Don McCanne points me to To Great A Burden (PDF), a report by Families USA which analyzes data on health care expenditures, and finds some pretty scary numbers and trends (my emphasis below):
More than four out of five people in families spending more than 10 percent of their pre-tax income on health care costs are insured.
50.7 million non-elderly Americans with insurance are in families that will spend more than 10 percent of their pre-tax income on health care costs in 2008.
More than three out of four people (75.8 percent) in families spending more than 25 percent of their pre-tax income on health care
costs are insured.
13.5 million Americans with insurance are in families that will spend more than 25 percent of their pre-tax income on health care
costs in 2008.
My point? These are the insured we’re talking about. The people who we quickly call “the covered.” And it’s gotten significantly worse in only 8 years:
Wake up, middle class. You don’t want to risk health care reform when you’re satisfied with your care, but how long until you’re part of the insured millions of families spending 25% of their income on health care?
And wake up, political candidates (and bloggers) that support individual mandates or continuation of the hodgepodge mess of private plans we have here–with their lifetime caps and pre-existing conditions, even the insured here are getting the rationing everyone’s so scared of under some sort of national system.
Just a few weeks ago, this editorial page told the story of Jan and Gary Clausen, who didn’t have the option of buying health insurance through an employer. They went out on their own and bought AARP-endorsed plans for about $700 a month. They were left with more than $200,000 in medical bills after Gary was diagnosed with cancer.
Some insurance.
If you support the current system, you support a system that does this to people.
Or this, Shadowfax’s incredibly sad CT scan and story about a 54 year-old uninsured woman with metastatic cancer who will soon be leaving her 4 children behind.
People seem to be taking sides in our little medblogger health care debates; I hear a lot of people that would be unhappy with a single-payer solution, but not a whole lot of other ideas to fix our health care system (ie: more negative ads than positive ones). The fundamental thing I don’t understand from libertarians is this: what’s a better option? Libertarians would have you believe that if we all just were responsible for our own health care costs, we would decrease our spending and la la la everything would be okay. But that’s not going to happen.
We have a law on the books saying that any ER has to screen patients who walk through the door. Now, you can take this law and do one of two things with it:
1) Keep it, and deal with the consequences that it creates.
2) Repeal it. (But let’s be honest, people, no one but wealthy crazies actually believes that this is reasonable policy.) So we repeal it, and ERs are allowed to turn away emergency patients (or patients who think they might be emergencies). We’re going to let people die on the streets? This would never, ever happen, and if it did–talk about health care revolution.
So here we are. We as a society have agreed that we will take care of the acutely ill, no matter the cost.
From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?
(A note: single-payer critics will say that single-payer causes tax increases; while this is technically true, as money would be directed to the government, it would not be new money, it would essentially be the same money that employers are already paying for health insurance to HMOs right now.)
Single-payer would cover everyone.
Single-payer would slow costs.
Single-payer would allow people true choice–to see any doctor they wanted, provided that the doctor was available to see them.
Single-payer would allow for lower prescription drug costs.
Single-payer would not “cherry pick” healthy people; single-payer would eliminate the American concept of “pre-existing conditions.”
Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.
I guess I could’ve done this myself, but thanks to Kaiser for doing it. I’m starting to think, as our title states, that pretty much everyone should see this graph. It affects how people understand health care, health policy, the uninsured, Medicare, Medicaid, everything.
Ready?
Okay, I know it’s just a bar graph, but read it. Seriously. I’ll wait.
You’re not reading.
Okay fine. Look at that. The 5% sickest people in our country make up HALF of our costs. The HALF of us that are the healthiest make up 3.4% of our costs. And the sickest people aren’t generally people that you see and think “Wow, they look ill.” They’re 10 times sicker. They’re people that spend months–MONTHS–in an ICU. They get admitted for something serious, and then they get a hospital infection. Or they have something else bad happen to them. They’re incredibly, incredibly sick. They’re on 20+ medications. They’re probably at least 50, if not 60, 70, 80, or 90. They probably have diabetes, high blood pressure, high cholesterol.
So see? When all the Talking Heads talk about “Health Savings Accounts” and being in control of your health care dollars, they’re focusing on a leaking faucet when there’s a Niagara Falls right next door.
