Jonathan Cohn on Medicare Part D: The Prescription Drug Benefit

The mess was, he says, predictable--and predicted:

The Plank : THE PREDICTABLE--AND PREDICTED--MEDICARE MESS: So the General Accounting Office report warned that the transition to the new Medicare drug plan might not go too well. Still, that report was issued in December 2005. And by that time, most likely, it was too late to put in place systems and/or programs that could have eased the transition to Medicare Part D. Right?

Well, sure. But it's not like that was the first time warnings had been sounded. For some time, experts have warned that the "dual eligibles"--people who qualify for both Medicare and Medicaid---would have the most trouble with the switch to a new system.... [T]hey are generally very poor and very sick... were automatically going to lose their prescription drug coverage, which Medicaid had provided previously.... [T]he most vulnerable people were going to have to undergo the most dramatic transformation. You didn't have to have fortune-telling powers to see that, without a lot of very intensive planning and hand-holding, this wasn't going to work out too well.... Here's what Jeffrey Crowley... told the Senate Select Committee on Aging in June:

However, given that the most vulnerable segment of the Medicare population is being moved into the Part D prescription drug program first, with not a single day of overlapping drug coverage by Medicaid and Medicare, it strains plausibility to believe that this transition can be perfectly seamless. There is an urgent need for Congress, prior to January 1, 2006, to establish a short-term, onetime transition period so that individuals can continue to rely on Medicaid if they are unable to access appropriate drug coverage through Medicare....

Dr. Carl Clark, CEO of the Mental Health Center of Denver, made the same essential point in March of 2005:

[W]e're concerned about the required transition of dual eligibles to the new part D, drug benefit and here's why.... [A]lmost 40 percent of the 6.5 million dual eligibles have cognitive impairments and mental illnesses. Dual eligibles are twice as likely as others to have Alzheimer's disease... lack the capacity to manage the automatic enrollment process....

And then there was this warning, issued all the way back in January of 2005, via an issue paper by the Henry J. Kaiser Family Foundation:

The transition of prescription drug coverage for dual eligibles from Medicaid to Medicare represents a major shift in care for a particularly vulnerable population... poorer health status and heavier reliance on prescription drugs... consequences of gaps in coverage and missed medications can be severe for this group... maintaining Medicaid as a backup source of coverage on a temporary basis or devising special outreach and education efforts...

The administration didn't completely ignore such advice. There was some outreach, some of it apparently well conceived (like enlisting local groups with multilingual speakers to reach immigrant communities). Still, it obviously wasn't enough.... Can't imagine government having such foresight or being so pro-active? Believe it or not, once upon a time it was ...

UPDATE: Senator Jay Rockefeller, Democrat of West Virginia, has just introduced a bill to help senior citizens struggling with the new Medicare drug benefit. Talk about grandstanding! Where was he last year, when there was time to fix the problem before it happened? Why didn't he propose something then? Oh, wait, he did ...

Comments

[PW]

Sorting through the options of the program, it's hard not to picture the 25-35 year-old Congressional staffers sitting around the old oak conference room table screwing around with numbers and having absolutely no sense of what it's like for many seniors to have landed - kaboom!-- on age and illness and diminishing income and trouble with both small print and "small print" and rightwing cruelty and cynicism.

Please don't dump on Jay. Be nice. Encourage him. Encourage him to talk. More. And in more depth. There's a lot to be learned from Jay.

[anne]

http://www.nytimes.com/2006/01/17/opinion/l17medicare.html

Fix the Drug Plan

To the Editor:

"States Intervene After Drug Plan Hits Early Snags" spells out the crisis facing many low-income elderly and disabled Americans who are falling through the cracks as they try to make the transition to Medicare prescription drug coverage.

This crisis was anticipated for some time, yet the Republican-controlled Congress repeatedly blocked remedies. In 2003, when the Medicare drug bill was debated, many of us in Congress fought to place safeguards for the low-income elderly, but those efforts were rejected.

Last year, Democrats introduced legislation to postpone the start of the transition for this vulnerable population by six months. We wanted to ensure continuous prescription drug coverage for all Medicaid recipients moving to a Medicare prescription drug plan, but every Republican in the Senate voted against this bill.

As a result of this refusal to act, thousands of low-income Americans aren't receiving the prescription drugs they need, and many states trying to fix the gap are incurring costs of up to a million dollars a day.

If Congress does not take extraordinary legislative action, we could see tens of thousands of Americans subject to unnecessary illness and hardship. The federal government must take emergency action and should also fully reimburse states and pharmacies for the unexpected costs they are incurring.

John D. Rockefeller IV
U.S. Senator from West Virginia
Washington, Jan. 12, 2006

[anne]

John Rockefeller along with Robert Byrd is a wonderfully conscientious Senator. I do admire both Senators. Rockfeller well understood the dangers faced in what was becoming an ever more chaotic approach to the transition of Medicaid patients to the Medicare drug plan, but the Senate majority would have none of such an understanding.

