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| The Basics | Medicares drug-plan mess
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The unintended consequence of a grand plan to offer prescription coverage to the elderly and poor is a bureaucratic mess thats left many paying more or simply doing without.
By Deborah Vrana
Days into the new year, Jan Scalia got her first taste of the new Medicare prescription drug plan.
Just released from the hospital for bronchitis and acute renal failure, she sent a friend to her local drugstore to fill her many prescriptions. Then the call came back: You arent in the computer system and you cant get your medicine. Even calls from her doctor proved futile.
It took more than two weeks for Scalia to get her Albuterol and Rocaltrol, a delay that worsened her condition.
I have nothing good to say about this plan," said Scalia, 48, a former nurse who rents a room from a homeowner in Pacific Palisades, Calif. Im just disgusted. This is not right.
Throughout the country, thousands of people have run into delays or outright refusals in getting desperately needed medication for such serious illnesses as heart disease and multiple sclerosis. At least 26 states have stepped up, providing emergency funds to buy the life-saving drugs.
The plan, the most significant change to Medicare since its establishment in 1965, offers drug coverage to Medicares 42 million mostly elderly beneficiaries through subsidized, private insurance policies. More than 23 million people have signed up.
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'Only a matter of time until someone dies'
Since the Jan. 1 rollout, the plan has been plagued by problems even some of its sharpest critics didnt expect.
- Some beneficiaries are being told they dont have coverage when they do. Others find that the drugs are covered but other needed supplies arent.
- Some beneficiaries havent received enrollment cards.
- Many with chronic conditions find that no plan covers all their medications.
- Wait times for information are long, and the information dispensed is not always correct. The Social Security Administration, which administers some aspects of the Medicare plan, says its help lines have been so overwhelmed that other services are beginning to suffer.
- Some are being overcharged dramatically, charged hundreds of dollars when they owe only a co-payment of $1 or $5.
- Some pharmacists have yet to be paid.
- California and Missouri have sued over a requirement that any savings accrued by state plans because of the Medicare changes be returned to the federal government. Both say its taking hundreds of millions of dollars away from those who need it most.
- Some plans require that beneficiaries switch to a particular pharmacy.
One of the main problems is with so called dual-eligible beneficiaries, such as Scalia, who were previously covered under both federal and state programs such as Medicaid. A provision in the new law automatically switched about 6 million low-income and disabled people -- previously covered by state programs, some more generous than the new drug plan -- into the new program on Jan. 1. That influx overwhelmed the system. It also left many of those dual eligibles -- nearly a third of whom are mentally ill -- with no coverage at all.
Barb Cebuhar, spokeswoman at the agency that runs Medicare, acknowledges the switch helped spark confusion but said officials are working overtime to resolve the issues. Additional staff has been added to its help line for pharmacists, she said.
We are telling people not to leave the pharmacy without their medications, she said, noting that the complaints seem to be subsiding and that more than 40,000 prescriptions are being filled each hour.
But still, at pharmacies throughout America, seniors wait in line only to be told they arent in the system or that the medication or supplies they need arent covered.
Its only a matter a time until someone dies from this, if it hasnt happened already, said Bonnie Burns, policy specialist for with California Health Advocates, a Sacramento, Calif.-based nonprofit for people on Medicare. There are some really sick people out there, and they arent getting the medicines they need.
Looking for improvements
Before the program, seniors had to pay full price for their drug coverage or buy supplemental coverage.
The Bush administration considers the benefit one of its major accomplishments. But at a hearing addressing the programs launch, Mark B. McClellan, the head of Medicare, acknowledged that the drug plan was too complicated and vowed to simplify it.
Giving some hope to confused seniors, McClellan said a looming May 15 deadline for enrollment may be pushed back. Under the current rules, if Medicare recipients fail to enroll before May 15, they will have to pay higher monthly premiums.
We feel there is still real value in this plan," said Steve Hahn, spokesman for the AARP, an advocacy organization that represents more than 35 million Americans age 50 and older. Yes, it can be confusing, it can be time consuming, but for those who stick with it and get into a plan that is right for them, there is real value.
Hahn said some of the early January glitches were being resolved by extra staffing, cutting complaint volume 75% in the past month.
But Eileen Harper, president of the Center for Health Care Rights in Los Angeles, an advocacy organization for Medicare beneficiaries, said while the number of complaint calls has declined, there are still serious problems.
People we are talking to are not getting care -- pharmacies are not getting a clear message, Harper said. Were also still getting calls from people who arent sure what plans they are in.
Harper said even when employees at her nonprofit check the persons status on Medicare Web site, they sometimes cant figure out what plan the person has automatically been enrolled in.
There is something wrong with this picture, she said.
Confusion is no surprise
Given the programs magnitude, some confusion was expected.
In October, Medicare launched a $300-million government education program, along with a handbook titled Medicare & You, to beneficiaries, a online tool to help estimate costs and a toll-free help line: (800) MEDICARE, or 1-800-633-4227.
The health insurers offering the plans also stepped in with their slick advertising campaigns, including one that featured the characters from the 1950s television show I Love Lucy. Roughly 10 insurers have been approved to sell the plans nationwide. In some states there are more, such as California, where seniors can pick from at least 18 insurers.
At Woodland Hills, Calif.-based insurer Health Net, which offers three plans from $17.65 to $21.99 a month, officials agreed the confusion has been troublesome. The insurer increased its call-center staff by 50%, and a spokesman said the volume seems to be declining.
Were not pleased it was like this, said David Olson, spokesman for Health Net. But given the scale, its not surprising.
There is some positive news. This month, Medicare released estimated indicating the drug benefits would cost less than expected, $678 billion over the next 10 years, instead of the $737 billion projected earlier. The average monthly premium for seniors is expected to be about $25, less than earlier estimates of $32.
A Kaiser Family Foundation study found that 7.4 million seniors will see their out-of-pocket expenses rise under the new plan, most only a few hundred dollars but about a third with dramatically higher costs.
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