PHARMA/POLICY/POLITICS: Medicare Part D–A mess that will need fixing when the grown-ups get back into power

Last week the most convoluted program in the history of Medicare began. I’ve heard comments from friends, neighbors and people in the press saying that they can’t make heads or tails of the new drug benefit. The Washington Post piled in on Saturday with yet more about how confused seniors are.

Whether you like it or loathe it, there are some interesting parts of the Medicare Modernization Act, including the HSA provision and the disease management provisions. But the main event–drug coverage–is neither rational nor ideologically consistent. It’s a dog’s breakfast put together to ensure that the PBMs and some private health plans have something extra to sell, and so that the pharmaceutical companies don’t have to deal directly with the government on pricing.

Now seniors are going to have to deal with a donut hole, out-of-pocket costs, in-network and out-of-network pharmacies, and deciding whether their employer-sponsored coverage is going to stay around. No wonder they’re confused.

And despite all this, the cost to taxpayers is going to be double what Congress was told it would be. Drug coverage for everyone (especially seniors) is needed. But the only prediction I can make is that a more fiscally and socially responsible government–should we get one–will be forced to re-sort this mess in the very near future.

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16 replies »

  1. I am a 70 year old low income senior, not on Medicaid. Currently having problems having prescription Restasis filled (dry eyes, Sjorgen’s syndrome). Constantly on the phone, calling first Health Net Orange, then Express Scripts, a mail order company. They reported they never received 1st prescription, then did not fill 2nd prescription, because they needed prior authorization. They did not tell me this until 3 weeks or so had elapsed. Dr. then faxed prior authorization, and I received confirmation of this (by mail) from Health Net Orange, which stated the authorization for Restasis was in the system.
    Guess again. Spoke to woman at Express Scripts, told (again) I need prior authorization. I’m on a merry go round. Spend hours on phone, get nowhere. I believe this is a bait and switch tactic. Also, I need 64 vials a month, which manufacturer (Allegren) states is only method of use. Health Net Orange will only authorize 32 vials. Because I only spend $5.00 for this drug, they are doing their best, I believe, to discourage me from staying with their insurance company, because this affects the bottom line.
    I would like to know if other seniors have posted comments concerning violations of our public trust. I will call again tomorrow, and if I do not receive satisfactory results, I will contact the attorney general of my state. And yes, Restasis is on the formulary of Health Net Orange. If they do not fill my prescription, it is blatant discrimination. There is no generic equivalent. It is priced higher than a brand name drug, last year was $162.00 a month. Please comment. Thank you. Christina

  2. Medicare Part D is designed to confuse. Don’t be razzle-dazzled by which or what to choose – there is but one choice – not to sign up. This will bog Part D down in the mud in which it was created. The largest category of seniors are those paying out of pocket for their prescriptions. This is the group plan D sets up to pay for the care of the next largest group – those who are unable to pay for their medications. Seniors who escape this extra burden are those who are on retirement plans which include a drug benefit. I presume they are excluded because they are already supporting the drug and insurance companys through former employers and/or tax money as military and government retirees. If the largest group of seniors (now paying for their drugs out of pocket) do not sign on – this fiasco scheme will fail – forcing the plan to be made a benefit to seniors instead of to insurance and drug companys. Those of us in the ‘out of pocket’ group will not receive beneficial co-pays until we have spent a sum of $2250 (calculated on ‘out of pocket’ cost plus supposedly the insurance co-pay in order to get us to the $2250 fast. Once at that amount we will pay each our own drug costs ‘out of pocket’ (no co-pay) up to the sum of $3600 per year! And do not forget the monthly premiums. We are being told you can find plans for $5 and $7. Can you imagine finding your ‘increasing as you age list’ of meds we are cautioned to be preparing for listed in these plans?
    BOYCOTT this insulting SHELL GAME!!!!!