It has to make one question how we’re spending our healthcare dollars. We’re shooting ourselves in the foot. Instead of providing preventive care and basic primary care to people, we wait until they get so very sick that they end up in the Intensive Care Unit, on 20 drugs.
Instead of making sure they’re managing their diabetes (or preventing them from getting diabetes in the first place), we let them get sick.
And once they’re so sick that they’ll likely never recover, we can keep them alive almost indefinitely, with no quality to their lives, just so we can hope and pray that they’ll recover… instead of keeping them healthy.
Is this not quite possibly the worst way to run a health care system, or is it just me?
Part D enrollee satisfaction: “This is called adverse selection, and is the main reason the program will not be successful over the long term. Simply put, the ones who sign up are the ones who will get more in benefits than they will pay in premiums.”
Item 1: Medicare is paying employers to maintain their retirement plan health care benefits, to the tune of $4 billion. These health benefits compete with Medicare Part D benefits.
Item 2: We already subsidize health care insurance, primarily through making business expenses for health insurance tax-deductible.
Item 4: Our President’s plan to fix the health care system, Health Savings Accounts, is primarily targetted toward the middle- and upper-classes, those who already have health insurance. It also ignores the fact that approximately 80% of health care costs come from approximately 20% of patients (the really sick ones).
What’s next? The government subsidizing the drug companies for taking part in the Medicare D benefit?
Is it just me, or does it seem like our leaders are just setting up the government to fail?
“I’m hearing shock from (state) Medicaid directors that we’re getting better prices than they are,” she told UPI. “I don’t know of any other government program where the real costs are less than the estimates,” she said, arguing that the plans are offering “affordable products” with low premiums and low deductibles. -Karen Ignagni, president of the health insurance association
If you haven’t been following the news, the Medicare Part D drug benefit is turning out to be a disaster–millions of seniors aren’t getting their prescription drugs, for any number of reasons: they’re not listed in the computer, the computer is giving pharmacies wrong information about costs, or the computer systems just aren’t working at all. Pharmacies are on hold for 2-3 hours for one single patient, and states are declaring public health emergencies and paying for the drugs themselves. Recently, the President told insurers the system isn’t working, and that, at least temporarily, there needs to be price controls.
This is a brilliant system for Pharma. They practically wrote the bill, saying how great it would work, and now private insurers and the federal government, who have to implement it, take the blame for a crappy system. Bravo Pharma, bravo! Jolly good play there.
I’ve been in contact with a really great Medicare patient advocate for the state of Arizona, and he’s filled me in on why some drugs aren’t listed in the Medicare Drug Calculator:
In your tutorial, you mention that you have questions with the “Enter My
Medications” section. First, the Federal legislation expressively
prohibited Medicare Part D from providing barbiturates and benzodiazepines,
so they won’t show up. Second, an approved plan is only required to provide
two drugs in each treatment category, so many drugs are not on many of the
formularies, although they are also required to provide “substantially all”
drugs available for the treatment of Cancer, AIDS, and a list of other
conditions.
As all of us who’ve used the Plan Finder know, the prescription information
that the person provides us (even with their prescription bottles in front
of us or a pharmacy printout) doesn’t always match what’s available in the
Plan Finder’s prescription drug drop-down lists. A weird example is that I
have sometimes found a brand name only by going to the name of the generic,
and vice versa.
There is a significant challenge to us who don’t have a medical background.
I can sometimes narrow the specific form of a drug down by going to
http://www.rxlist.com/ and finding how the drug is provided, as I don’t have
a current PDF. As a fictional example: I find in the drop-down list that
there are both an “EX” form of a drug and a “TG” form. Looking at this
website (or PDR, or whatever), I see that the “EX” is available in 2.5, 5,
and 10 mg tablets, whereas the “TG” form is in a 10 ml vial, and the
prescription that the person is taking is 5 mg.
I always tell the person being screened when there is uncertainty as to one
of their prescriptions or when I have to leave a drug off the list. I
recommend that they contact the company(s) directly and find out how those
prescriptions will be handled, before enrolling.
