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Brian Whorley, a health care executive, dives into the groundbreaking Medicare Prescription Payment Plan (MPPP), exploring its potential to revolutionize medication adherence and patient outcomes. With 54 million beneficiaries eligible, this initiative promises to alleviate cost barriers, reduce hospital readmissions, and save billions annually. Join the conversation to learn how providers can play a pivotal role in ensuring patients benefit from this transformative program.
Brian Whorley is a health care executive.
He discusses the KevinMD article, “How the Medicare Prescription Payment Plan provides a practical solution to medication nonadherence.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Brian Whorley. He’s a health care executive. And today we’re going to talk about “How the Medicare prescription payment plan provides a practical solution to medication non-adherence.” Brian, welcome to the show.
Brian Whorley: Thank you so much for having me on, Kevin.
Kevin Pho: All right. So let’s start by briefly sharing your story and journey.
Brian Whorley: I love health care. I’ve worked in it since 2007. Got my start at a 400-bed community hospital based here in Columbia, Missouri—Boone Hospital Center. I absolutely loved working in health care and being part of a mission to help people in our community better access and take access care.
I founded patient in April 2018 to help people better access and afford health care nationally.
Kevin Pho: Excellent. And today we’re going to talk about the Medicare prescription payment plan. Before getting to your article, let’s make sure we’re all on the same page. What exactly is that?
Brian Whorley: The Medicare prescription payment plan came into law in August of 2022 as part of the Inflation Reduction Act. What the design of it is, is to help seniors—help Medicare beneficiaries—access and better afford out-of-pocket pharmaceutical expenses. So my mom is part of this plan. She can opt in to the Medicare prescription payment plan. It’s free for her to call her insurer. Every single Part D plan must offer this to their members.
What it does is she’ll be able to walk into her local pharmacy. They’ll run her insurance card. They’ll see that she’s opted in to the Medicare prescription payment plan. Her insurer will pay her copay on her behalf at time of service, so my mom’s able to walk in, get her prescription, and walk out the door. No money changes hands at time of service. Her Part D plan is essentially fronting out-of-pocket responsibility at time of service.
She goes around, gets care all through the month. At the end of the month, she receives a simple statement from her insurer showing where she’s gone for care, how much care she’s gotten, and then it’ll say, “Hey, gosh, we’ve already paid the pharmacies X dollars on your behalf.” My mom will have the opportunity to review those payments, and then she can either pay that in full like she does her Amex or something else, or she can pay that over time throughout the whole plan year without any interest or fees.
So the idea is, “Hey, gosh, how do we help seniors? How do we lower the bar in terms of cost being a barrier to care? If we’re unable to change the price of care, the Medicare prescription payment plan is intended to improve the ability of people to pay that price at the counter and just give people time.” More people can afford 10 a month over 10 months than can afford 100 at a point of service. And so the intention here is to use time in order to sort of lower that bar—not remove responsibility from the equation, but to lower that bar and to make it easier to pay for care.
Kevin Pho: Before moving on, are we talking about traditional Medicare, or are we talking about Medicare Advantage plans, or does this apply to both scenarios?
Brian Whorley: It applies to both. Concepted and in law August 2022, it is now live nationally. So every single Medicare beneficiary who has Part D coverage—this is now a feature of their plan. They have to tell their insurance to turn this on: “Hey, I want to opt in to this.” But when they do so, they’re able to walk in, get care, walk out with their prescription. The pharmacy is paid in full for that full copay by their insurer. And essentially, what the net result here is going to ideally be is making care a little bit more accessible, affordable, and, I think, in a sense, equitable. It’s sort of a practical consideration of the ability to pay the price. So yeah, all 54 million Americans or 56 million Americans with Part D coverage—this is now a required component of their health plan.
And so it’s something that my company had already been doing for years outside of Medicare, commercially, but that practice is standardized nationally now.
