Dr. Dustyn Baker most recently completed her residency in Internal Medicine at the University of Chicago Medical Center, Chicago, IL. Her current focus on public health policy is related to the fact that Chicago is one of the top two cities in the U.S. with regards to hospitalization and deaths of asthmatics. This concern led her to help launch the Chicago BREATHE project, whose mission was to increase health literacy related to asthma and medical adherence for the largely black South Chicago population. Dr. Baker interned at the Department of Health and Human Services in Washington, D.C. as a program analyst after the passage of the Medicare Modernization Act. During that time, she was also selected as a Government Relations Intern for the American Medical Association. She has also held several leadership positions including Student Advisor to the Board of Trustees at University of North Carolina – Chapel Hill. Dr. Baker received her medical degree from Duke University Medical School, Durham, NC in 2007.
Dustyn Baker, MD, MPH
Internal Medicine Hospitalist, Weatherby Healthcare, Los Angeles, CA
The Medicare Part D Appeals Process: A Potential Barrier to Access?
The Medicare Modernization Act (MMA) of 2003 guaranteed the option of outpatient prescription drug coverage for seniors, thus increasing through the private insurance market. To ensure that all seniors have access to medically- necessary drugs, an appeals process exists in cases where a drug is restricted under a plan’s formulary.
However, observers of the multi-step Medicare appeals process note that the appeals system may be unreasonably burdensome for beneficiaries, given the requirement that the enrollee fill out detailed forms to initiate anappeal and understand the complex process.
Little is known whether the complex application process may disproportionately affect individuals who lack health care provider advocates. Most at risk may be racial/ethnic minorities who disproportionately get care in disjointed healthcare systems, are more likely to be health illiterate, and are less likely to have advocates. Therefore, we sought to explore potential barriers that beneficiaries encounter as related to the Medicare Part D appeals process and to identify the populations that are most impacted by such barriers.
To meet project aims we identified: (1) The readability of the Drug Plan appeals notices and forms needed for a senior to initiate an appeal, and, (2) potential problems with the current Medicare Part D initial redetermination request that could disproportionately limit the abilities of racial/ethnic minorities to appeal a coverage decision.
To evaluate readability we randomly selected plans through Medicare’s Drug Plan Data for 2011, as published by the Center for Medicare and Medicaid Services (CMS). From the websites of each randomly selected plan, we obtained (1) the Medicare prescription drug appeal form and (2) any descriptive explanation on the website for how a beneficiary should pursue an appeal. An independent health literacy expert then evaluated downloaded data. The expert assessed each plan’s data for its Flesch-Kincaid Grade and a qualitative analysis that included evaluation of the document’s style and content. A standard 12-question format was used in evaluating the qualitative portion.
To evaluate potential problems of the Medicare Part D Appeals process, a structured review of the literature and stakeholder interviews were performed.
Health Literacy evaluation identified overly complex, compound sentences with extended use of bureaucratic, legal, and medical language. The median Flesch-Kincaid score was grade 13 (equivalent to some college education) with a range of grade 7 to grade 21 (equivalent to greater than college education). Stakeholder evaluations and literature review identified that CMS requirements for timely appeals and notification to beneficiaries are often not met due to limited auditing capabilities by CMS. Furthermore, most at risk are individuals receiving care in disjointed medical systems.
The median Flesch-Kincaid Grade of 13 suggests that an individual would need at least some college education to understand and appropriately fill out the forms or need an educated advocate helping them with the process. Understanding how to initiate an appeal is an important patient protection mechanism and should be available for equal access by all seniors regardless of education level or presence of an advocate. Further research is necessary to understand the implication of such complicated forms and the complexity of the process on the ability of racial/ethnic minorities to gain access to prescription drugs.
Preceptor and Sponsoring Agency:
Dr. John Boyer, President and General Manager of Maximus Federal Services, Inc. and Mr. David Richardson, President of Federal Operations for Maximus