The Opportunity for Innovative Thinking: Medicare Part D.

Stanley Feld M.D.,FACP,MACE

I said there was plenty of room for improvement of the healthcare system and innovation.

The Medicare Part D doughnut hole (coverage gap) is punishing to the over 65 year old. Pricing of drugs bought with Medicare Part D are inflated. The price of drugs is so high that when patients reach their coverage gap (doughnut hole) of $2510 to $5250 they can not afford to pay the inflated retail price for the medication. Therefore they do not take the medication and develop the complications of their chronic disease. The complications of chronic disease increase the cost of healthcare.

Medicare Part D recipients are driving an evolving innovative change in purchasing prescription medication. Since payment in the doughnut hole (coverage gap) is money out of the seniors pocket they are looking for ways to save money and still be able to afford their medication. They are demanding that their physicians write prescriptions for generic substitutes. Physicians want to help their patients. When they can, they are prescribing generics substitutes.

Patients then buy the generic without using their Medicare Part D insurance for $4.00 at Wal-Mart. They avoid the $6.00 out of pocket expense plus the additional $50 to $150 dollars charged to their coverage gap. They have also learned to ask their physician to double the dose of the dose generic medication. They then use a pill cutter to cut the pill in half to take the prescribe dose. They save even more money on their prescriptions.

This consumer driven initiative was stimulated by Wal-Mart. It has saved Texans $79 million since September 2007 and patients nationally $613 million.

The pharmaceutical industry has not done a good job influences patients or physicians to insist on brand name medication. Five years ago their influence on physicians was much greater. However, the pharmaceutical industry has killed the goose that provided the golden eggs. They have flood physician offices with account sales representatives. The pharmaceutical sales reps bring lunch, arranged dinners and do everything they can to influence physicians to use brand name drugs. The increase activity by pharmaceutical sales reps has backfired and has annoyed physicians. Most physicians’ offices will not let account reps into their office much less let them bring in lunch.

The pharmaceutical industry has not been innovative or effective in proving their drug is better than the generic substitute. The physicians’ reflex is they have been used. They are the generic drug movement.

It is innovations like Wal-Mart’s creating an opportunity for patient to save their own money that will stimulate more creative innovations for the benefit of the patients in the future. Price transparency for drugs has been exposed by the market place without the need for government regulation. It should be obvious to all that the price of brand name drugs are excessively high.

It must be remembered that without patients and physicians there would not be a healthcare system. Patients have the power to create change to their advantage with a little help from their physicians if they understand the defects in the healthcare system. Previous innovations by facilitator stakeholders have taken advantage of the healthcare system. It is now the primary stakeholders turn to be innovative with the help of innovative entrepreneurs.