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Covering Medicare, Getting Out Of The 202 Area Code

Since the inception of Medicare's prescription drug benefit roll out, correspondent Wyatt Andrews has been looking into the subject often on the "Evening News." On Tuesday, Andrews and producer Andy Triay delved into it again (and probably not for the last time) as the May 15 deadline to sign up approaches. The story focused on some of the difficulties that nursing home physicians are facing because of the new program. I asked them to discuss how the story came about and what some of the challenges were in putting it together. (You can watch the story by clicking on the image below and you can watch and an extended interview from the piece


Like most reporting enterprises, the story began with a lot of phone calls. They began by calling health care trade associations, who led them to doctors and other health care professionals to see what kinds of issues doctors were encountering with the new program. Many of the people they spoke with kept mentioning the difficulties that issues like "restricted access" rules on prescriptions were having on nursing home care in particular. As Andrews describes the nature of the problem in his Reporter's Notebook (which is also worth a read):
"… insurance companies can 'cover' a certain drug but still restrict access to that drug. They often demand 'prior authorization' for a covered drug, meaning the nurse or doctor has to justify the prescription in advance and in writing. The companies demand 'step therapy,' basically demanding that a senior citizen try a cheaper drug and fail, before moving on to a more expensive drug.

Restricted access rules are applied for safety and cost control reasons. The companies want to make sure they are covering properly prescribed drugs and — to make more money — they want to steer seniors toward the cheapest effective drug."

The hurdles that result from such requirements are magnified at nursing homes, as opposed to regular doctors' offices for several reasons, Andrews told me. For example, whereas in a typical doctor's office the elderly might make up something like 15% patients, in a nursing home, 100% of the patients are elderly and inevitably require more medication. Further, there are fewer doctors going into the specialty of geriatrics, as the population of elderly people increases.

Eventually, Triay and Andrews had a conference call with a handful of medical directors at nursing homes across the country, who spelled out their problems with restricted access.

Dr. Jeff Kerr was on the call and ended up being the subject of the piece. "He stood out because he spoke passionately about the issue," said Triay. Kerr "was an outspoken and articulate critic," said Andrews, who added that Kerr was also appealing as a subject because he wasn't from a big city, but Rolla, Mo., "in the center of the center of the country." Triay, who, is based in Washington, D.C., along with Andrews, said: "We try to get out of the 202 area code." Additionally, said Andrews, Kerr was particularly useful because the patients in the facilities he oversees are a "wide range of people with a range of income levels."

Ultimately, Andrews and Triay decided to focus the piece on Dr. Kerr's story – a typical morning in his office – because it was the best way to get a sense of how the issue is affecting doctors and their patients. With policy issues like this one, "it's important to personalize [the story] and see it through someone's eyes," Triay said. Viewing it from the perspective of someone who is experiencing the effects of a policy makes a complex issue "easier to understand."

Triay and Andrews also spoke with a number of other doctors to get an idea of how prolific the problem was, and most responded that they were having similar problems with the plan. "Every doctor I spoke to was having problems," said Triay. "We did a ton of reporting to make sure that this was not an extreme or isolated case," he added.

"I did speak with two or three geriatricians who were having no trouble with the plan," said Andrews, but they happened to have more infrastructure in place than most nursing home doctors to handle the increased amount of work involved with the program.

Andrews spoke with a number of government and industry officials as well, and mentioned their responses to what he'd found with Dr. Kerr toward the end of the piece. Why didn't Andrews include an on-camera interview with a Medicare official? "I give great credit to the government," for working on the problem, said Andrews, "but I didn't find their response as compelling as Dr. Kerr's morning."

Andrews expects that "the industry and the government would likely disagree that Dr. Kerr's problems are pervasive, but not that they don't exist." But, as Andrews mentions in the piece, about a week before their story aired, the insurance industry adopted a "standardized form that any doctor can use with any plan to appeal a drug denial" – an obvious effort to streamline a complex process. In addition, Triay told me that as they were researching the piece, the Health and Human Services Department Inspector General's Office opened an investigation into the problem. Why wasn't a mention of that in the piece? Time constraints. "I've learned that everything in the piece has to be good, but not everything good has to be in the piece," Triay said.

"One of the hardest journalistic questions is: when is an anecdote a national news story?" Andrews said. "I am convinced that this is a national news story. Is it happening everywhere? Maybe not. Is the government working to fix it? Yes. Are they [working] fast enough? No."

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