Medicare: Part D Is For Disaster
Medicare, the insurance system for folks 65 and older, is about to get another addition tomorrow to provide prescription drugs to enrollees. There’s only one problem: it’s a complete disaster, and should be an embarrassment to every Congressperson that supported it. The following is an attempt to make sense of Medicare Part D in all its bureaucratic glory. I’m trying to write at a level anyone can understand, so you, or your parent, or your grandparent can understand it. It is not simple, and getting frustrated and confused is not a sign of stupidity.
A little background: Medicare has a couple parts. There’s Part A, which covers hospital care, and is pretty much automatic when the clock strikes midnight on your 65th birthday. There’s also Part B, which covers doctor visits, and costs those that signup for it $78 per month. Almost everyone has Parts A and B. There’s also Medicare Part C, which was passed in 1997 by the Newt Gingrich Congress, which allows people to enroll in an HMO for their Medicare, which can provide them with prescription drugs. (AKA Medicare Advantage, Medicare+Choice.) It could be its own post, so I won’t delve too far. Now, most folks love Parts A and B, which, not coincidentally, most people have. You turn 65, you check a box on a form, send it in, and you’re covered if you go to a doctor or have to be hospitalized. Easy as pie. Unfortunately, Medicare didn’t cover drugs, which are commonly needed by seniors, so the people said “We need drug coverage.” And All Was Good Bad.
But this new Medicare Part Disaster is no simple box checking. A senior can’t just say “Yes, I’d like cheaper medications,” and then the government does that whole “Helping the People” thing, because that’s the whole reason the People wanted the government in the first place. Medicare Part D requires a senior to compare plans–up to 85 in one area–and choose one based on a number of different factors and numbers. (It should be noted that this system was made under the guise of choice–the bill was heavily influenced by lobbyists. Take a second and ask yourself about the choice: do you honestly care which company provides your medications? Probably not. You just care that you can get them cheaper and have access to them when you need a refill.) You might think that there’s no precedent for such a simple, straightforward plan without the bureaucratic nightmare, but it’s not the case. There’s at least two: the Veteran’s Affairs hospital system and the state-run Medicaid program (which provides insurance for the very poor). These systems are not perfect, but their bureaucracy causes headaches for administrators, not for patients. Also note this: the law that made Part D specifically forbids Medicare from using its bulk purchasing power to get cheaper costs on medications for patients, but Medicaid and the VA both do this, too.
So how is this Medicare Part D thing supposed to work? In a perfect world, a person picks a Prescription Drug Plan (PDP) from one of many offered by different companies. That PDP pays for part of their drugs, after the senior pays for some as well. The PDPs differ on how much you pay per month, how much you pay up front, how much you pay per drug pickup, which pharmacies you can get the drugs from, etc. As you can imagine, if you have multiple drugs, and your spouse does too, it can be a total nightmare. But wait Vanna, there’s more: our nifty little terror here has another catch. For the first $2,250, you and Medicare split the drug bill (Medicare pays 75%). After that, for the next $2,850 of drug costs, you, the patient, have to pick up the entire tab. Once $5,100 is reached ($2,250 + $2,850), Medicare kicks back in, paying 95%. People call this donut coverage; you get to eat a bite until you get to the middle, then you get nothing, but then you get donut again once (if) you get to the other side.
Seniors are completely confused by this Medicare Part D. (And if you’re even still reading, aren’t you too?) It’s almost to the point that Jeff Foxworthy could do his redneck routine: “If you’re 65 and have recently pulled out your last remaining hairs, you might have Medicare Part D.” You have people with advanced degrees not able to make sense of it. Heck, I have a background in health policy, I’m two years away from being a doctor, and it’s taken me a good while to figure it out. If you don’t believe me, see Medicare complexity may scare off seniors or Confusion Is Rife About Drug Plan as Sign-Up Nears. Plus: A classic “screw you, seniors” quote from Michael Levitt, Secretary of Health and Human Services, who oversees Medicare: “Health care is complicated. We acknowledge that. Lots of things in life are complicated: filling out a tax return, registering your car, getting cable television. It is going to take time for seniors to become comfortable with the drug benefit.” Mikey, Mikey, Mikey… those things are complicated, but they shouldn’t be. That’s no excuse.
I hesitate to even recommend the Medicare website, as it’s its own disaster, but I don’t like most of the other websites out there, and they don’t have a formulary list out there. Terms (also taken from here, and then I’ll explain the Medicare calculator. (USA Today has a decent writeup, too.)
