Marilyn Stebbins, clinical professor in the UCSF School of Pharmacy, explains what has gone wrong with Part D so far, and how seniors can protect themselves and their drug benefits.
What does Medicare Part D change, and why?
In the 40 years since Medicare was created, there has never been a drug benefit until now. The federal government, however, had been subsidizing about half of the Medicaid drug costs. Part D represents an attempt to introduce free market principles into health care.
Although about 60 percent of Medicare beneficiaries have some sort of drug coverage (through employers, unions, Medicaid, VA, TRICARE, medi-gap private insurance, etc.) about 40 percent have had no outpatient prescription drug coverage at all. This bill allows for any Medicare beneficiary to voluntarily opt into a prescription drug plan.
Based on the reports now coming in, what is the biggest problem with the Medicare Part D rollout so far?
The largest problem has involved the dual-eligible beneficiaries, those who are enrolled in both Medicare and MediCal. As of January 1, these people no longer got their drug coverage through MediCal. They were randomly and automatically assigned to one of eight plans prior to January 1, 2006.
Yourself for Medicare Part D
Know how much you spend on prescription drugs (ask your pharmacist for
Compare plans by comparing prices for your prescription drugs
Make sure your prescription drugs are covered by the plan you choose.
If you are uncertain, call the plan's customer service number and ask.
Be sure that the pharmacy you want to use is preferred by the plan you
Resist the pressure to choose before you have all the information you
need to choose wisely. You have until May 15, 2006.
Once you decide on a plan, telephone the plan and sign up directly
Ask for all the appropriate membership and code numbers your pharmacist
will need to process your prescriptions. That way you will not have
to wait for your drug card to arrive in the mail.
If you have chosen a plan and want to change, you can do so until May
15, 2006. After that, changes can only be made during open enrollment
each November and December.
However, in many instances, the eligibility information on these patients was not received by these eight plans, meaning that assigned patients have not always been recognized as members.
Even worse, Medicare and the plans did not get correct information on those who are dual eligibles. The result has been that when a dual-eligible beneficiary goes to the pharmacy to get medications, he or she is told that they do not have the lower cost, supplemental benefit (or any benefit at all). The patient is then charged the wrong, and always higher, amount.
Not surprisingly, many such people are going without their medications because they simply can't afford to pay for them. Prior to January 1, these medications were covered fully by MediCal.
This has necessitated the state of California to pass some emergency mandates requiring that MediCal pick up the costs of a 30-day supply of medications for these dual-eligible patients until this can be sorted out.
How many people have been affected?
The Centers for Medicare and Medicaid Services estimated that about 15,000 people might be affected during this transition period, but I understand that 250,000 patients in California alone have had problematic claims since January 1.
What about the website signups? Any problems there?
Many people who signed up for their plan on the Medicare website were not recognized by the plan or by Medicare as having chosen that plan ― or any plan, for that matter.
Since these patients weren't recognized, there was no one to help them. Fortunately, many of these people kept their confirmation numbers when they signed up on the website.
Those with confirmation numbers were sent to a Medicare reference center and told that they would hear back from someone at Medicare in 48 to 72 hours. This didn't help much if the person was out of a drug! This problem seems to be remedying itself now.
Were the insurance plans really ready for the surge of signups?
Most of the insurance plans were not ready with enough customer service representatives, and patients were on hold for hours or disconnected. The other problem is that it has been impossible to get a prior authorization for a drug not on the plan's formulary.
And if you could even find a telephone number to call, you rarely got anyone live who would answer. Their recorded message would say, "Call volume is high; please call back later."
This is unacceptable for providers and pharmacists who are trying to get patients necessary drugs. I personally called all 48 plans recently, and only was able to talk to two live people. The rest of the plans either disconnected me or told me to call back later. One plan's message told me that my estimated wait time was two hours!
Could these problems have been anticipated and prevented? And if so, how?
Absolutely. There is no excuse for not having enough staff to answer phones. However, the fact that the Medicare has not been able to get good data to the plans is hard to predict or even imagine. I can't believe we waited 40 years for this, and no one anticipated what a nightmare it was going to be.
Are there any lessons learned so far that could help those who have not yet signed on to any plan?
If you decide to sign up with a particular plan and you can get through on the telephone, sign up with the plan directly.
The customer service representative can then provide all the necessary numbers to give the pharmacy, so that your prescription can be processed ― even if you don't have a drug card yet.
And don't sign up for any plan unless you have compared it with others. We are hearing stories every day from patients who have people calling and asking if they can come to their house to help them choose a plan.
Remember, these are salespeople who are trying to sell you on a specific plan, which might end up costing far more than one you would have chosen, had you done some comparison shopping.
Take your time ― you have until May 15, 2006 ― and either call HICAP [Health Insurance Counseling and Advocacy Program
] to get help or find a resource to help you navigate the Medicare plan finder on the web. You also can call the 1-800-MEDICARE number for help. Do not let anyone rush you into a decision.
Are there any red flags that could at least raise the consciousness of consumers before they choose a particular plan?
Not necessarily. The most prudent thing to do is to first know how much you are currently spending on drugs (without having a plan). Ask your pharmacy to give you a printout, if necessary.
When you compare plans, be sure to choose one that will cost you less than you are spending today. This may seem like a given, but I have seen patients sign up for plans that are going to cost them more. Many of them have signed up with the first plan that sent them an advertisement through the mail, thinking it would be right for them.
Also, patients need to be sure that the drugs they currently take are covered by the plan they choose. They need to call the plan and ask. If the answer is no, they should then ask what comparable drugs are covered, and take that list back to their doctor to learn if these are acceptable alternatives.
One of the many concerns expressed with Part D is that the decision to join a plan is based on an assessment of drug needs today. What happens if the person's drug needs change drastically next year and the chosen plan is not adequate? Can the person switch to a different plan readily?
Patients can change plans once a year during open enrollment (November 15-December 31 each year). However, once they join, they are with that plan the entire year. There is one exception this year only. This year, a patient has the right to change plans once before May 15 if they are not satisfied with the plan they chose.
Is there any chance that the whole program will be scrapped or somehow revised?
I doubt we will see it scrapped in the near future, but the processes clearly need to be changed before we have to go through all of this next year during open enrollment. However, we may see seniors "storm the Hill" and demand change!
Source: Jeff Miller
Official US Government Site for People with Medicare