Die from a doughnut? You'd better believe it! (From Suddenly Senior)

Saul Friedman

Family & Relationships

Newsday

July 8, 2006

Ruth M., from Smithtown, wishes the media would stop complaining about Part D. She explains that she had been paying $372 a month for three prescriptions and now, with Part D, her co-pays total $61. "So why all the complaining?" she asks.

What she may not realize, yet, is that in addition to the co-payments and any deductibles she and her husband pay (he takes about the same medicines), their accounts also will be charged with the cost of the drugs as paid by their plans. And with each plan charging different prices for the drugs, Ruth and her husband will find their accounts will add up more quickly than they expected to their initial benefit of $2,250 each. Then comes the doughnut hole.

Only now are Part D participants beginning to encounter that hole, the "coverage gap," between $2,250 and $5,100 when they must pay the full cost of their prescriptions while continuing to pay their monthly premiums. Only a few expensive plans provide some coverage in the gap.

Richard C. Rosier, 66, who is disabled, e-mails: "It appears that as of May 31, I have exceeded the $2,250. Surprise! One of my drugs, which retails for $680 a month ... must now be paid in full by me. I still am not sure how the system works, but it doesn't work well for me."

Barbara Christensen, of North Bellmore, who takes 14 prescriptions "to live," said she "went into a deep depression" when she hit the coverage gap in February. She tried not taking some drugs, but that didn't work. To save money, she's buying brand-name drugs from Canada, but those purchases don't count toward getting out of the hole.

Rita Ehrman of Amityville had been on an AARP plan that covered her medicines up to a maximum of $1,250 a year, which she reached every September. So she switched to AARP's Part D because the maximum was $2,250. "It was not spelled out that that amount equaled my payments [co-pays] as well as the plan payment. As a result, I am close to the doughnut hole in June. Part D was not a help to me.... The initial benefit has to be raised or the doughnut hole eliminated."

Finally, this heartbreaking, hand-printed letter from Michael M., of Farmingville, whose wife of 49 years has had cardiac and abdominal surgery. He listed the 13 critical prescriptions she takes. When he filled them the first time, he said, she was in the doughnut hole. Now he can't afford to pay full price for even a few, but doesn't know which ones he can skip. He said, "I'm confused, scared, don't know what to do. I could cry."

Members of Congress who designed this abomination and the well-paid executives at the Centers for Medicare and Medicaid Services who run it and defend it, created the coverage gap to prevent overuse of prescriptions and to save money (for tax cuts, Iraq and other so-called necessities).

They made no allowance for Michael's wife and millions of others who may be forced to skip medications they can't afford while they're in the doughnut hole. What that means - and this is not an exaggeration - is that the hole can kill.

On June 1, the New England Journal of Medicine, published a paper, "Unintended Consequences of Caps on Medicare Drug benefits."

The researchers surveyed 157,275 beneficiaries who in 2003 had HMOs that capped drug benefits at $1,000 a year. Another 41,904 beneficiaries who had unlimited drug coverage were surveyed.

The research, sponsored by the Kaiser Family Foundation, found that patients whose benefits were capped or reduced stopped taking medicines they couldn't afford. Their blood pressure, glucose and cholesterol levels worsened and "the savings in drug costs were offset by increases in the cost of hospitalization and emergency department care."

More ominous, the death rate for patients whose drug benefits were capped was 3.73 per 100 persons, compared to 3.05 for patients with unlimited drug benefits.

The researchers concluded, "This information can help us understand the effect of the new Medicare Part D plans, in which many patients pay in full for annual drug costs between $2,250 and $5,100." This year, the foundation says, more than half the 10.4 million Part D plan enrollees will fall into the coverage gap. Mental health patients taking the most expensive drugs will encounter the gap sooner than other beneficiaries.

Congress could raise the initial benefit or eliminate the coverage gap, but that's not likely. The consumer advocacy group Families USA has sought to stir action among inert lawmakers and CMS with a 15-minute documentary, hosted by Walter Cronkite, titled "The Problems With the Medicare Drug Program and How to Fix Them." If you have a good computer, you can see it at www.familiesusa.org or you can order a DVD.

Cronkite's solutions are obvious and simple:

Place the drug program where it belongs, under Medicare, and dispense with the costly, confusing array of private plans, each of which must return a profit to compensate agents, executives and stockholders.

Allow Medicare to use its bargaining power to negotiate the best prices for drugs, as the VA does, and as Medicare does for other medical services.

With the savings from these changes, it will be possible to eliminate the yearly doughnut hole.

Unfortunately, any such changes may have to await the next Congress and new leadership. Until then, for many ill and frail Americans whose lives depend on the drugs they take, the doughnut hole may be a death trap.

WRITE TO Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY,
11747-4250, or by e-mail at saulfriedman@comcast.net.