- Formulary
- A list of drugs that a company or plan decides it will carry. If a drug is “off-formulary,” generally your doctor has to make a special plea to use it and has to have a good reason. You also might have to pay more for it.
- Deductible
- What a Medicare member pays before drug coverage kicks in. Can be zero to $250 a year.
- Medicare Advantage
- Managed-care plans, such as an HMO. Medicare Part C. The plans may provide more services than traditional Medicare, but may limit members to certain doctors and hospitals.
- Premium
- A monthly payment for insurance.
- Quantity limits
- Dispensing limits on the quantity of a drug that can be prescribed each month.
- Step therapy
- Step therapy means a patient must try a lower-cost, often generic, product first. If it isn’t effective, the patient then “steps” to a different, often more expensive, drug.
- Co-Payment (Co-Pay, Co-Insurance)
- Amount you pay to get a drug after you’ve paid your deductible. Some plans have one flat rate, others have different rates based on the type of drug (brand name vs generic, newer vs older, etc)
If that wasn’t confusing enough for you, you clearly didn’t read carefully enough. Next will be a walk-thru (with pictures!) of how to use the Medicare Plan Finder thingy.
A librarian’s comment on the signup procedure: http://rochellejustrochelle.typepad.com/copilot/2005/11/online_medicare.html
Who the hell decided that the signup procedure for seniors who rarely use computers (stats in post) should be thru a buggy website!?
Graham–you are a deeply cynical young man. Just because you’re right doesnt change that!
Matthew
No body said we live in a perfect world. Medicare’s Part D prescription drug plan cannot and will not become a one size fits all solution. Each beneficiary must decide for themselves what is best for them, not only today, but also for the future.
It would seem that if one signs into WalMart/Humana’s Medicare D plan, one would be locked into Humana’s HMO for a year, with all its’ problems.
What we need to do is REQUIRE outcome based evidence on surgical procedures. We need a public print out of neurosurgeons fusing backs and putting rods in. What is the percentage of those operations that do not work? How many come back in for repeat surguries? We need our doctors who practice general surgery that save lives to be payed well, not neuro and orthopedics who practice sham surgeries!!!!
That again are those who sit behind the desk with nothing better to do. Why didn’t you all just keep medicaid???
I have no idea what you’re talking about, Becky.
You are right the pharm D plan is complicated and confusing. I have 2 Associates degrees, 2 Bachlors degrees and an Masters degree and I spent days trying to figure out what to advise my patients to do. Don’t you love it when Medicare says “speak to you medical care provider for assistance” and then does not tell your medical provider any more than they tell you? The short and long of the story is that every insurance approved by your state is in the process of trying to out do the others. So do not sign up for anything before the Middle of December. It is a work in progress. Take your time and find out what is best for you. With the advise that if you do not sign up, you will be penalized 1% of the premmium, per month for each month you do not sign up ( starting in May I beleive). If you are on Medicaid and Medicare you will get a letter in the mail telling you that you will be placed in xyz program until the next open enrollment, a year later. But if you do not like the plane they put you in, you are the only one’s who will not be penalized, if you decide to change. If you already have a script plan, by the end of the month, they are required to tell you in writting, if their insurance is the same as or better than medicare’s program. So if it is as good or better keep it. You can still sign up, with no penilty, if they cancel your plan at a later date. Your choice should be based on what will stretch the given amount, before the donut whole gets you, the longest for you. Some plans have out of pocket some do not. Some have co-pays and some do not. Some cover you in the donut hole and some do not. Some cover generics only and some cover both. Some cost as little as 10.95 a month and will wave the monthly fee meet their standard of low income. If you are low income you can apply for more assistance to help cover those co-pay and out of pockets. All in all I found that the computer is smarter than I am and that if you go to http://express-quote.net/medicaresupplementsdirect/id16.html and either call them or put your meds into the computer at their site, they will let you know what program will stretch your money the farthest and cost the least over all. They use a computer to figure it out. Beware the most costly plan may not save you the most. Generics do save you more. You will be getting print outs to let you know how much you have spent and how much you have left. If you have more than 185.00 per month you will hit the donut hole sooner each year, it changes. A hint is that the Humana plans seem to be popping up more frequently than others and they start as low as less than 11.oo a month. But again do not go by the cost. I am in the process of waiting for an answer for one of my pt’s. I called her meds in to the site and they will email me an answer. That way I know how long it takes to get an answer. Even if you do not pick the best plan for you, do not worry, open enrollment comes a year later and you can change then. Take your time and choose well.
