Preparing PharmD Students to Participate in Medicare Part D Education and Enrollment

Abstract

Objective

To create and implement a teaching module that prepares students to assist Medicare beneficiaries in evaluating and enrolling in Medicare Part D plans.

Design

A 6-hour module entitled “Medicare 2006: This Year, It's Different!”¹ was developed and first presented to students in February 2006. Material describing provisions of Medicare Part D was included as well as instructions on using the plan selection tools available on the Medicare web site. Learning activities developed included listing the top 10 things a Medicare beneficiary should know about Medicare Part D, participating in a mock patient counseling activity, selecting an appropriate Medicare prescription drug plan for a given list of drugs, and writing a paper explaining features of the plan they selected and justifying their selection.

Assessment

Assessment of the 64 students who completed the module was based on completion of individual Top 10 lists, participation in mock counseling sessions, and appropriate drug plan recommendations in plan selection assignments. Overall student response to the series was overwhelmingly positive.

Conclusion

Given opportunities to apply Medicare Part D knowledge in the classroom setting, PharmD students were able to empathize with the plight of elderly patients and took the initiative to participate in Part D education and enrollment efforts in their communities.

INTRODUCTION

With the institution of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), prescription insurance coverage became available to all Medicare beneficiaries for the first time in history through a new prescription drug benefit program, Medicare Part D.¹ Given the significant change in prescription drug coverage with Medicare Part D, it is no surprise that the response of beneficiaries, the majority of them senior citizens,² is laden with fear, anxiety, anger, and frustration. The primary methods of plan selection and enrollment offered by the Centers for Medicare and Medicaid Services (CMS) are via the Internet or the automated voice-recognition telephone system of 1-800-MEDICARE.¹ These technological advances are not types of communication with which many senior citizens are comfortable. In addition, because the number of prescription drug plans (PDPs) available in any given geographic region ranges from 40 to 60 plans,³ this vast array of choices leaves many Medicare beneficiaries confused about which plan to select and seeking help in evaluating their options. Half of all Medicare beneficiaries are expected to seek guidance from healthcare professionals, with 25% indicating that they will “very likely” seek help from their pharmacist and 75% stating that they expect their pharmacist to be “very” or “somewhat” knowledgeable about the prescription drug plan choices available.⁴ Therefore, elderly patients will be looking for someone to listen to their concerns, respond with empathy, and intervene with education to help them make informed choices regarding their prescription drug coverage.^5,6 The profession of pharmacy, then, is in a unique position to empower them with knowledge of the basic program structure and to help them sort through the drug plan options available in order to enroll. Pharmacy faculty members can prepare students to meet the demand for this needed community service by teaching them how to solve complex drug plan problems and to provide their elderly patients with the information needed to make educated decisions regarding their Medicare prescription drug plans.

At the conclusion of this module students should be able to: (1) describe standard and low-income provisions of Medicare Part D; (2) list formulary requirements for Medicare Part D plans; and (3) assist patients in evaluating and enrolling in Medicare Part D plans.

DESIGN

Aging and Drug Use in the Elderly (PHAR 426) is a 3-hour elective course open to students in the second- and third-professional years of the doctor of pharmacy (PharmD) program. The course focuses on topics relevant to prescription drug use in the elderly population, including patient adherence and prevention of medication-related problems. Substantial evidence exists that patient adherence to medication regimens will decrease when costs become a concern, especially in the elderly population.^7-9 Many of the elderly have relied on various discount cards and patient-assistance programs to help ease the burden of high prescription drug costs in the past. However, the changes brought about by the MMA and the implementation of Medicare Part D will require all Medicare beneficiaries to make a decision about prescription drug coverage.

The author has extensive experience assisting Medicare beneficiaries with PDP selection and enrollment, and was invited to be a guest lecturer in this course. The course is offered during the spring semester, so the first presentation of this module coincided with the initial enrollment period for Medicare Part D (November 15, 2005, to May 15, 2006). The lesson was designed as a reality-based educational experience to provide students with opportunities to practice utilizing the Web-based resources available to Medicare beneficiaries, evaluate the drug plan options available to them, and adapt their counseling skills to elderly patients with many unanswered questions. PowerPoint slides used by the author to facilitate presentation of lesson content were available to students on the class web site in Blackboard. Students were also required to access the Prescription Drug Plan Finder on the Medicare web site³ and Medicare & You, the official government handbook on Medicare published by CMS.¹

