Falling into Medicare's Part D "Donut Hole" in NYT

Two very good articles in the NYT regarding choosing the best plan in this open enrollment period.

I've fallen into the Donut Hole and let me tell you--It ain't pretty!  If I hadn't discontinued Boniva six months ago I'd have fell in much earlier----I only started part D in June so even without Boniva it took me less than five months of medications to fall in.  I got to the counter at my Pharmacy and when they presented me the bill ---my legs went out from under me.---Was about to pull out my credit card when I realized I would have exceeded my limit!   So, I took money earmarked for my utilities and paid with that---Which means I'm going to be getting some calls from their collection departments.---------I'll be making some really tough decisions next year.

For any of you facing these decisions the articles below may be helpful. 

Tender---I'm all with you on this subject!

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The New York Times

November 24, 2007
The Coverage Gap
There Are Alternatives: Insuring to Bridge the Gap or Opting Out
BY STEPHANIE SAUL

One way for Medicare Part D enrollees to deal with the “doughnut hole” is to insure themselves against it. Another way is to simply not get involved with Part D in the first place.

Nearly one-third of Medicare prescription drug insurance plans now offer to pay for drugs through the doughnut-hole coverage gap that Congress designed into the program. That is up from only 15 percent of plans that offered gap coverage in 2006, according to the Kaiser Family Foundation.

But the doughnut-hole gap insurance typically covers only generic drugs. That complicates the calculus for patients trying to determine whether to pay the higher premiums for such policies, which typically cost about twice as much as the $28 average premium for plans without gap protection.

For those able to rely solely on generic drugs, the cheapest approach in the short run might be to forgo Part D insurance altogether. Instead, they could simply shop at discount retailers like Wal-Mart, Costco and Target whose pharmacies offer low-cost generics for as little as $4 for a monthly prescription.

To determine what their coverage cost will be under Medicare, and help choose the approach that is best for them, consumers can visit Medicare’s Web site. There, beneficiaries can enter their specific drugs, as well as the pharmacy they want to use, to see their options. The software calculates the best plan for a particular beneficiary among the 50 or so that are typically available in each state. This year’s enrollment period continues through Dec. 31.

The cheapest plan is not necessarily the best. Among things to consider are whether the plan carries a deductible; what it charges for co-payments on individual drugs; whether it covers drugs in the doughnut hole, and whether there are restrictions on some drugs.

Some plans, for example, limit the quantities of drugs a patient may get each month. Others require prior authorization for some drugs — meaning that the doctor has to make a special call to the insurer.

Some plans have recently added extra levels of co-pays or moved drugs from one co-pay tier to another, meaning beneficiaries pay more than they expected when they pick up their drugs.

The Medicare Web site is relatively easy to use, but some people may still need help.

“Many seniors don’t use the Internet and don’t use computers,” said Elisabeth Clayton, a client services associate for the Medicare Rights Center, a nonprofit group based in New York that offers help to Medicare beneficiaries nationwide.

By phone, Ms. Clayton recently assisted a Medicare beneficiary from Oklahoma who was searching for a plan. The woman takes 10 drugs, including 7 generics.

By entering the woman’s list of drugs and her pharmacy in the Medicare Web site, Ms. Clayton determined that the best option for her would be an AARP plan with a relatively high premium — $64.10 a month — but no deductible. The plan also offered gap coverage and few restrictions.

The second-best plan, offered by First Health, had a far lower premium: $16.40 a month. But it would have ended up costing $250 more by the end of the year — and a full $1,100 more compared with the mail-order option on the AARP plan, according to the Medicare Web site.

Similar assistance is available through a program called Area Agencies on Aging in many states. In Hot Springs, Ark., for example, the West Central Arkansas Area Agency on Aging has been offering appointments to assist Medicare beneficiaries in selecting a plan, according to Dody Roberts, director of case management.

“All plans are not going to cover all prescriptions,” Ms. Roberts said.

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The New York Times

November 24, 2007
Patient Money
Strategies to Avoid Medicare’s Big Hole
By STEPHANIE SAUL

The Medicare doughnut hole is the federal provision that older Americans love to hate.

And that is not expected to change next year, when the doughnut hole — the nickname for a big financial gap in each person’s Medicare prescription drug coverage — gets slightly larger. If the past is a guide, many people will struggle to secure a full year’s supply of the drugs they need.

But despite the arrangement’s unpopularity with older consumers, some experts see a positive public policy trend when they peer into the doughnut hole. Because it potentially forces a Medicare enrollee to pay more than $3,000 from his or her own pocket during the gap period, the hole is helping curb growth in the nation’s drug spending by pushing people toward low-cost generic drugs.

And because the cheaper generics generally work just as well, patients are incorporating them into their permanent drug regimen, according to Dr. Tim Anderson, a pharmaceuticals analyst for Sanford C. Bernstein & Company, who is also a physician.

“Clearly, once you’re on the therapy, if you’re tolerating it and you’re saving money, there’s no reason to switch back,” he said.

