Despite the important good things about the March 10 Guidance, there are still a number of issues that are pretty bad.
- There was no reference in the Guidance to address the challenge or complexity of determining related/not related to the terminal illness. Although requiring a prior authorization process for all drugs infers there may be unrelated drugs that Part D must cover, providing education to Part D plan sponsors would have mitigated some of the damage from CMS' previous all or nothing stance related to certain classes of drugs.
- The requirements related to prescribers unaffiliated with the hospice are horrible. This is actually very close to ugly. CMS states that "To ensure care coordination, we believe prescribers who are unaffiliated with the hospice provider, in addition to providing the explanation regarding why the drug is unrelated to the terminal illness or related conditions, should also attest that they have coordinated with the hospice provider and the hospice provider confirmed the unrelatedness of the drug." Does anyone want to guess a) how hard this will be to implement; and b) the chilling effect this may have on hospice referrals as attending physicians and other prescribing referrers consider this additional hassle factor of working with hospices?
- There is no standardized form for the prior authorization process, although CMS did provide data elements that may be used. Hopefully these data elements will be adopted by most hospices and plan sponsors in order to eliminate the inevitable variability and inconsistency that is likely to occur without a standardized form.
- The prior authorization process and the hoops hospices will need to hop through in order to have unrelated medications covered by Part D are overwhelming. NHPCO has provided an excellent Compliance Guide to Part D on what hospices need to do to comply with the prior authorization requirements specified in the Guidance. The problem with it, through no fault of NHPCO, is that it is 10 pages long!! 10 pages! The systems and processes hospices will need to develop and implement in order to deal with this effectively are particularly challenging when at the same time hospices are dealing with getting ready for the Hospice Item Set, multiple new reporting requirements and ICD-10. Oh yes, and there are patients and families in need of care in the midst of it all...
What else? Did I miss any other bad things? Let me know in the comments section below.
Now for some concluding thoughts...
Posted by Heather P Wilson, PhD, CEO, Weatherbee Resources, Inc