Overview of Medicare Part D

Beginning January 1, 2006, prescription drug coverage was made available to all Medicare beneficiaries, regardless of income, through enrollment in a Medicare PDP. CMS contracted with private companies to negotiate discounted prices on prescription drugs on behalf of enrollees in their PDPs. Although the exact costs vary among plans and across states, the standard Medicare Part D plan has a monthly premium, an annual deductible, varying copayments, an initial coverage limit (widely known as the beginning of the “gap” or “donut hole”), and a catastrophic level. Once the deductible is met, beneficiaries pay approximately 25% of drug costs between the deductible and the initial coverage limit. Since Medicare Part D was originally designed to provide catastrophic protection for Medicare beneficiaries with large drug bills, plan enrollees are then responsible for 100% of drug costs between the initial coverage limit and the catastrophic level. After the catastrophic threshold is reached, Medicare pays approximately 95% of all annual drugs costs thereafter. Although costs are expected to increase yearly, the same process starts over each year. Medicare beneficiaries whose incomes are below 150% of federal poverty level and who meet certain asset restrictions may receive government assistance with premiums, deductibles, and prescription drug costs. These low-income beneficiaries have a similar plan structure, but without gaps in coverage and with much lower out-of-pocket costs based on income. Senior citizens with Medicaid prescription drug coverage who are eligible for Medicare will have their drug coverage transferred to Medicare upon becoming eligible.¹

When Medicare Part D was implemented, all beneficiaries had 6 months, from November 15, 2005, to May 15, 2006, to make a decision and enroll in a PDP. However, individuals who are newly eligible for Medicare have a 7-month period, beginning 3 months before their date of Medicare eligibility, to join. Although enrollment is voluntary, participants who choose not to enroll during the required enrollment period pay a penalty in the way of increased monthly drug plan premiums when they do enroll. This penalty applies for every month the person was eligible for Medicare Part D and did not apply. The beneficiary must also wait until the next open enrollment period in November of that year to join, with benefits being delayed until the following year, thereby increasing the penalty.¹

Every Medicare beneficiary must decide whether to enroll in Medicare Part D based on his or her current prescription drug coverage. For some beneficiaries with other prescription drug coverage, the choice is further complicated. Medicare beneficiaries who have other government insurance with prescription drug coverage, such as Federal Employee Health Benefits (FEHB), veterans' (VA) benefits, or military benefits (TRICARE), may choose to keep their current coverage, as these programs likely provide greater cost savings than Medicare Part D. If these beneficiaries lose their coverage, they may join a Medicare drug plan, without a penalty, within 63 days of losing their prior coverage. Furthermore, beneficiaries with prescription drug coverage from an employer or union must also choose whether to continue their existing plans. Employers and unions must notify beneficiaries of the extent to which their plans are at least as good as Medicare and are considered creditable coverage. Beneficiaries without creditable coverage must join a Medicare PDP within the given enrollment period to avoid a penalty. Beneficiaries with creditable coverage have a few options. They may choose to keep their employer-sponsored drug plan or they may add a Medicare PDP to the employer-sponsored plan for more complete coverage. However, joining a Medicare drug plan may limit or end their employer-sponsored coverage. If beneficiaries choose to remain with their creditable plans and involuntarily lose their coverage, they will also have 63 days from the date coverage is lost to enroll in Medicare Part D without paying a penalty. A third option also available to these beneficiaries is to completely drop their current coverage and enroll in Medicare.¹

After deciding to enroll in Medicare Part D, beneficiaries must then select a PDP that meets their individual drug needs and is accepted at their pharmacy of choice. Plans vary greatly in the drugs covered, costs involved, and participating pharmacies; however, CMS ensures that all PDPs meet minimum formulary requirements and plan specifications. Once a PDP is selected, beneficiaries are prohibited from changing plans for the remainder of the plan year, with a few exceptions. Beneficiaries may switch plans yearly during the annual open enrollment period from November 15 to December 31 of each year. Dual eligibles, however, may change PDPs at any time during the year.¹ Because there are so many regulations and so much is at stake, it will be important for those who will be called upon for help to be ready to provide the information and assistance needed.

Course Module

Many components of Medicare Part D are complex and difficult to understand, especially when trying to passively absorb a vast amount of material and numerous facts and figures. Therefore, this module was designed to include multiple types of activities in order to facilitate the learning of this complicated program and to maintain student interest. Prior to the first class, students were asked to read the sections of Medicare & You ¹ that describe the provisions of Medicare prescription drug coverage, the benefit structure, the costs involved, enrollment instructions, and subsidies available for low-income beneficiaries. Students were instructed to read these sections twice: first, from the perspective of naive senior citizens who had just received this 104-page book in the mail and were faced with understanding the content of the book enough to make choices that would affect the rest of their lives, then second as themselves for understanding in order to be prepared for class discussion. At the beginning of the first class, students were asked how they felt the first time they read the material and if they understood it. Most admitted feeling great confusion on the first read and frustration even after the second time through.