For more input on Pharm D,contact me at my e-mail address patti-art@verison.net Patti, ARNP
Should have a system like Australia. Govt price controlled set contribution and the Govt pays the rest . There is a set list of drugs
Perhaps, we should just relocate our seniors to Australia, even after moving fees it would be even more economical than paying for their drugs. . . . just as absurd as Plan D *sigh*
My dad was assigned to a program (Wellcare) and yet he has never qualified for Medicaid.
I’ve called Wellcare and told them that I hope their zero premium, $0 generics, and no donut hole is correct *but* I do not expect to later receive a bill or be accused of fraud because he was automatically assigned even though we’re telling them upfront that he doesn’t qualify for Medicaid.
Will we see problems down the road? My original advice to my parents was to wait until May to decide and perhaps the plans would get better if not many signed up. My fear is that this pre-assignment is due to the fact that many seniors are doing just that - not signing up - and this is a way to tie him into the system without his ok.
Thanks for any input.
Millie
I am on disability Medicare A an B, wading through the mire called D. The state already had me all hooked up and I semmed to be getting better. Now they are hooking me up with a PDP that doesn’t cover my main med that’s been getting me better. I have to decide. there is no one with real help. help to answer what would be best. If I knew I wouldn’t be disabled to begin with. This is the feelin one would get from playing russian roulette. In fact That’s what this is. They should have named it Medicare RR.
To Dan, I have been working day and night on my own time trying to help people with their part d. If you will send me a list of your meds I will try to find a pdp that will cover all or most of your drugs. I will need some info. So if you are interested email me at vernon93@earthlink.net. My spamblocker is high so you’ll have to put “dan’s drug list as your subject.
I am in my third year of pharmacy school and work at a retail pharmacy. I would have to agree that how the “government” chose to initiate its prescription drug plan is pure idiocy. I put government in quotations because every aspect of the process so far seems to suggest a strong drug company/PBM influence on the whole affair. The grand decision to make a senior’s search for a pdp a 100 page “Where’s Waldo” was obviously made up of many smaller cowardly, closed-door decisions. No Congressman or PBM executive could look you in the eye and honestly tell you that this was the best way to go about it. Regardless of all that, many eligible seniors will eventually get signed up (not as many as should be). Most will also see financial benefit from being on a part d plan. However, the whole system will suffer. Drug companies will ramp up their price increases to account for increased kickbacks they must pay to the big PBM’s to keep their drug on formulary and because everyone likes to increase their prices when they know the government is paying for it. The PBM’s will continue to squeeze pharmacies taking more and more pennies from each transaction. The overall value of the senior’s benefit will diminish as will our tax dollars.
I think it is time to kiss the assholes at the top, Congress included, goodbye at the polls. The morons sicken me to the point I will probably need meds soon.
Help somebody please! I am a Resident services coordinator at an independant living apartment complex for low income seniors. I have two college degrees and have studied this program until
I felt that I could fully understand it and relay the information to our residents. Most of my residents signed up on line with assistance from yours truly back in November and applied for extra help from social security before that. The medicare website is buggy, but with a little tenacity you can get your comparisons fairly accurate. Here is the problem I have a resident that received her part d drug card from Humana and has a letter from ssi stating that she is dual eligible and has been accepted for full extra help. Even though she has her card and letter her pharmacy is charging her 30.00 per perscription (she has 10) The pharmacy states that ssi has not yet contacted humana to let them know what her benefit is, so she must pay the full copay…the pharmacy says the letter from ssi is not valid. Medicare tells me that first the resident applies for extra help then the information is sent to medicare, when the resident signs up the information is sent to the provider then the information is sent back to medicare who then sends it to the resident. Meanwhile nobody is answering their phones(I was on hold literally for 5 hours the other day) Medicare, providers and ssi continually send their clients in a loop with a never ending cycle of unanswered questions. During the past three weeks I have been hung up on 3 times after being on hold for two hours, I have been given a number for an insurance company that connected me to a burger king restaurant and I was also put on hold to wait for a Z specialist and when I asked the agent what a z specialist was , she said.”I don’t know they havn’t told me yet!” What senior citizen can accomplish these feats without a computer and the only phone they have is a pay as you go cell phone? My residents are a millimeter away from giving up and discontinuing their much needed drugs. As a trained professional I can work 8 hours per day as their advocate and get nowhere…I also have a phone, a computer, and several resources for help. WHAT IS WRONG HERE!!!!!
