More Fun From Medicare Part D

by hilzoy

Tomorrow's NYT has an article about the problems poor people with mental illnesses are having with the new Medicare prescription drug plan. It's not pretty:

"On the seventh day of the new Medicare drug benefit, Stephen Starnes began hearing voices again, ominous voices, and he started to beg for the medications he had been taking for 10 years. But his pharmacy could not get approval from his Medicare drug plan, so Mr. Starnes was admitted to a hospital here for treatment of paranoid schizophrenia.

Mr. Starnes, 49, lives in Dayspring Village, a former motel that is licensed by the State of Florida as an assisted living center for people with mental illness. When he gets his medications, he is stable.

"Without them," he said, "I get aggravated at myself, I have terrible pain in my gut, I feel as if I am freezing one moment and burning up the next moment. I go haywire, and I want to hurt myself."

Mix-ups in the first weeks of the Medicare drug benefit have vexed many beneficiaries and pharmacists. Dr. Steven S. Sharfstein, president of the American Psychiatric Association, said the transition from Medicaid to Medicare had had a particularly severe impact on low-income patients with serious, persistent mental illnesses. "Relapse, rehospitalization and disruption of essential treatment are some of the consequences," Dr. Sharfstein said. (...)

At Dayspring Village, in the northeast corner of Florida near Jacksonville, the 80 residents depend heavily on medications. They line up for their medicines three times a day. Members of the staff, standing at a counter, dispense the pills through a window that looks like the ticket booth at a movie theater. Most of the residents are on Medicare, because they have disabilities, and Medicaid, because they have low incomes. Before Jan. 1, the state's Medicaid program covered their drugs at no charge. Since then, the residents have been covered by a private insurance company under contract to Medicare.

For the first time, residents of Dayspring Village found this month that they were being charged co-payments for their drugs, typically $3 for each prescription. The residents take an average of eight or nine drugs, so the co-payments can take a large share of their cash allowance, which is $54 a month. Even after the insurer agreed to relax "prior authorization" requirements for a month, it was charging high co-payments for some drugs - $52 apiece for Abilify, an anti-psychotic medicine, and Depakote, a mood stabilizer used in treating bipolar disorder.

The patients take antipsychotic drugs for schizophrenia; more drugs to treat side effects of those drugs, like tremors and insomnia; and still other drugs to treat chronic conditions like diabetes and high blood pressure.

"If I didn't have any of those medications, I would probably be institutionalized for the rest of my life," said Deborah Ann Katz, a 36-year-old Medicare beneficiary at Dayspring. "I'd be hallucinating, hearing voices.""

Great: we have people who get a $54 monthly cash allowance being charged a $52 copay for one prescription. But wait: it gets better! Consider the experience of looking through all those different prescription drug plans, each with their different copays and deductibles and formularies, deciding which to choose. Perfectly sane people with backgrounds in the health professions have said they find it almost impossibly confusing. Try to imagine how it strikes someone with a serious mental illness:

"Sponsors of the 2003 Medicare law wanted to drive down costs by creating a competitive market for drug insurance. They focused on older Americans, not the disabled. They assumed that beneficiaries would sort through various drug plans to find the one that best met their needs. But that assumption appears unrealistic for people at Dayspring Village.

Heidi L. Fretheim, a case manager for Dayspring residents, said: "If I take them shopping at Wal-Mart, the experience is overwhelming for them. They get nervous. They think the clerks are plotting against them, or out to hurt them."

Residents of Dayspring Village see worms in their food. Some neglect personal hygiene because they hear voices in the shower. When nurses draw blood, some patients want the laboratory to return it so the blood can be put back in their veins.

Under the 2003 Medicare law, low-income people entitled to both Medicare and Medicaid are exempted from all co-payments if they live in a nursing home. But the exemption does not apply to people in assisted living centers like Dayspring Village. (...)

"We are all aware that the next couple of months will be difficult for these clients, and that the possibility of a transition to a nursing home is their only option if prescriptions are not covered in assisted living facilities," Ms. Medina said in a memorandum to local social service agencies.

Luis E. Collazo, administrator of Palm Breeze, an assisted living center for the mentally ill in Hialeah, Fla., said many of his residents were forgoing their medications on account of the new co-payments. "Because of their mental illness," Mr. Collazo said, "they don't have the insight to realize the consequences of not taking their medications. Without their medicines, they will definitely go into the hospital.""

And who do you suppose will pay for their hospitalization, or for their stay in a more expensive nursing home? We, the taxpayers, of course. Not that that will begin to make up for the damage done to those mentally ill patients by going completely psychotic. That damage will not be made whole.

Paul Krugman reminds us (sorry, TimesSelect) how we got into this mess:

"Consider the career trajectories of the two men who played the most important role in putting together the Medicare legislation.