It may not be a message that brand-name drug makers want to hear. But with the Medicare Part D drug program enrollment period now under way, through Dec. 31, analysts predict millions of older Americans will study generic drug prices and options as they select an insurance plan. Some economists say that many Medicare enrollees, through carefully planned use of generics, can avoid reaching the doughnut hole altogether.

When the Medicare Part D program began in January 2006, makers of name-brand drugs considered it a welcome stimulus to overall use of prescription drugs. The industry knew the doughnut hole might steer some patients toward generic drugs, but not necessarily so soon.

“I don’t think they anticipated how quickly this kind of event could shift patients toward utilizing generics,” said Peter C. Demogenes, a senior director of the research firm Wolters Kluwer.

Congress carved the doughnut hole into the Medicare prescription drug plan as a way to limit the federal outlay. But architects of the plan made sure some costs were covered for all Medicare beneficiaries upfront, while also seeing to it that the sickest would get help with catastrophic drug costs on the far side of the doughnut hole. Once a beneficiary has made it through the coverage gap in any given year — in 2008, after the total cost of drugs has reached $5,726 — prescriptions are generally covered at 95 percent.

About 4.2 million people reached the gap last year, according to a Wolters Kluwer study, and many of them switched to generics as a way to keep their out-of-pocket costs low. Others started using generic drugs even before they reached the doughnut hole to avoid the higher co-payments their policies charged for brand-name drugs.

In 2006, an estimated 59.6 percent of the Part D prescriptions were filled by generic drugs. By the first quarter of 2007, the most recent period for which data are available, the generic rate in Medicare had edged higher, to 61.5 percent, according to Medicare figures.

Billy Tauzin, the president of Pharmaceutical Research and Manufacturers of America, the trade association for brand-name drug companies, said it was clear that the Medicare program, including the doughnut hole, was helping drive the use of generic drugs. And the popularity of generic drugs is cutting into the profit margins of branded drug companies, he added.

Mr. Tauzin, a former congressman, said his group had made several proposals to Congress for shrinking the doughnut hole. Among the suggestions, he said, was to count the free drugs that companies sometimes provide to lower-income Medicare beneficiaries as part of the patients’ running total of drug costs. Doing so would make their catastrophic coverage kick in sooner.

“We can help them, but it doesn’t count toward getting them out of the doughnut hole,” Mr. Tauzin said. “That’s not fair.”

Kerry N. Weems, the acting Medicare administrator, said the doughnut hole was not the only reason that generics were on the rise. The Part D program over all has made consumers more price-conscious, he said, noting that Medicare’s Web site lists the prices of pharmaceuticals dispensed at each drugstore participating in a particular Medicare plan. “It will show you month by month for the entire year what your yearly expenditures are,” he said.

In 2008, the gap in the standard Medicare drug benefit begins when a patient’s total drug costs have reached $2,510, including the portion paid by Medicare and the patient’s own out-of-pocket deductibles and co-payments. The beneficiary must then absorb 100 percent of costs out of pocket for the next $3,216, until total drug costs have reached $5,726. Only then does the catastrophic coverage kick in.

While federal assistance is available to help the poorest patients with premiums, deductibles and co-pays under the Medicare program, those who fall just above the poverty guidelines and cannot get extra help sometimes simply stop taking their medications once they reach the doughnut hole or rack up big credit card debt to pay for them.

Debbie Mullaney, the pharmaceutical coordinator for a community health clinic in Cumberland, Md., said her clinic looked for ways to help such patients get their medications.

When people reach the doughnut hole, she said, they must continue to pay their monthly Part D insurance premiums — typically $30 or so — even as they also pay for their medicines out of pocket. During that period, the clinic tries to help patients switch to generics or supplies them with free samples from brand-name drug companies.

“We always try steps to get them on something they can afford and get them some accessibility,” Ms. Mullaney said.

A recent AARP survey found that among Medicare beneficiaries who reached the doughnut hole, 15 percent decided not to fill a prescription.

Dr. James D. King, a family physician in Selmer, Tenn., estimates that 50 to 70 percent of his Medicare patients hit the doughnut hole — at which point they switch to generics, ask for free samples or simply stop taking their medicine.

In some cases, Dr. King said, patients elect to switch to another type of drug altogether to reduce costs. For example, patients taking Benicar, a blood-pressure treatment that is not available as a generic, may switch to lisinopril, a generic that also lowers blood pressure but sometimes causes the side effect of coughing.

Another example he cited is that patients taking Plavix, a brand-name blood thinner, might simply use aspirin, a blood thinner that is not as effective but is much cheaper. “It’s not unusual to have a patient who is taking anywhere from 7 to 13 medications every day,” said Dr. King, who is president of the American Academy of Family Physicians. “We start to look at which ones you absolutely need to be on and which ones you don’t.”

Lillian Russell, 86, a widow from Hummelstown, Pa., takes eight prescription drugs. Even though five of them are generic, she reached the doughnut hole this year in July. Her prescription drug bill in September, which she paid entirely on her own, was $727.91. Mrs. Russell believes she will remain in the gap for the rest of the year.