  3. This is by way of anecdotal information. There is a group of six of us retired folks who meet for coffee at McDonald’s every morning. Some of us have Medigap. We all have Medicare A&B. None of us plans to sign up for Part D.
    Part D is not comprehensive in its coverage, (what with the nonsensical “donut hole”) which in turn supports our belief that the rest of the Part D must also be suspect.
    The premiums can and will change annually, and upwardly. We also can’t convince ourselves that its value as a “catastrophic prescription drug benefit” is worth the cumulative costs. It certainly isn’t worth it if one’s prescription drug costs are low. Also we get our medication from Canada. We realize that the Administration’s response will be to criminalize the practice. Fine. If they/you want to label your parents and grandparents as criminals, go ahead. We take the view that these “violations” are as much heeded as the 55 mph posted speed limits on Rt. 270 in Maryland. If you know what we are talking about, you know that this 8 lane divided highway operates more like a NASCAR race; bumper-to-bumber at 70+ mph.
    Part D seems to benefit the insurance and pharmaceutical companies; we are just the herd of senior citizen policy holders who get to pay the premium.
    Since as a group we already are of limited means, we are rather chary of signing up for a added cost program.
    Note: as Senior Citizens, we may be losing some of our grey matter, but we can still read and count. And Medicare Part D doesn’t add up as far as we’re concerned. That there is this frenetic campaign to sell us on our need for Part D only serves to increase our skepticism.

  4. I’m curious that there is no discussion or comment anywhere I have looked about the contents of the PDP formularies, except for the indirect information available via the Medicare Website. The formularies vary a good deal in regards the amount of management tools, AKA prior authorization, quantity limits or high copays, and they don’t all list the same drugs. All this can change, and in fact is changing now, I have been monitoring some of the formularies. The formularies are just a part of what people need to consider, and the way the prior authorization and other limits will be managed is unknown, but still I would have expected a dozen websites to be up rating the plans and the formularies; if these were PDA’s, cars or music CD’s it would have been done in a trice. Doctors have been told that they cannot recommend a PDP because that would be some kind of conflict of interest. The patients can’t figure it out, they are going nuts, and there is no critical consumer voice addressing this. You could say it is all a sham, smoke and mirrors, and that in a year there will be 4 plans left standing with all the formularies and management tools changed, but people want to believe they have a choice, I almost would rather they think that for a while and let reality sink in slowly rather than have panic on New Year’s Eve.

  5. List the Medigap plan that will pay for $20,000 a year Rx bill. Did you say AARP has one or am I exactly right again?
    I notice no one came to your defense on this one. It’s interesting that you thought seniors could buy Rx coverage in America when that would be against the law. The government Medigap plans A – J were not a good answer for you was it Matthew?
    Next you will say you won this arguement like you always do. Trust me Matthew, you can’t win because you are so wrong.

  6. Matthew,
    You are right and wrong. You are correct that the vote on the Rx Bill was held open as conservatives were “Won Over” with the tax free HSA. Exactly like I said, geeez. At that exact moment in TIME I became a Bush Republican, hez a wizard. My Representative, Lee Terry (R-NE) knew I would stand up in his meetings, again, and rake him over the coals he he would of voted “NO” against the HSA. So in a small way I feel a bit thankful that I harrassed my own Rep. so much.
    You are confused about seniors being able to purchase Rx coverage in the US, to say the least. Rx can cost a lot Matthew. Montel Williams said his MS Rx costs $1,500 a month. Neil Cavuto has MS too. President Bush promised Rx coverage in Medicare and he delivered.
    (More than 10 lines deleted by ed)

  7. Ron, I’m a US citizen and I can badmouth the President, you, or anyone else all I like, and cut the crap about who won WWII. The Germans had already turned back from invading the UK before the US got into the war, and WWII was actually won by the Russians. Not that I’d expect a fool like you to know any history, but you might stop insulting me personally.
    Unfortunately you also don’t know anything about health care. You say “it was illegal for a senior to purchase Rx coverage in America before this Rx Bill.” Have you never heard of MediGap insurance? Probably not. Heard of AARP; I understand that they used to sell some…
    Why don’t you go away and try to learn something, anything, before you come back here and spout off. Just once it would be nice to not have to correct your BS in every post. I am beginning to lose my patience.
    And if HSAs were the determining factor in the bill, why didn’t your good bud the Pres and his men pass them separately, rather than sneaking them into an unrelated bill for which they had to hold the vote open for 3 hours and pay bribes to their own house members to get passed?