Thomas Scully was a hospital industry lobbyist before President Bush appointed him to run Medicare. In that job, Mr. Scully famously threatened to fire his chief actuary if he told Congress the truth about cost projections for the Medicare drug program.

Mr. Scully had good reasons not to let anything stand in the way of the drug bill. He had received a special ethics waiver from his superiors allowing him to negotiate for future jobs with lobbying and investment firms - firms that had a strong financial stake in the form of the bill - while still in public office. He left public service, if that's what it was, almost as soon as the bill was passed, and is once again a lobbyist, now for drug companies.

Meanwhile, Representative Billy Tauzin, the bill's point man on Capitol Hill, quickly left Congress once the bill was passed to become president of Pharmaceutical Research and Manufacturers of America, the powerful drug industry lobby.

Surely both men's decisions while in office were influenced by the desire to please their potential future employers. And that undue influence explains why the drug legislation is such a mess."

But besides Scully and Tauzin, the Congressional Republican leadership, who drove this bill, and President Bush, who signed it, surely deserve a lot of the blame for how it has turned out. If the patients at Dayspring Village who used to imagine that the clerks at WalMart were out to get them start having paranoid fantasies involving members of Congress who are willing to sacrifice the sanity, and perhaps the lives, of Medicare's most vulnerable recipients just to gratify their contributors and to be able to gain a short-term advantage in the 2004 elections, they will not be wrong. Just because you're a paranoid schizophrenic doesn't mean they aren't out to get you.

Comments

[Debbie(aussie)]

Wouldn't it have been better for the insurance compamies to take over particular paitents. With the current set up there is no way it was created with recipiants needs in mind. Surely the cost of this dibarcale can only increase if the once stable paitent requires hopitalization and for assistance. Change the life of some of the mentally ill and you might never get them back. I am not an american, but I can see that this has been handled atrociously. All for the drug companies nothing for the ill who need thier drugs regularly, at reasonable cost.
Makes me a little bit less angry at our PM. I don't like the man nor do I support his party. But he stuck to his guns over the oz-us free trade talks and would not allow any changes to our PBS (pharmacutical benifits scheme).

[blogbudsman]

First of all MPD is a mess. My folks, who pride themselves on figuring things out and finding the best situation for them, are now paying double for their prescriptions in addition to the fee that ate their Social Security COLA. However, if this abominable program can shine some light on the pitiful plight of the mentally ill that has evolved over many administrations from both parties, then something good might result yet. Hilzoy,I guess I'm disagreeing with the aim of your argument, but support the need for that argument none the less. We be strange bedfellows, no?

[Slartibartfast]

Does Congress have a GoBack button?

[bob mcmanus]

Manufacturer Assistance Programs to End

I don't know if this is on-topic or not, just another feature of Medicare Part D. Dallas Morning News used to archive its article to subscription pretty quickly, so I don't know how long the link will last. DMN, a very conservative paper, has been running a daily front page series on Part D and health issues. Some quotes:

"Ed and Patricia Weymouth get 10 medications free from pharmaceutical companies, but that help will end in May."

"He's shopped for Medicare drug plans for him and his wife but has found the cheapest ones will add $216 a month to their drug costs."

"The drug company assistance programs have been a godsend for people who don't have insurance and can't pay for their medications. They are especially valuable for people with chronic or serious illnesses who take expensive medicines."

"As Medicare's drug coverage takes effect, the pharmaceutical industry has started scaling down its patient assistance programs. Two companies will no longer take applications from people over 65; others will help only seniors who don't enroll in the drug program."

In most cases, the companies hand out the prescriptions free to lower-income adults. In others, they charge only a few dollars.

"In 2004, the assistance programs filled 22 million prescriptions worth $4.1 billion for 6.6 million people, according to the Pharmaceutical Research and Manufacturers of America. A quarter of those patients were 65 or older."

"Industry officials argue that their hands are tied. The inspector general's office of the Health and Human Services Department has told them that companies risk violating the federal anti-kickback law if they give free prescriptions to anyone enrolled in a federally subsidized drug plan." (my emphasis)

Personal experience:My mother, after a liver transplant, was on anti-rejection drugs for three years. The drugs would have cost $1200 a month without an assistance program from Novartis. That was just one indispensable drug.

[cleek]

kids...

Congress, when the members were elected, was given a mandate to do this. you had your chance to avoid this four years ago.

[hilzoy]

Bob M: about antirejection drugs: here's a bizarre fact about Medicare (not specifically Part D): at least as of a year ago, they covered antirejection drugs only for 3 years.