Also, here’s a list he sent me of drug classes that have to covered under Medicare Part D:
REQUIRED COVERAGE FOR “ALL OR SUBSTANTIALLY ALL” MEDICATIONS FOR:
Cancer medications
HIV/AIDS treatments
Antidepressants
Antipsychotic medications
Anticonvulsive treatments
Immunosuppressants
(source: CMS webcast PowerPoint slide 4, 9/28/05)
MEDICATIONS EXCLUDED FROM COVERAGE UNDER MEDICARE PART D:
Drugs for:
Anorexia, weight loss, or weight gain
Fertility
Cosmetic purposes or hair growth
Symptomatic relief of cough and colds
Prescription vitamins and mineral products
Except prenatal vitamins and fluoride preparations
Non-prescription drugs
Barbiturates
Benzodiazepines
(source: CMS 2005 REACH training, Module 10, May 29, 2005, PowerPoint, p.
59)
When do I have to decide by?
You have until December 31, 2005 to enroll in a plan that starts January 1, 2006. But May 15, 2006 at the latest, if you’re a current Medicare beneficiary. If you become Medicare-eligible in the mean time, or after these dates, you have 7 months from your 65th birthday to enroll.
What happens if I enroll after that?
Unless you’re already in a drug coverage plan (from a pension benefit, for example) that is certied as good or better than Medicare Part D, your monthly premium can increase by at least 1 percent per month of delay.
What if I start a new drug that isn’t covered under the plan I signed up for?
Your doctor can petition for an exception. The plan has 72 hours to determine if it will grant an exception. Denials can be appealed, but it could take awhile.
Can I change my plan?
Once a year, from November 15 to December 31, you can change to a new plan. You can also change if you enter a nursing home or move to an area that your current plan doesn’t cover.
Will co-pays go up?
The plans can increase co-pays or drop coverage, but they have to give a notification 60 days in advance. Unfortunately there’s no choice but to pay this increase, although a vice president of Humana claimed this “would be unlikely,” unless a drug manufacturer started increasing the drug cost.
Before we start, I’d recommend getting your pill bottles or list of medications in front of you. And maybe a glass of water. This may take awhile. Here we go, kids:
Hold down the shift key and click on this link. (When I say click, I mean take the left mouse button–or the only mouse button on some computers–and click.) This will take you to the Medicare Calculator and open a new window, while leaving this one open. Here’s a clip of what you’ll see (without the pink and grey box):
That pink and grey box is your key. That usually means there’s something important. Click on that first link, “Compare Medicare Prescription Drug Plans.” That’ll bring you here:
Now click on the orange arrow on the right side of “Find a Medicare Prescription Drug Plan.” Okay so far?
Next, if you’d like, you can enter all your info from your Medicare card in the top area that says “Personal Information.” To enter information throughout this tutorial, you left-button click on the box where you’d like to enter information, and then start typing, just like this one:
For the general search, which will work just fine, click the “General Search” box:
Now it gets confusing. First, enter your zip code in the box. That’s #1 on the graphic.
The next step requires your own personal information. If you have some other way that you get medications–maybe through Medicaid, your previous or current employer, etc, click the appropriate box. For most people, just click the box next to “None of the above.” It’s pink-grey highlighted as #2. (Any box you check takes you to almost the same page anyway. Sigh.)
Next, are you qualified for an extra discount on drugs according to your income and the Social Security Office? If not, click “No,” #3.
Then click continue, #4:
Next, click “Choose a Drug Plan Type.” Keep going, you’re doing great!
Now they want to know if you have Medicare Advantage, also known as Medicare+Choice, which is already helping pay for your prescription drugs now. If you have no idea what I’m talking about, click the lower box, “Search for Medicare Prescription Drug Plans.” Otherwise click the top box. Now you’ll see:
From here, you can start viewing the plans in your area. However, since the best deal you’ll get is based on the medications you take, I’d recommend entering them in the system. If you don’t want to do this, just click “View Plan List.” If you’d like to follow my recommendation, select “Enter my Medications.” Great!
Here’s why I had you get your medicine bottles out: You need to enter the name of each (either the brand name or generic name is fine) in Box #1. The click the button (#2) to add the medication.