Following this commentary-focused introduction to the module, the first 2 hours of the lesson were organized to be presented in the traditional lecture format using PowerPoint slides to illustrate standard and low-income provisions, formulary requirements, and enrollment information for Medicare Part D. (A detailed outline of lecture content is available from the author upon request.) It is accepted that some complex concepts should be introduced in a traditional lecture format for knowledge and comprehension before students are asked to engage in higher-order thinking skills of application, analysis, synthesis, and evaluation.¹⁰ Since the author has extensive personal experience with educating Medicare beneficiaries on this program, however, several “real-life horror stories” were planned during the lecture to break the monotony of a passive lecture format. These stories allowed the author to give insight into the emotions surrounding a very confusing time in the lives of many elderly adults.

Prior to beginning the second class period, the material presented during the previous lecture was reviewed. The second session consisted of facilitated online navigation through the Medicare Prescription Drug Plan Finder available on the Medicare web site.³ Again, firsthand experience with the plan selection and enrollment process was an advantage in this lesson in that the author was able to point out “tricks” for using the Plan Finder and to identify changes in the navigational structure of the web site as they were made (in one instance, the day the change occurred). The author was also able to identify features of individual drug plans that are only learned from experience, such as which plans offer “free” generic medications. In this particular class, students were indeed learning about current events in the profession of pharmacy. At the end of the class period, students were instructed to spend some time navigating the Medicare web site on their own before the next session.

“Meaningful learning is facilitated by articulating explanations, whether to one's self, peers, or teachers,”¹¹ so these preparatory activities culminated with an opportunity for students to apply the information they learned in a mock counseling session. Students were divided into 5 groups for the next class period and asked to nominate a spokesperson for the group. Each member of the group was instructed to develop a list of “The Top 10 Things Every Medicare Beneficiary Should Know About Medicare Part D.” Group members then submitted their Top 10 lists to the group spokesperson who was assigned the task of using the lists as background information to counsel a Medicare beneficiary, a dramatic role played by the author, during the next class. These 10-minute mock counseling sessions were designed to illustrate the wide range of questions and emotional situations that a pharmacist may encounter when counseling an elderly patient on Medicare Part D options, with challenges from the author reflecting actual experiences with Medicare beneficiaries. Based on the information provided and the spokesperson's ability to meet the challenges presented to them, groups were subjectively judged by student peers on an evaluation scale of 1 to 4 (1 = below average, 4 = superior), with the prize being class bragging rights. Fourth-year PharmD students who had experience providing Medicare Part D education in the author's advanced practice clerkship served as judges to remove perceived evaluation bias associated with an in-class group competition. Students were evaluated on eye contact, voice (volume and enunciation), appropriateness of vocabulary, content presented, comprehension of material, ability to answer questions, adherence to the time limit, and overall presentation.

The module concluded with an individual assignment in which each student was given a different list of drugs taken from real patient cases in the author's clinic and instructed to use the Medicare web site to select an appropriate Medicare drug plan for the given drugs. The pharmacy school's computer laboratory was utilized for this class segment. Students were allowed to make some choices for their “patient,” including the zip code in which the patient lived and the patient's pharmacy of choice, but they were instructed to assume that the beneficiary did not qualify for government subsidies to help pay the plan's premium or deductible. Students were told to use their professional judgment to select 2 or 3 Medicare PDPs which might be suitable for their hypothetical patient. Using data for the selected plans and the plans' premiums, deductibles, and prices for each drug, students were instructed to write a paper comparing the 3 plans and justifying their choice. Students were not given any length restrictions for their writing; however, they were told that the author should not have any unanswered questions after reading each justification. Students submitted their price comparisons and justifications at the next class meeting.

At the end of the module, students were given the opportunity to become a part of the CMS MedicareRx Volunteer Initiative. This national initiative effort matches volunteers with local community organizations to provide one-on-one assistance to Medicare beneficiaries in need of PDP information and enrollment assistance.¹² Those students who participated in the initiative received packets from CMS which contained materials to assist them in their volunteer efforts. Students were also encouraged to complete the University's standard online course evaluation survey at the end of the semester for the author's lectures in this elective course. The survey used a 5-point Likert-type scale, with 5 being positive (ie, 5 = strongly agree and 1 = strongly disagree).

