A relentless search turns up a much-needed medication at a fraction of the price for one Medicare beneficiary.
When your ability to breathe depends on a single medication, and that medication is suddenly in very short supply, where would you turn? Thankfully for "Mark," his doctor turned to Evolent Care Partners (ECP).
Mark, a retired health care professional, struggles with several chronic diseases, one of which is a serious lung condition that can lead to difficulty breathing. While there are a few drug options for managing the symptoms, Mark found only one to be especially effective. Unfortunately, that medication, which is a treatment used in a nebulizer, became nearly impossible to find during a nationwide shortage in late 2021 and early 2022.
Mark knew that, without the drug, his condition was likely to worsen, leading to decreased lung capacity, possible hospitalization and perhaps even death. He shared his concerns with his physician, a member of ECP's accountable care organization (ACO), who called in help from the ACO's Complex Care Program. Julie Deczkowski, an experienced RN Care Advisor, was assigned to what everyone knew would be a difficult case.
"When I spoke with Mark and with his physician, neither one had much confidence that I would be able to find the medication during a nationwide shortage," Julie recalls. Despite his doubts, Mark was happy to accept her help, and Julie set to work calling pharmacies, durable medical equipment providers, various agencies and anyone else she could think of. Complicating her search was the fact that Medicare Part D prescription drug plans don't cover this treatment, so she would need to find a supplier that could bill the medication to Medicare Part B.
After a thorough search on his own, Mark had managed to find one pharmacy that had a supply, but that pharmacy didn’t bill Medicare Part B. Desperate to manage the flare-ups common to his lung condition, which caused coughing, chest pain and shortness of breath, Mark had been paying out of pocket—more than $1,000 for a one-month supply. But soon, even that source dried up.
After dozens of calls over the first few weeks of her investigation, Julie's search also had come up empty. "That's when I reached out to my management and to other team members to get ideas," Julie explains. "I was determined to exhaust every possible resource before I admitted defeat."
Equipped with some suggestions from her teammates, Julie hit the phones again. This time, her efforts were successful. In fact, she found two sources, one of which billed Medicare Part B.
Care Management's Potential
Now, Mark's vital medication is delivered to his door at a cost of only $26.95 per month. Initially, Mark was shocked that his participation in ECP's Complex Care Program had paid off. Later, when Julie followed up to make sure everything was going well, Mark reported that he was thrilled with the results.
While Mark's experience as a health care professional gave him some understanding of the Medicare system, it could be difficult for most people to navigate on their own. So, in addition to focusing on specific needs, ECP's care management teams have the knowledge and access to resources that enable them to find solutions. "It's what we're here for," assures Julie. "When we can help and meet our patients' needs, that's the ultimate satisfaction."
Every day, members of Evolent's care management teams use their clinical expertise and problem-solving skills to help individuals overcome serious health challenges. The Heart of Care series tells stories from the field that highlight their dedication to patients.
