Notebook: Medicare In Nursing Homes

Wyatt Andrews Looks At Drug Plan's Impact On Seniors And Doctors

(CBS) 
Kerr’s next patient has a host of ailments, one of which is incontinence. She also is unsteady on her feet. He wants her to take a drug called Enablex, which he says has the fewest side effects, but her insurance plan does not cover Enablex. A note from Kerr’s nurse says the insurance company wants him to call regarding this.

Kerr gathers up an inch-thick stack of papers to make an entire round of phone calls to various insurance companies, in an effort to do his hurdle jumping all at once.

His first phone call for a (different) patient is successful. He gets through immediately and the insurance company agrees to his request for a prior authorization. Great. But he has to call again in six months. And he — the doctor — has to call. It can’t be the nurse.

His second phone call regards the Enablex issue and winds up taking 25 minutes. The insurance company wants a letter faxed to them justifying the Enablex prescription. The company says it’s tier 1 (preferred) drug is oxybutinin, a suggestion that makes Kerr bolt upright. “Oxybutinin has too many side effects,” he complains on the phone. Kerr tells us later oxybutinin would make this patient drowsy and increase her risk of falls. “I can’t ethically do that!” he bitterly exclaims.

Later the insurance company offers Ditropan XL, which is extended release oxybutinin, but Kerr wants no part of it.

What did I take from watching Kerr fight these battles? First, I think we have to look at Medicare part D as a great thing for most seniors. (Maybe not for taxpayers, but let’s focus on seniors)

But the insurance industry needs to give nursing home patients a lot more latitude. Step therapy, for example, where they are asking very frail patients to fail on a cheaper drug, before covering more expensive therapies needs re-examination. Kerr reports that during an outbreak of infections last winter, the insurance companies demanded he try the antibiotic cipro, even as he protested it wouldn’t work. Two patients went to the hospital — at a cost to taxpayers that far exceeded the better drugs.

It’s also obvious the insurance companies should demand less of the doctors' time and allow prior authorizations and appeals to be handled by staff. If your mother was in this home, you would not want Kerr on the phone so much; you would want him out on rounds. Geriatric doctors have no time as it is.

So if you’ve ever wondered why critics call Medicare part D too complicated, consider Dr. Kerr’s daily math. His patients use six different insurance companies. That’s six different companies; all with different rules — which can change month to month — and you multiply all of that by some 300 patients.

And we just watched him for three hours.