Antirejection drugs, for those of you who don't know, are what you take when you've had a transplant, to prevent your body from rejecting the transplanted organ. You have to take them for life (it's not as though the transplanted organ stops looking to your immune system like an enemy invader after 3 years.) If you stop taking them, your body rejects the transplanted organ, and you need a new transplant.

Transplants are a lot -- a LOT -- more expensive than antirejection drugs. They are also a lot worse for the person having the transplant (any really major surgery is pretty much guaranteed to be worse than a successful drug regimen), and besides all that, they use scarce organs.

At least as of a year ago, though, Medicare paid for transplants, including new transplants, but only 3 years of antirejection drugs.

That makes no sense at all.

cleek: they had a mandate to get a prescription drug benefit. They did not have a mandate to do this.

And bbm: it had to happen sooner or later ;)

[lily]

There is an article in the New York Times magazine about medical care in Cambodia. In frustration with the corruption of their government one of their ministires contracted with an international nonprofit charity to set up hospitals. The plan has worked very well and now poor Cambodians have free basic health care. Since the FEMAing of our government agencies and the starvation of our infrastructure is rapidly transforming us into a Third World country, perhaps we should investigate the non-profit international charity route to provide medical care for low-income Americans. Maybe Bengladesh will send us another donation.

[bob mcmanus]

My error hilzoy, mom survived seven years after the transplant. And I simply don't remember where or how we got the Cyclosporin(A-R drug) in the first years. The Novartis assistance program was a Godsend, though with massive paperwork and a three-month renewal. Of course, the A-R drugs eventually ate her kidneys.

With all respect, I don't like to use personal anecdotes in argument for a lot of reasons. One of which is the you become open to:"Well, even though Part D (or whatever) helps thousands of people, you don't like because it isn't perfect for your idiosyncratic problem. Rather selfish, huh?"

In any case, I can't make enough sense of the complications of Part D (or won't be bothered) to know how my family would have been affected back when we had a shelf of daily drugs.

[Jackmormon]

As an almost total bystander to this Medicare fiasco, I manage nonetheless to be personally affected by this post: I live across the street from an assisted living mental health facility, and having had no trouble with the residents in six years, I would really like that state of affairs to continue. Selfish of me to hope they get the drugs they need, I suppose.

[cleek]

cleek: they had a mandate to get a prescription drug benefit. They did not have a mandate to do this.

i guess i failed to make my sarcasm clear. :)

[Pooh]

Just thought I'd pass this nugget along. Apparently Abramoff had a piece of Plan D.

[john miller]

I can't believe that I am even halfway agreeing with bbm, but he is right in that this abominable program may shed some light on the problem of mental illness in thsi country.

Generally speaking there are two chronic mental illnesses that will impact someone enough that they would end up on Medicaid: schizophrenia, which is highlighted in this post, and severe bi-polar disorder.

There are two major problems which are tied into these two diseases.

The first is that patients with these two disorders tend to be the most medication non-compliant of any suffering from mental illness, even under the best of conditions. Put another stumbling block in their way, and non-compliance is almost assured.

Many of them are not so severe as to require living in an assisted living environment, and may either be watched over by family or even do some independent living. This puts them even more at risk for relpase.

Secondly, especially for schizophrenics, a relpase into psychosis due to lack of medications can bring forth very violent tendencies. This places not just themselves but other people at risk.

When we look at the ultimate cost of this program, already far higher than we were assured it would be by this administration, we have to take into account the cost of increased acute care required for those who could not handle the increased cost of drugs or even have access to them due to the confusion caused by the implementation.

In addition to that are costs potentially created by the consequences of not having medication incurred by society at large.

BTW, bbm was correct that neither party has been very good about treating with the mentally ill, although some Democrats at least attempted to get full parity for insurance coverage for treatment of mental illness, while Republicans backed and passed a meaningless parity act, which only eliminated dollar limits, but not day or doctor visit limits.

[Paul]

And who do you suppose will pay for their hospitalization, or for their stay in a more expensive nursing home? We, the taxpayers, of course.

Unlikely, I expect. No one will pay for their hospitalization or institutional care. Taxpayers have already decided not to pay for them. Patients like these will be "out-sourced" to whatever family care they can rely on, or to homelessness. A lot of them will become just another crazy person we try to avoid on the street.

[nemo quisquam]

You might win an Emmy for this thread. Oh, right. Take the leash off the abusers and put it on the abused. Just a small suggestion for the Republicans. The "D" in Medicare Part D should always be typed with a semicolon as in ";D". Maybe the emoticon will help peoples' attitudes.

[Barry]

"Does Congress have a GoBack button?"

Posted by: Slartibartfast

No, but it does have a 'flush' button. Hopefully, enough Americans will use it in November.

[hilzoy]

Paul: the people in question are already enrolled in Medicare and Medicaid. That being the case, it seems to me like a pretty good bet that we will foot the bill.

