and I put her on generic sulfonylurea. I don’t care for that class of medication because it is felt to burn out the pancreas faster and lead to needing Insulin sooner but it has to be better than nothing. She took it 2 months and report abdominal cramping every single day so had to stop. She had daily diarrhea on metformin. So the only option I have since she can’t afford meds is to try and cover her with samples that I get from drug reps. Some doctors don’t even take samples anymore but I can’t imagine doing that because then how could I help my patients over 65 with limited incomes when they get to donut hole or can’t afford from the outset. If this person didn’t plan well for retirement that’s one thing but she has to pay for drug coverage that doesn’t cover her drugs. That doesn’t seem fair to me.

I also would like to know how I will be judged effective as a physician when faced with these barriers to treatment. Humana can audit me to see how many of my diabetics have an A1c less than 8.0 and yet they don’t cover the meds at a level these patients can afford. Shouldn’t they be the ones that are judged? How about the insurance companies get audited and regulated? I believe most physicians are following their professional oath and doing whatever they can to help their patients. So to “judge” our effectiveness on outcomes we can only contribute to in a very, very small way is ludicrous.

I hope this doesn’t fall on deaf ears. I want to see my patients get the care they need with LESS red tape. I don’t know who’s the voice of physicians anymore so I hope you will listen to this one person as a fair representation of what is going on in the trenches.

Sincerely,
Rebecca K, MD