  8. Let me help you confused people out. If a senior is spending $1,000/month or $12,000/year on Rx the Max they can owe is $3,600/yr plus 5% coinsurance with the new Rx coverage (with the ultra confusing donut hole and all). It’s pretty simple for seniors who are paying a lot for Rx. The President promised Rx coverage in Medicare and he delivered.
    Everybody knows the Rx bill was passed because of HSAs. Tom Baker thinks the HSA is a sideshow, ha ha. Dr. Eric wants to find out what the Dems want, that’s funny too. The Dems are the party with no ideas and even less power. Dr. Eric – the Dems want Socialized Medicine. You used to know this, remember? Matthew you have no children, remember? You have a single HSA plan. I’m always so amazed about a Brit who can come to America and bad mouth our elected President. Like I’ve said Matthew, without the US you would be speakin’ German right now.
    If you actually cared Matthew you would have pointed out that it was illegal for a senior to purchase Rx coverage in America before this Rx Bill. Eric wants to keep the ban on seniors from purchasing Rx coverage yet today. But Eric also told me HSAs were designed to do away with PPOs. Docs like to size up their patients and drain them of all cash if they can.

  9. “The Durbin-Berry-Schakowsky bill…. the Medicare Prescription Drug Savings and Choice Act of 2005 (H.R.752/S 345)…..
    A. Establish a standard drug-coverage plan administered by Medicare.
    B. Mandate negotiated prices for prescription drugs.
    By creating at least one standard drug-coverage plan administered by Medicare nationwide, this Democratic alternative would provide a simple option for those confused with the complexities of the plethora of competing private plans. With a recent Kaiser report finding more then 60% of seniors to not understand the program, a standard Medicare plan will help alleviate the current confusion with prescription drug benefit.
    Negotiating group-purchasing agreements with the drug companies can lower costs to both users and to taxpayers. According to the CBO, the Veterans administration and Department of Defense have saved an average of 41% and 42% of the wholesale costs of drugs though price negotiation. These saving could be used to help plug the “doughnut hole” and still save taxpayer money.
    ….57 current Democratic cosponsors in supporting the Medicare Prescription Drug Savings and Choice Act of 2005.”

  10. Matthew- I would make the case that we (the USA) cannot afford the program now. Reps from Cato and Heritage have made excellent arguments why this is so.
    One of the problems, as you know, with the program is the issue of “dual eligibles”– perhaps the most vulnerable group who are both on medicare and medicaid. The current system has problems, but is at least a known entity.
    This is a bad bill- re: drug plan- both sides ought to recommend its post-ponement.
    BTW- if you have info on what the Democrats will be campaigning on in 2006, you might be a step ahead of Senator Schumer and Howard Dean- both of whom have made it quite clear that the Dem’s plan is to be univeiled after the first of the year.

  11. Eric. If I was King, I’d stop it and immediately replace it with a totally reformed universal health care system that included drug coverage. In the real world if the choice is this or nothing, I’ll take this only because it’s such a screw-up that the Democrats can win back the Congress by campaigning to fix the mess the Republicans caused, and it does give some small measure of coverage to some poorer seniors who don’t get it now. Plus it wastes a lot less money than Bush’s fun other adventures in the desert and mortgaging my (and your) kids’ inheritance to give his rich friends a bigger tax cut.

  12. Matthew– that is not a real answer to my question– you do, then, support the implementation of what you call a “dog’s breakfast”?

  13. I find it very interesting that big Pharma increasingly sees the MMA as perhaps less than it was cracked up to be. Every exec I’ve spoken to foresees inevitable price erosion. Ideally (i.e. from the vantage of the overall health system and economy), this will lead to a shift in incentives, reducing the number of me-too drugs.
    On the other hand, I am not at all confident that HSAs will amount to anything other than a small sideshow, at best. At worst, we’ll see substantial outcomes losses as seniors zealously protect their “savings”, rather than seeking necessary care.

  14. It doesn’t need to be delayed. It needs to be fixed. No chance of that with the current bunch of clowns running the country. Hence the needs for grown-ups, (of which I grant you McCain is one).

  15. Matthew- do you support Senator McCain’s and Representative Flake’s proposals to delay implementation of the part D program for 1-2 years?