[john miller]

Hilzoy, most of them, especially those that are in a supervised setting, will probably end up getting the crae they need, and will be paid by Medicaid for the majority.

The bigger problem is for those who were marginally functioning and not in a supportive environment and may end up in far worse shape before they are discovered, frquently by the police. We will still foot the bill, one way or another, but stabilization will probably take even longer.

It should be recognized, that just restarting on meds does not automatically mean everything is okay. Generally speaking, each subsequent psycotic break takes longer to stabilize.

[john miller]

Yes, the word is psychotic, and I do know how to spell, generally speaking, just really poor at typing.

[DaveC]

In the article hilzoy cited:
Most of the residents are on Medicare, because they have disabilities, and Medicaid, because they have low incomes.

I still don't quit understand how the Medicare works for the younger patients, such as Mr. Starnes, 49.

Somewhere I picked up on some other over-restrictive regulations imposed on physicians by Medicare. Is it true that physicians who accept Medicare cannot perform procedures that are not Medicare-approved, even if this is for self-pay patients who are not on Medicare? I just vaguely remember this. Can somebody help me out on how this works?

[hilzoy]

john miller: yes, that seems to me to be the most important point (and one that I've been thinking of writing a whole post on, except that other aspects of my life keep intervening): that for a lot of medical problems, clearly including major psychiatric disorders, relapses make things worse than before, and so it's not just like e.g. getting a headache, which you can subsequently make go away, and then be good as new again. More like, say, marital infidelity: you can apologize, and do everything you can to make things right, but your marriage may never be the way it was. Likewise, I think, with some psychotic breaks.

The difference between marital infidelity and the effects of Medicare Part D, of course, is that marital infidelity is your own fault. Being forced to abruptly stop your antipsychotic medications is not. Through no fault of your own, your life gets broken in a way that it is hard, and sometimes impossible, to set right.

Thanks, Congress.

[Kiersten Marek]

This irks me lots. First, as a clinical social worker, I have seen what happens when psychotic people go off their meds -- they go into a terrifying place, both for them and for the people around them. They become more violent both toward themselves and toward others. They make society less safe. In fact, perhaps this medicare crisis should be added to the list of ways in which the Bush Admin. has made America less safe as a nation. We are threatened both from without and from within.

Also, what is the killer is that people are forced to choose a plan and MUST stay on it for a year. But the plan can change which drugs it is covering anytime it wants. Thus, the unrectifiable uncertainty for people about which plan to choose. What if I choose plan #12 because it covers Lipitor but then plan #12 decides not to cover Lipitor anymore? I'm stuck footing the bill for an expensive drug for the rest of the year, or not taking it and risking major health problems.

Don't tell me our elected representatives couldn't have fixed this problem. I met with Senator Jack Reed in Feb of 2004 regarding this plan, and people spelled out then that it would be wrong to make people stay on plans for a year when the plans were not held to the standard of at least providing what they said they would provide when the person signed up. Nevertheless, this was not fixed. So infuriating, and Jack Reed is a democrat, albeit a heavily-financed-by-pharmaceutical-giants democrat. Are all politicians just basically in the pocket of the drug companies?

Trying not to give up hope for better political leadership, but sometimes it's just so hard.

[hilzoy]

Kiersten -- thanks for working on this back when it might have made a difference. Don't give up hope. We need people like you, who don't just watch government but try to engage with it and make it work for all of us, far too much for that.

And I think this might make a lot of people realize that policy is too important to be left in the hands of ideologues.

[Pooh]

Also, what is the killer is that people are forced to choose a plan and MUST stay on it for a year. But the plan can change which drugs it is covering anytime it wants.

Doesn't this just scream "bait & switch"? The more I read about the mechanics of this program, I wonder who could possibly have thought it was a good idea for its "intended" beneficiaries. I'm mindful of KenB's concerns not to conflate implementation with policy, but still, this is just bizarre.

[kenB]

The "lock-in" feature is definitely policy and not implementation -- it was actually proposed and very nearly implemented in 2002, for the Medicare+Choice (now "Medicare Advantage") program that the part D coverage has been folded into. The idea behind it, AFAIK, was that commercial health plans lock their customers in for a year, so why shouldn't the "commercial" version of Medicare work the same way. However, it was removed at the last minute due to objections from various quarters. In fact, our clients are pretty much against it, mainly because it creates staffing problems -- instead of fairly stable work levels spread out over the whole year, there's a bulge in November-December and lighter volume the rest of the year.

As for drug plans changing their formulary in the middle of the year, my understanding was that members of that plan would then be eligible for a special election period to be able to switch to a different plan. But that's not my department, so I'm not at all sure of that.