[anne]

Brad DeLong, as any sane person, would like to insure that patients in desperate need of medicine can continue to get the medicine. That patients not suffer damage beyond repair by lack of drugs. That those patients in need not be made worse off by the lunatic private administration of the Medicare drug plan.

[anne]

http://www.nytimes.com/2006/01/19/opinion/l19drug.html

To the Editor:

As soon as the legislation passed for the Medicare prescription drug benefit, I began to tell people that they were going to have to ask a Republican how to use the benefit. I was right, sort of.

As a psychiatrist in a public clinic with approximately half of my patients on Medicare or Medicaid, I am dismayed. Dozens of my patients have had prescriptions rejected, and attempts to obtain overrides have left me on hold for hours, often never to speak with anyone.

Furthermore, although I'm lucky enough to live in a state that has vowed to keep poor people medicated and am also reasonably well educated, I haven't yet figured how to carry out my state's vow to ensure that nobody is refused medications.

Now that even Republicans are pronouncing the program botched, where do affected Americans turn for real help in navigating this plan? Besides, is it even worth trying?

Because the plan is so generous to the pharmaceutical and insurance industries, even with tweaking, it will never be either cost-efficient or user-friendly.

J. Wesley Boyd, M.D.
Needham, Mass., Jan. 16, 2006
The writer is a lecturer in psychiatry at Harvard Medical School.

[anne]

http://www.nytimes.com/2006/01/19/opinion/l19drug.html

To the Editor:

If the Bush administration really wanted to help people on Medicare with their necessary drugs, it would have worked very hard to make the plan simple. Making it hard helps only some, who can either figure it out or who are lucky by virtue of their particular circumstances.

Anyone who works with the elderly or the disabled knows that they often have trouble figuring new things out. It engenders fear, confusion, embarrassment, and is sometimes heartbreaking.

This again shows us how out of touch this administration is with most people.

James Thomas
New York, Jan. 16, 2006
The writer is a neuropsychologist.

[Howard]

anne, as you know, for months, i've suggested that dems should declare this fiasco unfixable and call for its recision and a do-over, preferably when we can afford it.

given what we're seeing here, and the unlikelihood that it's going to get better any time soon, i wonder what you think of that position now?

[anne]

No; We can and must afford proper medical care for Americans. We can and must afford a Medicare drug plan in which the only change is the allowing Medicare to negotiate drug prices. We can afford to save the lives of our grandparents and parents, as every developed country does with relative ease.

[anne]

Were a Medicare board able to negotiate drug prices not only would there be a fair countervailing of what can easily be monopoly pricing power of drug companies, but there could be a dramatic simplification of drug plans offered by private insurers. The current failing of the Medicare drug plan however is caused by an Administration and Congressional majority not being able to take precautions for almost 2 years that would allow for smooth transfer of Medicaid patients to Medicare.

[anne]

That patients in need with the most severe illnesses could be be readily transferred from Medicaid to Medicare after repeated pleas and warnings of an approaching problem by knowledgeable Democratic members of Congress such a John Rockefeller and Edward Kennedy is beyond understanding and conscience.

[anne]

http://www.nytimes.com/2006/01/22/opinion/22sun1.html?ex=1295586000&en=27c6a3fd46d84ff0&ei=5090&partner=rssuserland&emc=rss

January 22, 2006

The Medicare Drug Mess

After getting off to a promising start last fall, the new Medicare prescription drug program has stumbled badly in recent weeks, leaving tens of thousands of patients unable to obtain essential medicines. We can only hope that Medicare officials fix the glitches quickly before public disenchantment undermines prospects for enrolling enough people to give the new program real prospects for success. When the dust settles, it will be imperative to pinpoint how the problems arose, how much they reflect government ineptitude or malfeasance by private companies, and how further fiascos can be avoided.

The immediate problems have little to do with the most common complaint against the program, namely that many people find it dreadfully confusing to choose a good drug plan from a bewildering array of options offered by private insurers. Instead, most of the snags occurred in the part that should have been the easiest to execute smoothly - the automatic switchover of more than six million poor people from the Medicaid programs in their home states to the new Medicare drug program.

The Medicaid recipients were randomly assigned to a private drug plan, with the option to switch to another if they were dissatisfied. Along the way, as data bounced from one bureaucracy and set of computers to the next, some people's names dropped out of the system. Others, though listed as enrolled, were not earmarked as they should have been for the lowest level of co-payments. Thus many poor people found that when they showed up at the pharmacy they either were denied coverage or were asked to pay hundreds of dollars in deductibles or co-payments. Pharmacists who tried to call the private drug plans could seldom get through. And some plans improperly refused to approve drugs during the transition as they were required to.

