Bracing for Medicare Changes: DISABLED, SENIORS FACING DIZZYING CHOICES

By Barbara Feder Ostrov, San Jose Mercury News, Calif., San Jose Mercury News, Calif.

Dec. 29–On Friday, Thomas Bellevance will make a last pilgrimage to his pharmacy with no small amount of trepidation. He’ll receive a larger-than-usual supply of Buspar, Lexapro and Seroquel, powerful psychiatric drugs that keep his schizophrenia and bipolar disorder in check.

He has no idea what’s going to happen when it’s time for a refill.

On Sunday, a historic expansion of Medicare to cover prescription drugs will lead to higher co-payments, fewer covered drugs and a confusing array of choices for 1 million Californians, Bellevance among them.

The people affected by these changes are so-called “dual eligibles” — patients who have Medicare, the federal health care program for seniors and the disabled, and Medicaid, the federal health program for the poor that is known as Medi-Cal in California.

Traditionally, Medicaid has provided free or very low-cost prescription drugs to these patients, who number 6.3 million nationwide. But starting Sunday, dual eligibles will be forced into new Medicare Part D prescription drug plans that are more complicated, confusing and restrictive than their previous drug coverage.

For the first time, these patients will have to pay a small amount for both brand-name and generic drugs, although nursing home residents will be exempt from those co-payments. Certain classes of drugs, including some anti-depressants, will not be covered by Medicare, although California, unlike other states, has stepped up to pay for them at a cost of $93 million annually.

Medicare officials say they’ve taken many steps to ease the transition. But their assurances are met with foreboding and skepticism by state health authorities and advocates for the elderly and disabled. They worry that dual eligible patients could show up at their pharmacies on New Year’s Day and not be able to get the medicines they need.

These patients are considered Medicare’s most vulnerable. All are poor and many are poorly educated. About one out of three have a mental impairment. One out of five live in nursing homes. They are sicker and take more prescription drugs than the average Medicare patient, for serious conditions such as diabetes and Alzheimer’s disease.

“The federal government has done a lot, but this is so large and complicated and affects so many people that we are very concerned,” said Stan Rosenstein, a high-level official at the California Department of Health Services who oversees Medi-Cal. “All of the systems will have to work perfectly and in very high volume for everything to work out.”

To prevent the nation’s dual eligible patients from being left without drug coverage, Medicare has enrolled them randomly into a Medicare Part D prescription drug plan. If patients fall through the cracks and aren’t automatically enrolled, pharmacies will be able to immediately enroll them in a backup plan, said Jeff Flick, a San Francisco-based regional administrator for the Centers for Medicare and Medicaid Services.

There is no guarantee, though, that a particular plan will cover the specific drugs the patient takes, or include the patient’s nearest pharmacy. And while dual eligible patients formerly could get prescriptions for free if they couldn’t afford a small co-payment, pharmacists now can refuse to dispense a drug if patients can’t pay.

As a result, state officials are allowing dual eligible patients to get a three-month supply of drugs before Sunday. They’re advising patients to bring their Medi-Cal and Medicare cards to pharmacies when they pick up a prescription.

Medicare officials review plans’ lists of covered drugs, or formularies, to make sure they include appropriate medications and do not discriminate against people with specific medical conditions, Flick said.

“When necessary, we’ve got to be able to put the formulary aside and get the drug the patient needs,” Flick said.

Advocates, family members and nursing home administrators also are scrambling to help patients review their plans and, if necessary, enroll in another that’s a better fit.

It’s a frustrating process according to Leonid Kats, a San Jose retiree who found that the prescription drug plan he’d been randomly assigned did not cover all of the 11 medicines he takes regularly for ulcers, asthma and other health problems.

After meeting with an insurance counselor at the Council on Aging Silicon Valley, Kats returned home to enroll in one of three recommended plans.

He could not complete the enrollment online, describing it as technically difficult. Trying to enroll by phone, he found himself on hold with one insurer for two hours, only to be disconnected. Finally, he enrolled in a plan. Unlike Medicare-only recipients, Kats and his wife can change plans monthly, so if the plans aren’t appropriate, they can quickly find another.

Still, “it’s not so easy as it’s supposed to be,” Kats said. He will now have to pay about $33 a month for his drugs, affordable on their income of $1,400 a month but not something he looks forward to.

“It was better not to pay, but now we have to pay,” Kats said. “So we will pay.”

The changeover is perhaps more troubling for Bellevance, who has been hospitalized more than a dozen times in the past two decades for his mental illness and experiences paranoia when he doesn’t take his medications. Without government assistance, his drugs would cost $43,000 each year, he said.

His caseworker helped him pick a plan that appeared to cover his drugs, but when Bellevance called to confirm, the insurance company said Buspar, an anti-anxiety medication, wasn’t in its formulary and he would have to pay more than $130 for a 30-day supply.

“I’ve made a hundred phone calls and I can’t get anywhere. There must be 4,000 combinations to this,” Bellevance said. He pulled out a booklet that Medicare had sent him. “Nobody understands this book. My niece is studying medicine and she doesn’t understand this book. It is very, very complicated. It’s just a complete mess.

“I do best when I don’t have to change medications,” Bellevance said. “I’ve been told not to worry, but I think there are going to be a lot of problems.”

Contact Barbara Feder Ostrov at bfeder@mercurynews.com or (408) 920-5064.

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Copyright (c) 2005, San Jose Mercury News, Calif.

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