Unraveling the Impact of Medicare Coverage on Continuity of Care

PART ONE

Mr. James Scott is a 77 year old African American man who was diagnosed with prostate cancer following an elevated PSA and needle biopsy. Other diagnoses included diabetes, hypertension, high cholesterol, and status post cervical laminectomy eight years ago that left him an incomplete quadriplegic (independent respiratory function) requiring total care (Katz Index of Independence in Activities of Daily Living Scale score of 0 (6 = complete independence in and 0 = total dependence). Mr. lives with his wife of 56 years, Mrs. Esther Scott in their single family rancher home. Mrs. Scott is slightly overweight, hypertensive, and has some osteoarthritis in her hands and knees.  Given Mr. Scott’s age, the urologist recommends Zoladex injections every three months for his prostate cancer that was given in the outpatient department of the local hospital.

Mr. Scott has Medicare Parts A, B, and D.   Medicare Part B is covering the urologist visits and injectable Zoladex administration costs every three months.  However, when Mr. Scott and his wife arrives for the next administration, the urologist informs Mr. Scott that he can no longer give him the Zoladex injectable, because the hospital is losing money (i.e., Medicare is not reimbursing the hospital the cost of the Zoladex). He tells Mr. & Mrs. Scott that if they want to continue the Zoladex injections, they will have to pay out of pocket. Mr. Scott states he cannot afford the medication.  The urologist instructs the nurse to see what she can do to help Mr. Scott.  Then, the urologist exits the examination room to see the next patient.

The nurse requests to see Mr. Scott’s Medicare Part D Prescription Drug Plan membership card. The nurse copies the card and states we will call in a prescription (nurse does not specify the name of the prescription and the elderly couple do not inquire about the name of the prescription) to the local community drug store.  The nurse instructs the couple to return when the prescription is filled.  Three days later, the elderly couple picks up the stapled prescription bag, bring it to the outpatient department for administration.   Mr. Scott, accompanied with by Mrs. Scott, receives the abdominal injection and goes home.

Two months later, Mr. Scott discovers that he is in now in the donut hole of his Medicare Part D Prescription Plan.  They send a copy of the Medicare Summary Statement to their daughter who is a nurse.  The daughter contacts the urologist to inquire about what Mr. & Mrs. Scott were and were not told regarding the prescription that they picked up? Upon further investigation, the daughter learns that the hospital outpatient pharmacy had replaced Zoladex, with less expensive Lupron injection which was administered every four months instead of every three months for Zoladex.  The daughter raises concerns about the urologist’s failure to follow the American Patient Care Partnership brochure principles. The daughter insists that hospital reimburse Mr. Scott.  The hospital maintains that neither the urologist nor the nurse can be expected to know about donut holes or prescription plan gaps. The onus was on Mr. Scott and Mrs. Scott to know his risk of entering into the donut hole.  The hospital is under no obligation to reimburse Mr. Scott.

PART TWO

1.     Daughter submits a complaint to the Medical Board regarding the urologist’s behavior.

2.     Daughter submits a complaint to Medicare for its refusal to cover the costs of the drug under Medicare Part B, instead of Part D, to prevent Mr. Scott’s transition into the donut hole of Medicare Part D Prescription Drug Plan.

3.     The Medical Board ruled against Mr. Scott stating that no documentation in chart demonstrated his objection to the inability to pay for the Zoladex.

4.     The Medical Board did not determine that the urologist or Pharmacy Department were under any obligation to inform Mr. Scott of the replacement of Zoladex with Lupron.

This case study allows medicine (e.g., urologist), nursing, pharmacy, social work, and law to discuss several issues:

1.     What are the problem(s) and ethical dilemma(s) depicted in this case study?

2.     What are the relevant ethical principles and laws highlighted in this case study?

3.     What are potential solutions to these problem(s) and/or ethical dilemma(s)?

4.     Does the hospital Ethics Committee have a role to play?

5.     Does Risk Management have a role to play?

6.     Who (professions) should participate in these discussions?

7.     Who should advocate for the Mr. & Mrs. Scott?

8.     Does the Mr. Scott have grounds to sue for malpractice?

9.     What is the best solution to this situation?

10.  How should the solution be implemented and evaluated?