Nobody knows how many people were affected, but officials acknowledge it may be in the tens of thousands. California alone says that some 200,000 of its one million Medicaid patients had trouble getting medications during the switchover, an astonishing error rate. More than 20 states stepped in to guarantee drug coverage until the glitches are resolved. They had little choice, given the potentially catastrophic consequences for people who depend on their medicines to keep mental illness at bay, pain at tolerable levels and diabetes or other ailments under control....

[R FLANAGAN]

re Medicare Plan D preparation.

When trying to figure out Plan D for myself
I stumbled on an issue of an IT magazine from last summer discussing the Medicare's attempt to develop the system now in use
to help users' plan selection.

The article's analysis of Medicare's work
schedule led to a consensus that the program could not possibly be available in time. And it wasn't . In November I attempted to use it for myself and was stymied by errors. Theoretically it calculates your personal annual costs under each of the plans in your state. I chose a few plans at random and attempted to
manually confirm Medicare's calculations. In some cases I could , in others no.When I redid that exercise in December the ones which I couldn't confirm presented a different total cost which now agreed with my previous calculation. Bad luck for any one who decided based on the faulty November program !

While that program is better than nothing , it is in no way user friendly I suspect because its objective is actually to facilitate premature decisions . Each time you interrogate tne answer is accompanied by an irresponsible suggestion to enroll immediately by simply touching a tab. Instead it should at a minimum provide a check list of the supplementary information elsewhere in sub systems that should first be consulted.

For example if you request the list of plans providing your particular med the system responds with that list and the usual "enroll now" tabs - but without
suggesting the other sub programs providing vital supplementary information.For example
to visit the "landscape" program to learn what % of the most important meds are covered by the plan you are investigating. Nor are you advised that the med you are interested in is provided at wildly varying prices from plan to plan depending on the tier to which it is assigned. My suspicion is this is less a design failure than a deliberate attempt to capture enrollments
in order to reach critical mass.

Sorry for the length but this is a case
where the devil is in the details.

[anne]

R Flanagan

Thank you for the interesting comment. When writing about the lack of pricing details, you note "My suspicion is this is less a design failure than a deliberate attempt to capture enrollments in order to reach critical mass." Please continue this thought. Would the fault be with Medicare or the private insurers?

[anne]

http://www.nytimes.com/2006/01/22/opinion/22sun1.html?ex=1295586000&en=27c6a3fd46d84ff0&ei=5090&partner=rssuserland&emc=rss

[Michael] Leavitt announced with great pride that some 24 million of the elderly had drug coverage. But 20 million of those 24 million already had drug coverage, through retiree plans, Medicaid or other programs.

The real measure of success will be how many people sign up who previously had little or no drug coverage - a pool estimated at 12 million to 14 million, or possibly more. Only about 3.6 million signed up voluntarily for Medicare's new stand-alone drug plans in the first 60 days of the enrollment period - a modest figure undoubtedly due at least in part to the complexity of the system. Worse yet, those who would benefit the most from the new drug coverage, namely low-income people entitled to special subsidies, have been disproportionately slow to sign up....

[anne]

R Flanagan

Will the drug benefit indeed be significantly helpful to you?

[r flanagan]

QUOTE
less a design failure than a deliberate attempt to capture enrollments in order to reach critical mass." Please continue this thought. Would the fault be with Medicare or the private insurers? UNQUOTE

My comment is uninformed speculation ,trying to understand why Medicare went as far as it did in assisting users' and then stopped on the 3 yard line.

In simple minded terms , Medicare's responsible ,it's their program. Clearly it solicited comments from some community , that's implied by the IT mag article to which I refer. Almost certainly insurers were included , and ,e.g. AARP was not.

Not as uninformed speculation I can
point to facts concerning the drug Humira . Insurer A classifies it as tier 4, copay of $600 , advance permission required.
Insurer B classifies it as tier 2,$50 no advance permission. A and B would have different motivation on Medicare's encouraging diligent research.

But while I can't conclude anything about the insurers' role ,I can observe the design of the Medicare system could have been done by Brownie .

QUOTE
Will the drug benefit indeed be significantly helpful to you?

Posted by: anne | January 22, 2006 UNQUOTE

Not now.I use the VA.My wife will probably get a small benefit now. Who knows about the future.

However I've just finished helping enroll a friend whose meds cost $2400/month .She'll reach the catastrophic level by March and the
thereafter Plan B will cut that to $120/month.

Because at least this catastrophic coverage
is potentially so useful we should beware of discouraging potential enrollees. It could
be a matter of life of death.

As to whether the catastrophic coverage
will be diluted or cancelled as a budget catastrophe ,we'll see.

[anne]

R Flanagan

"Because at least this catastrophic coverage is potentially so useful we should beware of discouraging potential enrollees. It could be a matter of life of death."

Thank you :)