Kevin Pho: All right. So you frame this as a solution to help with medication non-adherence. So talk about your article and talk about how costs act as a barrier to medication non-adherence in the first place. How does cost act as a barrier?
Brian Whorley: There is credible evidence of liquidity sensitivity in health care—the idea that member cost share has an effect on consumption. This idea that member cost share is always going to be in place as a part of good plan design, and it’s essentially a pragmatic approach to say, “How do we ensure that a 10 copay, a 20 copay, a 60 copay, a 600 amount isn’t going to stand in the way or cause someone not being able to pick up that prescription?”
There was a great study written on this in 2020—it’s “Liquidity, sensitivity, and health care.” Three authors wrote it. Within that, they talked about in 2018, a third of Americans skipped picking up a script due to cost-related non-adherence. The sort of idea of businesses like GoodRx or others—it’s just this concept that the price we pay matters, and our ability to pay that price matters. And so, rather than sort of wishing or wanting a world where that price is zero dollars for everyone all the time, it’s sort of a recognition that there will be a price to pay, but we have to ensure the ability of people to pay that price and to more effortlessly ensure that everyone, whatever’s in their wallet today, can still pick up that prescription.
Kevin Pho: So give us a practical example of this prescription plan in action. Let’s say someone goes to the pharmacy to pick up a medication, and say it costs 1,000. So if someone opted in to a Medicare prescription payment plan, give us an example of that 1,000 being spread out over time.
Brian Whorley: Let’s use my mom. She opts in. She tells her insurer, “Hey, I want to turn this on.” She can do that via online, phone, email, whatever. She walks in, she’s going to present her insurance card, but the pharmacy is going to run that insurance card, and since it’s a thousand dollars, CMS has identified a likely benefit of 600 or more. I think in a practical sense, even a 60 script could be a barrier. But today, the way the law is written, a 600 script causes the pharmacy management system to actually throw up a flag and alert the pharmacist, “Hey, this is a person who is likely to benefit from the Medicare prescription payment plan.” It will print out a “likely to benefit” sort of notice. The pharmacist, pharmacy tech—they have a requirement now for medications over 600 to inform the person, the patient, that, “Hey, you’re likely to benefit from this, in case you haven’t heard about it.”
Then they would actually run a secondary BIN/PCN and charge that 600 instead of collecting it from my mom there at point of service. They would essentially charge that to her insurer. The insurer pays the pharmacy. So the pharmacy has certainty of payment. My mom walks out the door with her prescription. Then, at the end of the month, the insurer—essentially running software like ours under the hood—compares to a CMS-driven table. That table says, “Hey, for folks who opt in in these months early in the year, divide that 1,000 over the course of the plan year in this manner,” and it essentially gives her the payments that she has to make throughout the course of the year.
Always no interest, no fees of any kind. It’s just simply that 1,000 divided out. It’s not a clean, even division, but it is spread throughout the course of the plan year. And my mom can either pay that in full at the end of the month, just like she does every other bill she receives, or if she wants to hang on to her money a little longer, she can just make those payments as prescribed on the statement.
Kevin Pho: And like you said, there’s no fees, there’s no interest equivalent charges. It’s basically that price spread out over a period of time. And the end number that they end up paying would be the same as if they paid it upfront.
Brian Whorley: That’s absolutely right. The spread is a little wonky. It’s a little uneven. It’s just the way the law is written. We’ve developed a calculator—there are calculators out there on different insurers’ websites—but it is spread out throughout the course of the year. That’s right. Folks who opted in during the open enrollment session—the most they would pay in a month over the plan year is about 167, which is great. The new out-of-pocket max is 2,000, so take 2,000 divided by 12 over the course, that’s the maximum they could pay in that time. If they enroll later in the year, then it changes the equation.
