ESRD, transplant patients, experiencing Medicare Part D problems - AKF survey.

Americans with End Stage Renal Disease (ESRD) are experiencing significant problems with the federal government's Medicare Part D prescription drug program and are reaching the notorious "doughnut hole" faster than most beneficiaries, according to a new survey conducted by the American Kidney Fund (AKF).

The Medicare Part D coverage gap i.e. doughnut hole occurs when a beneficiary has used $2,400 to cover medication costs. When that occurs, no additional expenses will be provided to patients until covered expenses reach $5,451. Once patients reach the catastrophic limit, Medicare Part D pays 95% of their drug needs.

The AKF survey, which was conducted with almost 700 social workers from dialysis centers and transplant centers who were working with more than 58,000 kidney patients, approximately 15% of the total number of kidney failure patients covered under Medicare Part D.

In brief, the AKF survey found:

*Nearly 60% of kidney failure patients have problems paying for their medications while in the coverage gap;

*Kidney failure patients are likely to be unaware of the Medicare Part D programor, when they are aware and seek to enroll are likely to experience administrative difficulties during the enrollment phase;

*Have prescription drug costs that are twice as high as the average Medicare beneficiary, making it more likely they will experience difficulties filling the coverage gap, and consequently may forego medications;

*Overwhelmingly, kidney failure patients face significant problems accessing medications through their Part D plan's formulary; and

*Many patients report having difficulties paying premiums or deductibles.

"These survey findings confirm that patients with kidney failure are having serious challenges with Medicare Part D for several reasons. Most notably, these patients often reach the coverage gap (doughnut hole) phase of the program faster than other beneficiaries because their medication costs are often twice as high," said LaVarne Burton, AKF CEO. "When kidney patients are in the coverage gap, they have difficulty affording the out-of-pocket costs of treatment and often forgo essential medications."

The survey did not distinguish between ESRD patients and transplant recipients.

Beth Witten, Medicare Modernization Program Manger for the National Kidney Foundation, told Transplant News that while transplant recipients are continuing to experience "serious problems" the number seems to be dwindling.

Witten provided a snapshot of recent problems reported to her.

*At least one pharmacy has knowingly billed Part D claiming the patient didn't have a Medicare covered transplant i.e. the patient did have a Medicare covered transplant, to get payment under Part D. Witten says she suspected the pharmacy doesn't have a Medicare Part B provider number and suggested to the social worker they report it to the Office of the Inspector General.

*A patient who was approved for backdating of Part D extra help was refused reimbursement by the plan and the pharmacy. The Centers for Medicare and Medicaid Services (CMS) had to be involved to solve the problem.

*A Medicare Advantage (MA) plan covered cyclosporine under its Part B benefit but required prior authorization for Myfortic which is also Part B covered. Witten says the pharmacy that billed it said rumor has it that MA prescription drugs get more money for Part D than for Part B drugs. She has reported it to CMS but has not heard that it has been resolved.

AKF grants program established

AKF said it used the findings from the survey to develop a Medicare Part D Grant Program for Prescription Bone Disease Medications. The program, which is open to eligible dialysis patients in the US, offers up to $2,000 per year in Part D prescription assistance for the costs of bone disease medications.

However, the AKF's fund also helps enrollees with their costs while in the coverage gap and says the assistance from the program counts towards patients "true-out-of-pocket" (TrOOP) costs. Under Part D, out-of-pocket costs must be categorized as TrOOP costs in order for the patient to move to the catastrophic coverage level under which Medicare covers 95% of drug costs.

AKF said dialysis patients who are not currently in the coverage gap may get grants from the program that can be applied to the patient share of the cost of obtaining bone disease medications. The program covers commonly prescribed bone disease medications, including Fosrenol, Hectorol, Phoslo, Renagel, Sensipar, and Semplar. Complete eligibility requirements and applications are available online at www.kidneyfund.org. A PDF of the entire survey is also available at the same Web site or by calling [phone].