Hitting the Medicare doughnut hole early

Reading articles like this irritates me more than just a little bit. I have written extensively about the coming Part D doughnut hole already.

Furfaro, a disabled heart-transplant patient, hit the doughnut hole last month when he tried to fill a prescription for two medications. Instead of two $25 co-pays, the pharmacist charged him $661 and $329 for the prescriptions.

“I threw a fit,” he said. “What am I supposed to do? I don’t have $661 in my pocket.”

Stuff like this comes down to personal responsibility. As the person in charge of Medicare consultation at my place of employment, we killed ourselves educating people about the plan. We did everything humanly possible to 1) educate people and 2) help them pick the plan that was right for them based on their current drug therapy. From the perspective of my pharmacy, there was nothing more that we could have done to educate people and help them make the right decision. Nothing.

Millions of people and millions more family members are going to be experiencing this shocking and crushing problem,” Hayes said.

The Medicare doughnut hole is a strange compromise between lawmakers who wanted to limit the cost of the program and those who wanted it to cover as many people as possible.

While it is an “advocacy” group’s job to push for more, more, more — there are limits, and these limits were advertised, and most importantly, there were and are plans which do not have a doughnut hole. A pharmacist cannot help it if someone didn’t pick a plan that would suit their needs better. At some point, it must be the patient’s responsibility to take care of themselves. It is not that pharmacist’s issue that this patient happened to be on Prograf and that Prograf costs a lot of money, however that pharmacist does end up looking like the bad guy, even though he or she was just bearing the bad news.

The fact that plans exist without a doughnut hole is conveniently conflated with the basic plan that the federal government outlined about a year and a half ago, before the private sector finalized their plans. Perhaps it is because the journalist doesn’t know, but more probably, it is because leaving this fact out tugs on the heartstrings that much more.

If his health deteriorates further, Furfaro said, he’ll just get admitted to a hospital and receive his medicine that way, as Medicare will pay all bills if he is hospitalized.

In Mr. Furfaro’s shoes, I would do the same thing, and it is something that will be addressed as in a year or two. With the doughnut hole, some people will always run out of coverage through poor planning, catastrophic occurrences, or what have you, and they will go to the hospital to continue getting their medications. However it is in the government’s best interest to keep people out of the hospital when they are picking up the tab, because it is more expensive to keep someone in a hospital bed than it is to pay for their medications at a retail pharmacy.

In the meantime, the current Part D plan has worked out astoundingly well, and it is certainly off to a very good start. Where the money will come from in the future to continue its funding is anyone’s guess, though.

Update 12.26am: I forgot to mention that Part D providers are required to send monthly notices to their subscribers telling them how much of their benefit they have used up, so if Mr. Furfaro had been doing his due diligence, he wouldn’t have been blindsided by the doughnut hole.

[tags]Medicine, pharmacy, Part D, doughnut hole, Medicare Part D[/tags]

5 thoughts on “Hitting the Medicare doughnut hole early

  1. I would not say that the Medicare Part D rollout has gone astonishing well. It was already +30% under the desired target enrollment levels that the gov’t had projected. The penalty, I don’t agree with at all. More importantly is the funding issue. With Medicare Part A&B already in dire straights, this Part D will only make a bad situation far worse in the end when a reliable cost metric is determined. The ultimate failure of Part D is that it does not actually help those in need the most. This is why there is even a doughnut.

    Putting yourself in the place of an elderly person, I would not be so frustrated that it took time to educate these people about how and why they should switch or not. You would have to assume that everyone got adequate information to make a decision. My mother being 78 yrs old and I a MBA graduate, had all of the resources to navigate the process. I made a sophisticated spreadsheet (also checked how the #’s for her meds were calculated to reflect her annual cost) to see which plan was best for her. I also asked questions that most Part D users would not think of like is there limits to the total number of refills allowed in a year for a particular drug(lots of things varied by plans). For the state of NC, there were 39 plans that I needed to analyze. Quite a daunting task for people without access to computers, transportation to those that might help, hours of waiting to answer questions, trying to see if they can actually survive the doughnut in addition to all other normal expenses, etc.

    Most Americans don’t have a clue as to how complicated the US healthcare system is today. How many people actually know that Medicare pays a nice portion of a medical student’s education, especially during residency, to hospitals. It’s too easy to say personal responsibility alone without understanding the situation many individuals may face. I am not excusing some accountibility on the individual, but how much blame should really rest on their shoulders alone? In our society today, it seems that it is an all or nothing sum which is a gross exaggeration of the truth (in my opinion).

  2. Thanks for taking the time to reply. Allow me to address some of your points:

    The penalty, I don’t agree with at all.