ASSESSMENT

Student performance on the 3 evaluative exercises of this module was very successful, with average scores on the individual Top 10 lists, mock counseling sessions, and individual Medicare plan selection assignments all at or above 90%. Students' responses on the course evaluation survey items were also uniformly positive, with the author's scores ranging from 4.6 to 4.8.

As the author predicted, real cases of the emotional struggles of Medicare beneficiaries prompted many student questions that actually anticipated lecture content planned for the class period. So, although much of the material was organized as a traditional lecture, once students started asking questions, many of the teaching moments were actively led by student inquiry into the lecture content rather than passive absorption of the author's narration of slides. Once again, students expressed the frustration that must be felt by elderly Medicare beneficiaries. This feedback and interjection of personal opinions about the complexity of the program provided the author with illustrations of the students' ability to empathize with their elderly patients. In addition, the author's personal experience with the implementation of Medicare Part D since it first appeared “on the scene” was advantageous in that the author was in a position to provide information that was not available in any textbook. The mock counseling sessions were also well-received by students. Just as the author's real-life stories prompted questions during the first class session, the role-playing situations led students to anticipate what might occur given various patient circumstances.

DISCUSSION

By learning to outline the basic provisions of Medicare Part D, summarize the benefits of participation in the program, and evaluate available options, students learned to provide information on a complex program in a stepwise manner. Given the complex design structure of Medicare Part D, it was beneficial to present students with “the facts” and then give them opportunities to apply the facts they learned to multiple case-based problems.

Class participation in the CMS MedicareRx Volunteer Initiative was not one of the original expectations of the course module. The author was notified of the creation of this program by CMS and received the request to participate in the initiative on the last day the module was taught. The opportunity was then offered to students at the next class meeting. Since only 16% of students in the class volunteered for the program, the author would not consider the participation rate as successful as one would like. Consequently, inclusion of this volunteer initiative as a service learning activity has been incorporated for subsequent offerings of this series. Those who did get involved, however, reported having received requests for assistance with enrollment programs from social service entities and non-profit organizations. Several students in the class also reported providing Medicare Part D information and enrollment assistance in their roles as pharmacy interns at local pharmacies and at pharmacies in their hometowns in other regions of the state almost 1 year after completing this lesson. One student even reported being asked by her supervising pharmacist to help educate the pharmacy staff on Medicare Part D. On a personal note, many were also able to help their grandparents choose and enroll in plans.

The technical components of Medicare Part D can be “learned,” but the emotional aspects associated with this program can only be “experienced.” Tales of elderly widows having to make difficult financial decisions alone for the first time in their lives illustrated to students the nurturing human qualities necessary to be a caring pharmacist. In the process, this created a classroom environment in which students felt comfortable enough to speak up. One reward to the author was the opportunity to witness the development of compassionate future pharmacists during the course of the module. As Berger states, “The pharmacist who sees the patient as one who is struggling with the process of change and respects the patient and the struggle will be far more successful.”¹³ By teaching students to respond with caring, concern, and comfort, we can ensure that they will support their elderly patients through the many changes they will face with regard to their prescription drugs.⁶

The new Medicare & You handbook published annually by CMS describes all plan-year changes in detail. The navigational design of the Prescription Drug Plan Finder on the Medicare web site has also undergone several changes since the initial enrollment period. These changes will therefore require regular updates to the content of this module. At the time this lesson was originally presented, the technology configuration of the classroom used was such that wireless Internet was not available. This deficit somewhat limited teaching of the use of the Medicare Prescription Drug Plan Finder to instructor-led illustration via large screens in the front of the room. Classrooms with wireless access will allow students with laptop computers to navigate the system along with the instructor for future presentations of this module. One unique modification being considered by the author for future role-playing sessions, however, came from a suggestion by a student prior to the first mock counseling session. “If you're going to act like a Medicare beneficiary, are you going to dress up like a stereotypical senior citizen, too?” Whether costume changes are involved or not, training future pharmacists to meet the needs of the growing elderly population with an understanding of this complex health care program is an invaluable asset to the elderly community and the profession of pharmacy.

SUMMARY

The desired outcome for this lesson was for students to be able to assist Medicare beneficiaries with the decision-making process during this confusing time, and the successful participation of the students in Medicare Part D education and enrollment efforts in their communities indicates that they were well-prepared for the task. Students who have a firm grasp of the basic provisions of Medicare Part D and some of the idiosyncrasies of the plan selection process will be able to quickly adapt to the expected annual changes in plan structure.