Mediocrity in Prescription Drug Coverage for American Citizens

If you can't screw them outright, confuse the hell out of them! --unattributed, but surely stated by someone.

While helping to care for my elderly mom this week, I saw an advertisement for a national pharmacy chain. They offered to list the different Medicare Prescription plans along with a list of an individual’s medications in order to assist in deciding which plan best suits any given patient. Partly as a result of that, and partly because this particular pharmacy is located on the most accessible corner of the nearest intersection to my mom’s house (traffic in Wilmington, NC, has been the worst in the state for the past six years), we switched her prescriptions over to this new pharmacy and had them generate a report for us.

I learned that President Bush and the Republican Party are vehemently hawking a plan that is not at all user friendly. It also seems to benefit the pharmaceutical and insurance industries more than it does the patients it should be intended to assist. This last statement, of course, is questionable, depending upon how devoid of insurance and care an American might be. Here is what I could understand, based on what I have read in the report for my mom.

Mom has about 12 different prescription medications that she has to take. Each of them is significant in choosing the plan that best suits her needs. If she chooses a plan today based upon her medications and her medical regime is changed because of clinical changes in her health, then a plan that she has chosen may no longer be the best plan for her. In fact, the unsuited plan may bring profit from her misfortune to the pharmaceutical or insurance companies. It is my understanding that once you have selected your plan, you are stuck with it, although I am not sure for how long.

The first thing I needed to know was how many of mom’s prescriptions are covered by the plan. Some cover all of the meds to some extent, while others only cover part of the list. If this were simple, we could find the list of plans that cover 12 of 12 medications and then further sort them out by other factors to make our decision. This is not a simple process however, so we must move to the next step.

We now need to know which of four categories medications fall into for each plan. I will use terms that make sense rather than the euphemisms that the government uses. There are basically four categories of meds: 1) drugs for which you pay little money, 2) drugs for which you pay moderate money, 3) drugs for which you pay most of the cost and 4) drugs that are not covered at all. Depending on the expense of the drugs that you take, this stratification is very significant.

Suppose for example that three different plans cover all 12 of your medications and a fourth plan only covers 11 of 12. Depending on the category into which a plan places your individual medication, your charges for the same drug will vary across plans. For example, if you take the drug Zestril for high blood pressure, it may be in a plan where you pay a $10 co-pay in one plan, or a $28 co-pay in a second or a $56 co-pay in the third, or maybe, it will even be completely omitted from reimbursement and you will have to pay full price.

Next there is the question of monthly deductible. Each plan has one. Some run as high as $64/month and others are cheaper, as low as $28/month, but you will have to pay that amount each month just to have the opportunity to participate in the plan.

So, if you only take one drug and it normally costs you $12 and that drug is in the third category in the plan you have selected, you could find yourself paying over $100/month to obtain your prescription through this plan in order to cover the copay and the monthly deductible. However, if your drug plan has a low deductible, and covers only 11 of your 12 drugs, then it may actually be a better deal that a plan that pays for all 12 of your meds. The stinking slap in the face is that you might find yourself paying a portion of your deductible and a $56 co-pay for a drug that used to cost you far less.

This is one of the worst kinds of puzzles to present to the elderly and disabled to work through in making some of the most significant decisions of their lives. They may find themselves required to know about a list of 20 or 30 medications, both by trade and generic name. They will have to try to sort out which plan covers the most of their expenses at present and hope that their status doesn’t change significantly compared to the coverage of their selected plan. We, in North Carolina, are lucky to have a rather limited selection of plans from which to choose. A friend of mine in New York has over 140 different plans that he must evaluate to make his decision.

My largest concern about this kind of bureaucracy is that there is a slightly different impact/efficiency between drugs of the same class. If drug A is a preferred drug in a plan and the plan encourages you to substitute Drug A for the Drug B, a drug that your doctor felt was best for you, what will be the effect on your health? In HIV treatment, for example, there is a drug class called Protease Inhibitors. Some of them work well in some patients and others do not. If your plan refuses to pay for a drug that works for you and it costs $1500/month, will you end up switching to another drug that works less efficiently because of cost or pressure from plan administrators? If so, this could mean progression to death or to bankruptcy, neither option that should be acceptable to an American citizen.

If I have understood this plan, then it is mediocre, confusing and shameful for a country as rich and powerful as the United States. We would be much better to arrange reduced cost purchases of all drugs from pharmaceutical companies and then pass the savings along to all patients for all of their medication needs.

In conjunction with this plan, I am also seeing companies striving to cut back on their employee benefits to a minimum standard of care. It is frightening to me that our country is striving for mediocrity. When companies decide that despite their profit line, they are only required to offer the average level of benefits offered in the industry. Why is it acceptable for them to decide to cut their benefits to the lowest common denominator? It is truly sad that the rich who direct the bottom line can decide upon the level of health care that is provided to the people who are actually responsible for making their money!

There are many people who will benefit to some extent from the new prescription plans, but there are others who will suffer from it. Is this the best we can do, America?

Categories: Bush mediocrity Medicare+Prescription+Drug+Plan confusion complexity