    The penalty is necessary, otherwise people won’t sign up. Unfortunately sticks work better than carrots when getting people to do time-sensitive things. I addressed this in one of my first blog entries — or rather, Drugwonks did, and I copied it and linked them up because they’re a great blog.

    With Medicare Part A&B already in dire straights, this Part D will only make a bad situation far worse in the end when a reliable cost metric is determined.

    The architect of the basic Part D plan (McClellan) knew that cost would be an issue. Right now, Part D costs are 30% less than initial estimates. This isn’t because of a lower number of seniors signing up for the plan, but rather because private companies are better at cutting costs than government agencies are. (Because it affects their bottom lines, obviously.)

    The ultimate failure of Part D is that it does not actually help those in need the most. This is why there is even a doughnut.

    This is a fundamental misunderstanding of what Part D was supposed to accomplish. It was never supposed to help “those in need the most.” It was meant to help most seniors get most of their medications at reduced prices to achieve positive therapeutic outcomes.

    State programs are in place to help those at or below the poverty line, and most of these people receive subsidized versions of Part D in my experience, but Part D was never designed to replace welfare and state medicaid programs.

    Putting yourself in the place of an elderly person, I would not be so frustrated that it took time to educate these people about how and why they should switch or not. You would have to assume that everyone got adequate information to make a decision. My mother being 78 yrs old and I a MBA graduate, had all of the resources to navigate the process. I made a sophisticated spreadsheet (also checked how the #’s for her meds were calculated to reflect her annual cost) to see which plan was best for her. I also asked questions that most Part D users would not think of like is there limits to the total number of refills allowed in a year for a particular drug(lots of things varied by plans). For the state of NC, there were 39 plans that I needed to analyze. Quite a daunting task for people without access to computers, transportation to those that might help, hours of waiting to answer questions, trying to see if they can actually survive the doughnut in addition to all other normal expenses, etc.

    By and large, I agree with you on just about everything you stated. Unfortunately, due to the nature of medicine, there is no simple one-size-fits-all solution — though UnitedHealth/AARP came close with their universal plan. Most of the X number of plans in a given state are variations of 3-5 common themes. Deductibles, monthly premiums, and whether a doughnut hole are the variables surrounding a basic formulary for a plan administered by a given company.

    Personally, I have not ever seen a plan that limited the number of refills on a prescription to less than 12, unless it was a controlled substance.* Generally 12 refills is sufficient because scripts expire after 12 months. (Technically there is no expiration on non-controlled maintenance meds, though most pharmacies won’t fill a script that’s more than a year old, so it’s largely a moot issue.)

    * Some mail-order only plans don’t cover refills, but they’re the exception rather than the rule.

    You would have to assume that everyone got adequate information to make a decision.

    They did. If a person was on social security, they got a Medicare booklet in the mail. Many people threw it away, because the prospect of reading it was daunting. This amounts to the “I’ll bury my head in the sand and maybe it will go away” nonsense that I saw a lot of at the end of last year and the beginning of this year.

    I am not excusing some accountability on the individual, but how much blame should really rest on their shoulders alone?

    I’d rather take responsibility for facilitating my own good health. Somewhere, sometime, a line MUST be drawn. It is simply not possible for the government or medical professionals to take care of every aspect of one’s health. (Honestly, would you want the government responsible for your health, finances, etc? I wouldn’t…) Employers generally offer a choice of health plans to their employees, and then they must make the best decision. Why should Medicare be any different? So long as resources are provided to those that don’t have outside sources (children, friends, whatever) of help — which did and still do exist — expecting someone (or their families) to be responsible for their or their loved one’s good health is not an unreasonable expectation.

    You can only hold someone’s hand so far and so long before they need to learn to walk on their own.

    This post may be of interest to you as well. (Please keep in mind when you read that post that I am not a Republican.)

    Again, thank-you for your thoughtful reply.

  3. i think the guy that said if mr. furfaro did his deligent work he would not be in this mess is a jackass! first off there was no info given because nobody not even the hmo customer service people knew what was happening. everytime one would call for info you would get a different story. second the pharmacy did not eeven know. thrird a heart transplant patient of 1000 a month is not going to be able to pay. you have to uise your common sense, if this guy was diabled before transplant that means he had no savings to pay for this medicine.

    frnak furfaro

  4. i think the guy that said if mr. furfaro did his deligent work he would not be in this mess is a jackass! first off there was no info given because nobody not even the hmo customer service people knew what was happening. everytime one would call for info you would get a different story. second the pharmacy did not eeven know. thrird a heart transplant patient of 1000 a month is not going to be able to pay. you have to uise your common sense, if this guy was diabled before transplant that means he had no savings to pay for this medicine.

    frnak furfaro

    Are you drunk or just angry? ;)

    Second of all, use the Medicare Part D comparison tool to help pick the best plan for you when November 15 rolls around.

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