Strengthening and protecting Part D is an important challenge

It is difficult to remember now, but prior to the enactment of Medicare Part D in 2003, millions of Americans who relied on Medicare for their health-care coverage, did not have access to a comprehensive prescription drug benefit. My, how times have changed.

On Sept. 18, an historic summit was convened to celebrate the 15th anniversary of Part D. Attendees heard from patient advocates, experts and policy makers who have seen firsthand Part D’s life-saving impacts. We were also honored to be joined by the man who signed it into law — President George W. Bush.

{mosads}Today, Part D boasts a vibrant marketplace, robust enrollment and diverse plan offerings. More than 43 million Medicare recipients — nearly one in eight Americans — benefit from this remarkable bipartisan achievement, nearly double the 22.5 million enrollees when the program began.

The rising enrollment is partially due to Part D’s incredible popularity among those who use it. Medicare Today’s 2018 Senior Satisfaction Survey of approximately 2,000 seniors conducted by Morning Consult found that nearly 85 percent of seniors are satisfied with their Part D coverage.

In addition to its popularity, Part D has been instrumental in improving the health for many people. Several studies show that Part D has prevented diseases, improved survival rates and cut down on the number of hospitalizations. It has also consistently beaten initial cost projections — costing taxpayers $555.8 billion less than originally projected.

I believe its biggest success, however, is its ability to improve lives. As the deputy executive director of the AIDS Institute, I can tell you that without Part D, those living with HIV/AIDS would surely see an increase in the number of hospitalizations, worse health outcomes and lower quality of life. This is particularly true as people with HIV are living longer and age into Medicare. Simply put, Part D is saving and prolonging the lives of millions of Americans.

Although Part D has been wildly successful since its launch, we cannot lose sight of looming challenges.

Many beneficiaries are being confronted with issues dealing with access and overall affordability. Increasing financial challenges, including specialty tier and non-preferred drug cost-sharing, the lack of an annual out-of-pocket maximum and prices that do not reflect manufacturer rebates and discounts add to these challenges. Additionally, beneficiaries may not have access to preferred access pharmacies that could offer low cost-shares.

Without congressional action, beneficiaries will experience added costs as the amount of drug spending before reaching the catastrophic coverage phase will increase $1,250 by 2020. This “out-of-pocket cliff,” combined with other proposed policy changes, could devastate beneficiary access to necessary medications.

Another factor in high out-of-pocket costs is the actual drug price that beneficiaries must pay, particularly in instances where a beneficiary faces a deductible or a coinsurance. In Part D, the price — during the deductible phase or a coinsurance for the drug — is based on the list price and does not account for any rebates or discounts that might actually reduce the overall price.

Further complicating matters for people are that many Part D plans require a coinsurance, rather than copayments, for non-preferred brands. Coinsurance for these tiers can be up to a staggering 50 percent. For drugs covered on the specialty tiers, the coinsurance amounts can range anywhere from 25 to 33 percent, leaving beneficiaries paying thousands of dollars in out-of-pocket costs for drugs and biologics used to treat cancer, multiple sclerosis, rheumatoid arthritis, HIV, hepatitis C and other conditions.

Other policies are also placing unnecessary barriers to patients’ access to the medications recommended by their physicians. For example, “fail first” policies require beneficiaries prescribed an expensive medication to first use a less expensive or plan-preferred medication and experience that medication’s failure before the plan will pay for the original, more expensive prescription.

As policymakers and others discuss future changes to the Medicare Part D program, I am hopeful they will pay special attention to ensuring that every beneficiary has timely, affordable access to the medications they need to live a healthy life.

Solutions should focus on improving the exceptions and appeals process, providing greater formulary oversight, implementing an out-of-pocket cap, applying rebates at the point of sale and ensuring manufacturer discounts are a component of true out-of-pocket costs.

The task of strengthening and protecting Part D is a challenging one, but if the beneficiary remains the focus, significant and lasting improvements for all are well within reach.

Carl Schmid is the deputy executive director of the AIDS Institute, a national nonpartisan, nonprofit organization dedicated to supporting and protecting health-care access for people living with HIV/AIDS, Hepatitis and patients living with chronic diseases.