The purpose of this essay is to discuss Medicare Part D, as well as the influence of the various interest groups and governmental entities during this process. This essay will discuss both the policy process and the policy environment (the key players involved and other circumstances that shaped this policy-making effort), how stakeholder groups influenced the final outcome of Medicare Part D legislation, the specific strategies and tools that were used most effectively, and if the fact that Medicare Part D passed corresponds with my understanding of policy and politics.
Medicare Part D, also called the Medicare prescription drug benefit, is a United States federal-government program to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries in the United States. Enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006 (Wikipedia, 2010).
In December 2003, the Medicare Prescription Drug, Improvement and Modernization Act (MMA) became law. The act created the Medicare Part D drug benefit to provide drug coverage to elderly and disabled people who did not previously have it.
The stand-alone prescription drug plans that are the lynchpin of the program did not previously exist. The structure of the program is clearly intended to increase the role of private plans in Medicare (The Commonwealth Fund, New York, 2006). Prescription drug coverage under Medicare Part D will not be offered directly by Medicare but by private prescription drug plans and Medicare Advantage organizations. The law outlines the standard benefit, but the private plans can modify the benefit design.
The private plans set their premiums, design their own formularies and are free to use cost management tools such as prior authorization, step therapy, or quantity limits. Medicare reimburses plans for a share of their drug costs (The Commonwealth Fund, New York, 2006).
The various stakeholder groups that influenced the final outcome of Medicare Part D legislation are democrats, advocacy groups, US senate, the Bush Administration, and republicans. The democratic lawmakers wanted to see a variety of legislative changes to the Medicare Part D drug benefit including: more drugs added to the formularies drug plans cover, a delay in the deadline for beneficiaries to sign up for the drug benefit. Beneficiaries who enroll after the deadline must pay a higher premium which is increased by 1% of the premium amount for each month not enrolled for the duration of their participation in the program. Individuals who first become eligible for Medicare after December 31, 2005, are given 3 months later their date of eligibility to enroll in the program before they are subject to the late enrollment penalty.
Democrats argue that beneficiaries need more time to consider their options to decide among the many different private health plans (The Commonwealth Fund, New York, 2006). Democrats proposed that Medicare drug plans be required to provide beneficiaries with a 60-day supply of any drug that is not covered by the plan and to provide a 60-day supply of medication when a pharmacist cannot confirm a beneficiary’s enrollment in a Medicare drug plan. They also propose creating a standardized appeals process, with medications provided during the appeal. Other provisions include prohibiting drug plans from eliminating medications from a formulary once a beneficiary has enrolled or from raising the cost of drugs in mid-year, and beneficiaries could change drug plans if a plan did not cover needed medications.
Democrats have also proposed requiring Medicare to reimburse family members, charity organizations, and states that covered drug costs for beneficiaries unable to obtain drugs because of administrative problems with the drug benefit, and allowing pharmacists to bill Medicare directly for prescription costs for beneficiaries whose enrollment could not be confirmed because of administrative issues (American Health Line, 2009).
The advocacy groups such as the National Mental Health Association, the Epilepsy Foundation, Paralyzed Veterans of America, and United Cerebral Palsy called for changes in Medicare Part D to guarantee prompt reimbursement to beneficiaries who have been overcharged for copayments and pharmacists who have covered the cost of medications for beneficiaries because of problems with the drug benefit (American Health Line, 2009). AARP, a membership and advocacy organization which represents over 35 million people over age 50, supported the MMA and prescription drug bill. AARP’s support was considered a critical factor in the bill’s passage. “AARP believes the Medicare Prescription Drug Program is an important step in providing access to affordable prescription drugs for older Americans and those with disabilities (AARP , 2008). The US Senate, on March 15, 2006, approved an amendment to the fiscal year 2007 budget resolution that would authorize (but not require) Health and Human Services Secretary Michael O. Leavitt to extend the May 15 enrollment deadline.
The Bush administration does not support extension of the deadline. The Bush Administration and Republicans argued that implementation problems with Medicare Part D should be fixed by management tools, rather than legislation. Signing up for Medicare part D would require a lot of time and getting the word out to the individuals that qualify then the questions they may have would require a strategic plan. The plan that I found related to the Medicare part D policy is the Outreach strategy. Several key challenges were identified when conducting Part D outreach. Dual eligible enrollees are going to receive several mailings from different federal agencies, so they may feel swamped with complex materials, many state agencies and organizations are also conducting outreach to their consumers at the same time, much of the federal and state outreach on Medicare is targeted to people age 65 and older, rather than to adults with disabilities, states must be prepared to deal with low-income subsidy applicants, who may apply at either local Medicaid offices or through the Social Security Administration (NCHSD, 2005).
To address these many challenges, a multi-pronged approach to reaching Medicaid enrollees with information about Medicare Part D, combining a variety of methods. The first method is direct mail could be a letter with detailed information about Part D, a brochure with information and suggestions for further action, or a simple postcard offering further assistance. Because CMS and SSA are sending out letters, there is some concern about adding to the volume of mail enrollees are going to receive during the coming months. Enrollees may not pay attention to mail, especially if it’s hard to understand. Mailing address information in state Medicaid files is often inaccurate. Finally, literacy and language barriers must be considered. Direct mail campaigns will want to make sure their materials are clear, concise, informative and accurate.
The next strategy is outreach events such as stand-alone conferences or participation in a disability-related conference. A strategy that Louisiana intends to use is to invite dual eligible MBI enrollees or potential enrollees to a conference at which they will learn basic information about Part D and also have the opportunity to participate in one-on-one counseling about Medicare Part D. The conference will include a meal and enrollees will be invited to bring along family or other people who help them make decisions about healthcare. These types of events can address the importance of family members’ role and their need for information, as well as the consumer’s need to get information from a trusted resource (NCHSD, 2005). Telephone Information and 800 Lines are another useful tool.
A toll-free telephone line to make information about Medicare Part D available. This approach could be very important in reaching individuals who don’t read or are uncomfortable with written materials, or who don’t use the Internet. This approach presents the challenge of staffing the phone with people who can provide accurate information, and publicizing the existence of this resource (NCHSD, 2005). The last outreach strategy would be the use of the Internet. Internet may prove to be a useful tool in making accurate information available and accessible to a wide range of individuals and organizations who are disabled and can’t leave home to attend outreach clinics and are more comfortable researching the material on their own. The Medicare part D policy was a surprise to me, mainly because of the cost, the drugs that are not allowed, the enrollment process, and the amount of time it took for it to be passed. The more I researched articles and read comments this policy seems to be mainly for pharmaceutical companies’ profit, instead of for the consumers.