Please excuse my lower case and bad punctuation, I am tired after a long day on hold
hi, I sell medicare part D for a large company in CA, I have to say I hate the person that designed it. But….its not that hard. Most people never reach the hole, and only a few go past it. The formularies ARE on medicare.gov….and I love that website, I dont think its a mess at all. I strongly believe in private insurance, and Im happy this is happening. I have spoken to people who have been paying over 700$ a month for a medigap plan with rx coverage, this plan is a huge relief for a lot of people and the only reason they are scared of it is all the hype.
Medicare Part D is great for everybody in saving money…it is the confusion of choosing from so many companies, the method in which to sign up and the implementation of the program that is the trouble. Seniors are giving up on the program from frustration and are not getting their drugs. Today one of my residents disclosed that she stopped taking her cancer drugs for a month while she is still waiting for her drug card to arrive in the mail. The pharmacies do not want to cooperate because they will have a backlog of billing issues. When the mentally ill are trying to function without their drugs trouble could arise as well. The implementation of this program is a disaster worse than Katrina.
I agree, Deb, although if we just used the VA’s drug purchasing system, people could save even more money.
You’re absolutely right; a pill is of absolutely no use to a person unless it gets into their mouth. Any step that prevents that from happening decreases the drug’s efficacy.
I had 20 spine operations, fixation with 10 screws & 2 plates. HIV and some mental issues. For the last 6 years Perdue, the maker of Oxycontin gave me 30 days notice that I no longer qualified for the Perdue Pgm because their patent ran out and Generics caused lost revenue and that I was eligable for part D. Initial Injury was 1974 I’m 50 now and am opiate tollerant. I take 8 x 80mg Oxycontin/day (640mg/day) None of the 42 part D Inc Co cover this $10 a pill drug. #240 a month will cost me $2,400 plus my HIV medication is $1,500/mth ( no generic available) That is $3,900 a month. Generic Oxycode ER cost $7 each at Walgreens. I am AFFRAID I will end up in the emergency room in a state of Detoxification. Up until part D I could function well my pain was under control. Aparently none of the Part D Companys will allow #240 pills a month. I have herd everything from Comapny A covers just 1 pill a day to Company B allows a 30 day supply, however when I compute 30 days by the price they cover the max pills were 60 and in case of company C 120. At best only 1/2 of my medication “might” be covered. Here is the weird part. Some companys are telling me only my co-pays and “covered drugs” count towards the hole, drugs not covered don’t count. One lady at Blue Cross/Blue Script told me I could only get 1 pill a day no mater what medication I take. I’m 50 and on Medicare at $1,152 a month. My cost (via Medicares site) are projected to be min $6,000 yr to a max of $27,000 a year. My taxes went up, living in Fla my HO Ins almost double. Even though my house is paid off I will have to sell it for I see no way to afford the $6,000 and pay me taxes and HO Ins. Part D may be a Godsend to most in the longrun but it is causing me to loose my home plus place my health at risk. Detoxification from Oxycontin is said to be worse than stopping Heroin. I also ntice where NON of the plans cover sleeping Medication nor nerve pills. Xanax and Valium are not covered PERIOD. No doubt I will hit the doughnut hole fast. There are no Generics for HIV Medicines Kaletra and Combivir. ($1,500 a month) I make to much to qualify for Medicaid and Ryan White programs etc. HIV is no longer the death sentance it one was. My situation is a Catastrophe but I a not suffering from a Catastrphic disease. Maybe I can with a inpatient drug program cut back on my Oxycodone ER but I CANT STOP MY ANTI HIV DRUGS! SO I see no choice but to sell my house. Hello trailer trash, here I come. (No offese intended, just a saying) I forsee mental folks commiting suicide, heart patients and bllod pressure patients having heart attacks and strokes after they can no longer afford their drugs. Why in the hell or How in the hell did the government allow such a complex system to be offered to the people less able to select what is offered is beyond me. Is that the goal? Make the plan so confusing that delayed sign ups and mistakes save the Feds money in the long run?
Please send me any info you have if this is a bad product for me. I am 42 years old, and on total disability. Thanks a MILLION, Gary Steven Smith