And so, Kevin, there are aspects of this to be improved and iterated on over the years. But out of the gate today, 54 million Americans now have the ability to have their insurer essentially front that money. My mom can leave her purse at home, walk in, pick up her prescriptions, walk out. If I’m a provider, which I am not—if I’m a physician—I now at least know there is this universal plan that everyone on Medicare has, where whatever medication we want them on or prefer them to be on, they have another way to pay. They have an augmentation of their ability to pay that.
Kevin Pho: Now, when you talk to Medicare beneficiaries, is this a relatively well-known feature? Is this something that they’re surprised to hear is a feature? In general, how well known is this among beneficiaries?
Brian Whorley: It is a brand-new program, so I wouldn’t be surprised if 99 percent of your listeners on this podcast—if this is the first time they’re hearing about it. Certainly, CMS has put out education about this. The insurers must notify plan members in 2024, prospectively, identifying people with high spend who are likely to benefit. Those folks received letters in the mail during the fall. When people present at pharmacies with medication costing 600 and up, the pharmacy will now be telling folks about this.
I think on a practical basis, more folks could benefit from this—even below the 600 threshold. The common idea is, gosh, if the copay at a pharmacy is high, a lot of pharmacies will call in advance and ensure that the patient is able to pay before they even order that medication if they need to order it, because they don’t want to be stuck with medication that someone can’t purchase or return it as stock in an expensive way. So the universe of who can benefit from this is the full universe.
But this is a new program. It’s going to take some time for folks to realize it, but they will. They will realize that the net result of this will be more folks taking the medication that you would prefer them to be on. This is going to lower that cost at the point of service as a barrier to care without, importantly, removing responsibility from the equation. We’re just giving people an easier way to manage that responsibility, which I think is a step in the right direction. I think that’s a step toward more adherence, and it’s just a pragmatic sort of purple idea.
Kevin Pho: What are some ways physicians like myself can facilitate and inform patients to potentially consider the Medicare prescription payment plan?
Brian Whorley: I think, yeah, you know, gosh, there has to be a moment where if someone is in your office and you really think that this is the right medication or treatment for them, and you hear that sigh or see the look on their face, you know that’s a bridge too far. This brings that bridge a little closer. It’s free to them. This is an expansion of Medicare benefits. They don’t pay a penny more, right? This gives folks who may have previously thought, “Gosh, I’m not going to go pick that up,” or, “I’m going to break this pill in half and it’s a time-release medication, so it’s not even doing the same thing,” the assurance that more people are going to be better able to pick up that prescription to take their medicine that you want them to take in order to get the outcomes that you would want.
So I think folks just being aware of it is an important part, helping to inform or educate their patients that this is now an option. I think over the years to come, Kevin, this expands into the commercial world as well. I think employers follow this lead. I think this merges into the medical side as well. But today, the 50-plus million Americans with Part D coverage have this available to them, and they’ve got to navigate their plan’s websites and whatnot in order to turn this on or opt in. But once they notify an insurer—by 2025, they have 24 hours to opt them in. So if someone’s sitting in your office today, inform them of that. “I’m going to call the number on the back of the card,” and tomorrow they could pick up that prescription at zero at the counter. They still owe the money—it’s not free, right? This doesn’t turn it into a free program—but at the end of the month, they’ll get a nice clean statement, they can pay it in full or, again, as prescribed over the entire year, and just smooth that out. Ideally, it’s less often that folks represent with a small problem that becomes a medium or large problem due to non-adherence. Every physician must have seen something like that, and this is just a pragmatic approach to address what was previously out of their reach—out-of-pocket sort of out of reach. This is designed to enhance that.
Kevin Pho: We’re talking to Brian Whorley. He’s a health care executive. Today’s KevinMD article is how the Medicare prescription payment plan provides a practical solution to medication non-adherence. Brian, let’s end with some take-home messages you want to leave with the KevinMD audience.
Brian Whorley: Every single person should consider the Medicare prescription payment plan. Beneficiaries can opt in today, at any time in 2025, in order to better access and afford health care.
Kevin Pho: Brian, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Brian Whorley: Thank you, Kevin.