If all goes according to plan, the medication will appear down below, in this new pink-grey box #1. If there are multiple medications with the same name, or if the system is confused about a generic name, it’ll make a display like in box #2. Simply click the medication name you wanted, and click box #3. Once you’ve got everything entered and every medicine appears in box #1, click box #4. (Note: some medications will not be in the system, and I have no idea what this is. I tried different medications, spelled correctly, and they couldn’t be found. I’m not sure what to do about this. I’m sorry.)
Once you click the “Continue” box, you’ll stay on the same page, but another box will pop up.
If you’d like to enter your specific medication dosage (10 mg or 20mg or 40mg, for example), click the “Choose My Drug Dosage” button. In the effort of simplification, we’ll skip this step–besides, you can do it later if you’d like.
Likewise, if you want to pick up your meds at a specific pharmacy in your area, you can do that now with the “Select My Preferred Pharmacy.” But note: certain plans may work with some pharmacies and not others. If you want the absolute lowest cost, click “Continue to Plan List.” If you want to pick your pharmacy from one locally, click “Select My Preferred Pharmacy.” Also note: if you want to get your meds by mail, the Plan List page will show you which plans will mail your drugs to you.
Finally! We’re on the list of your plans! They’re sorted by lowest yearly price. The rest of this just explains the final plan page with letters:
A: Click this box and up to 2 others to compare three plans. Click C to do the comparison.
B: Click this box for more options about the plan–the exact costs, how much you could save if you only used generics, enroll in the plan, etc.
C: See A.
D: Change your mind about wanting a specific pharmacy? You can do that here.
E/F/G/H: Here you can update the pill strength of each medication, or add more.
Now, if you want to sort the plans by something other than total yearly price, you can click on the column title and change it. Note that all these numbers really depend on what drugs you take, so it’s important to enter them accurately. Remember, Annual Deductible is how much you pay until Medicare starts paying its 75% for your first $2,250. Monthly Drug Premium is how much you pay per month to take part in the plan no matter how many drugs you use, and Monthly Cost Share is how much you pay as a co-pay when you get the drug.
I really hope this helped someone. Damn long writeup by my standards.
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)
Blogging is probably like sending angry emails: you should wait until you’ve calmed down. But I just can’t help it right now. I’m livid.
So I’ve become something of a patient advocate recently with all this geriatrics and frail elders and polypharmacy and whathaveyou, so I thought it’d be a good idea to try to get a grip on the Medicare Part D stuff that’s going around to physicians and Medicare recipients. (My father and grandma tried to attend an information session, but it was so crowded even at the encore performance that they couldn’t get in. Note: this is not a testament to how popular the new plan is; it’s a testament to how damn bureaucratic, confusing, and complicated the thing is.) So I do a Google search for medicare part d to get some general results. I get a ton of ads (a clear sign that there’s money to be made by all comers), and I click on some ads, some links. A mish-mash of everything to get an overview, and possibly recommend a site or two to my one or two readers.
I come to my first site, and this is the one that drives me over the edge: AARPMedicareRx.com. I see AARP in the URL, and assume it’s a special site the AARP has created to help its members. Then I see the AARP logo in the top left corner, and assume I’m right. I click on “Learn the basics,” and get this first paragraph:
If you’re eligible for Medicare, you have a new option for getting coverage to help with the cost of prescription drugs: AARP MedicareRx Plan is a prescription drug plan that is approved by Medicare. This national plan is provided by United HealthCare Insurance Company* and begins January 1, 2006.
I’m confused. “What? I thought there were multiple options for the Medicare Part D plan, not just one.” I re-read, I scroll down to the asterisk, and reailze I’ve been had. This is not an AARP site at all; no, it’s a United HealthCare Insurance Company website with an AARP (“pharmacy services” bullshit) logo. And if a third year medical student with a major in health policy and a pretty good understanding of the US health care system makes this mistake, you can bet countless others will, too. I’m sure that’s the goal. Show the AARP logo so you get the confidence of the AARP, then tell consumers there’s *one* new plan to help people out.
I’m disgusted. If anyone knows who I could contact to complain about this blatant deception, please let me know. (Isn’t this what the copyright laws were supposed to be for? Protecting consumers from misleading or fraudlent information?)
This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.
I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!
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