“Unfortunately, two of the drugs I have been on are fairly new ones and are very expensive and there is no generic for them,” Mrs. Russell said. Though generics are not always an option, some economists say that with proper planning, some patients who entered the doughnut hole this year could have avoided it.

A study by Express Scripts, the pharmaceutical benefit manager, said that an analysis of 220,000 patients found that 23 percent of those who fell into the doughnut hole in 2006 could have skirted it by using generics to cut drug costs. Such planning, though, requires that patients talk to doctors about their finances. Many people are embarrassed to bring up money when discussing prescription drugs with their doctors, and many physicians never broach the subject with patients.

A study of more than 1,100 patients published by The Journal of the American Geriatrics Society found that four of five wanted doctors to discuss medication costs, but fewer than one in five doctors did. One in three patients in the study who cut back on their drugs because of cost said they had never asked their doctor for help in reducing expenses.

Dr. Ted D. Epperly, a physician in Boise, Idaho, and president-elect of the American Academy of Family Physicians, said that patients were sometimes embarrassed to discuss their finances.

“Usually I’m a little blind to it if they’re in the doughnut hole,” Dr. Epperly said, “mainly because they’re proud people, and they feel their obligation isn’t to share that with the doctor.”


 

Guess this is what Tender is Alluding to

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An Impossible Promise From John Edwards

John Edwards

The Ad: When I'm president I'm going to say to members of Congress and members of my administration, including my Cabinet: I'm glad that you have health care coverage and your family has health care coverage. But if you don't pass universal health care by July of 2009, in six month, I'm going to use my power as president to take your health care away from you. There's no excuse for politicians in Washington having health care when you don't have health care.

Analysis: John Edwards's new Iowa ad is very effective rhetorically--and based on a false premise. A president has absolutely no power to rescind federal health insurance for members of Congress, as the Edwards campaign admits.

"He would introduce legislation, that's all it is," spokesman Eric Schultz said. "He would introduce legislation and ask them to set a deadline for themselves." While a President Edwards could mount public pressure based on the 47 million Americans who lack health insurance, Congress is, to put it mildly, unlikely to relinquish its own coverage. In fact, some experts argue that such a law would violate the 27th Amendment's ban on "varying the compensation" of members of Congress without an intervening election. Schultz said Edwards would ask senior administration officials to voluntarily give up their health coverage if he fails to pass universal coverage.

The ad captures the former senator's passion and underscores his message that the Washington political system is broken. But Edwards is making a promise he can't keep.

--Howard Kurtz
From the Washington Post
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May be viewed as an impossible promise--- but its the Bully Pulpit he is after.

And hey---Isn't using the Bully Pulpit something that President GW Bush has been very successful at for many years?

I agree with you Iodine but I am so infuriated by the whole thing that we really have to bring to light what is really happening here---so the legislators will not be able to make these decisions in the dark of night and then sweep it all under the rug. I really don't care how they do it--just get healthcare back on the front page and don't let up.

How many people are aware of the craziness that happened last year?

I think when these guys are irresponsible enough to pull something like this they should be targeted with a big bullseye on their back, hunted down and prevented from ever getting in a position of authority again.  Get these Bozos out of office!

Prices under the private drug plans in Part D are 75 percent higher than those negotiated by the Veterans Administration. Prices are also 60 percent higher than in Canada, 5 percent higher than at Drugstore.com, and 2 percent higher than at Costco [New Medicare Drug Plans Fail to Provide Meaningful Drug Price Discounts in the San Francisco Bay Area, Committee on Government Reform, Minority Staff, 03/06/06]. They are even higher than the prices in the preceding drug discount card program [Medicare Drug Plan Prices Are Higher Than Medicare Drug Card Prices, Committee on Government Reform, Minority Staff, 02/21/06]. The Medicare Modernization Act prohibited the government from using the clout of more than 40 million beneficiaries to negotiate for lower prices. The MMA also divided the population into smaller groups, also undermining the ability of the private sector to negotiate. To the extent beneficiaries are saving money, they are doing so thanks to government subsidies, not good discounts.

"A group in Congress is working to change the way Part D works. These legislators want a simple, affordable plan that allows Medicare to negotiate lower drug prices the way the Veterans Administration does. They call their plan the Prescription Drug Savings and Choice Act (H.R. 752)."
 
Of course that was defeated----They cannot negotiate prices the way the VA does---BY LAW!

"The politicians who came up with the doughnut-hole idea had a choice, the sponsors say. They could have sided with older Americans and empowered Medicare to run an affordable program that would benefit seniors, or they could side with the private sector drug companies and shift costs onto seniors.

At a July news conference, U.S. Rep. Darlene Hooley (D-Ore) criticized pharmaceutical companies that "killed every attempt to allow Americans to benefit from the same low drug costs that other countries enjoy." Now, she said "an increasing number of seniors are finding themselves facing the ‘doughnut hole’ and once again being forced to choose between buying the drugs they need and putting food on the table."

Congress can make healthcare more affordable. A starting point would be to eliminate the doughnut hole. Next would be taking Medicare drug policy out of the hands of private insurers and requiring the government to negotiate lower drug prices."----Don Kuehn