Q. What is Medicare
Part D?
A. Congress approved
the Medicare Modernization Act in 2003 to provide affordable prescription drugs
to seniors and the disabled. It took effect in 2006. Some 36 million people are
now enrolled in private insurance plans that pay most of the cost of their drugs.
Medicare spent $62 billion subsidizing the program last year.
Q. Where does this
data come from?
A. When pharmacies
dispense prescriptions to Medicare patients, they transmit information to Part
D plans about the patient, the prescriber, the drug, its strength and retail
cost. The plans pay the claims and then submit the data to the Centers for
Medicare and Medicaid Services, which oversees
Medicare. ProPublica obtained and analyzed data for
2007-2011 for this project. We are currently displaying data for 2011 —
covering more than 1.1 billion prescriptions and refills. (We had previously
displayed data for 2010; that information is no longer available.)
Q. Why is my health
provider not in here?
A. Medications
administered to Medicare enrollees during an office visit or in a
hospital are covered by another part of Medicare, not Part D. That means they
will not show up in our data. In addition, providers who did not write at least
50 prescriptions (including refills) of at least one drug under Medicare Part D
will not show up. Nearly 364,000 providers are reported on Prescriber Checkup.
Q. How do you know a
provider’s specialty?
A. We used the primary
specialty chosen by the health professionals themselves. Providers are required
to identify this specialty when they apply for a federal health care ID number.
(In cases where we did not have a prescriber’s ID number, or if a specialty is
not specified, no comparisons are shown in Prescriber Checkup.) A provider’s
chosen specialty doesn’t always mean the person has special training or
certification. For example, some doctors select a specialty called
“Specialist,” which can be a catchall for providers of different fields.
Be
aware that doctors may have incorrectly entered their specialty or may have
changed specialties without updating their profiles. Some classified themselves
as a group practice; we identified this in parentheses next to the specialty.
The date each provider updated his or her profile is noted.
Q. What does it mean
if my doctor has longer or shorter average prescription lengths?
A. When a provider
writes a prescription, he or she specifies how many days the patient should
take it. We looked at the average length of prescriptions for every drug and
every provider and compared it to peers in the state. In some cases, for
example, a provider may write shorter prescriptions while adjusting a patient’s
medication. That could make the provider’s prescription count appear higher
than peers. On the other end, if providers write prescriptions for more days
than average, they may have fewer prescriptions.
Q. What about the
cost of drugs?
A. Each prescriber’s
profile page notes the total retail price of their drugs and the average price
per prescription. These prices include patients’ copayments and the amount
reimbursed by Part D insurance plans. But the costs do not reflect confidential
rebates that drug companies negotiate with insurers. As such, the listed price
is likely to be higher than the final price paid. A report
from the inspector general of the Department of Health and Human Services calculated
overall manufacturer rebates of 19 percent for the 100 name-brand drugs that Part
D spent the most money on in 2009.
Q. Why do you display
the percentage of a provider’s claims that are covered by the low-income subsidy?
A. The low-income
subsidy has been an integral component of Part D from the start. The government
picks up the vast majority of drug costs for the poor, making a generic drug no
more than $2.65 and a name brand no more than $6.60. As a result, poor patients
and their doctors have little financial incentive to choose a generic over costlier
name brands.
Q. Why is a
provider’s percentage of name-brand drugs relevant?
A. About three-quarters of drugs of drugs dispensed in Medicare are generics. When doctors choose more name brands, their costs are typically higher. Generics often work the same as name brands and have the same active ingredient. Although some medications do not have exact generic versions, there usually is a similar one in the same category. A doctor’s percentage of brand-name drugs may be a gauge of how cost effective
that doctor’s prescribing is. Specialists who treat some conditions, such as
HIV/AIDS, use more brand-name drugs because there are few available generics to
treat them. Also, a small number of hospitals and health centers serve as safety net providers for the poor and receive rebates from pharmaceutical companies for name-brand drugs they prescribe, under a federal program distinct from Medicare. (It does not apply to physicians in private practice.)
Q. What does the bar
graph in the “Another View” section of a
provider’s page mean?
A. Prescriber Checkup features a
chart comparing prescribers to others in their state and specialty. It clusters
prescribers based on their drug preferences and volume. On the chart, a
provider who appears far to the right has drug preferences and volume that
markedly differ from others.
Q. What’s not
included in this data?
A. Prescriber Checkup
doesn’t cover Medicare enrollees who receive drug coverage from current or
former employers, the U.S. Department of Veterans Affairs or some retiree
health plans. Part D does not include drugs dispensed in a hospital, hospice or
during some short rehabilitation stays in a skilled nursing facility. It also
does not include medications administered in a doctor’s office, such as intravenous
cancer drugs. These are covered by other parts of Medicare.
