Drug Plan May Hurt Some It's Meant to Help

[Guest guest]

Drug Plan May Hurt Some It's Meant to Help

By Alonso-Zaldivar

WASHINGTON — Although she was partially paralyzed in a car crash 22

years ago, suffers from lung disease and has only a meager income,

64-year-old Margaret Dowling is able to live independently in her own

home, thanks to a motorized wheelchair and nine prescription drugs

that she takes every day.

But now, Dowling fears that her hard-won independence may be in danger

— not from the ravages of injury or disease, but from an effort by the

federal government to improve healthcare for older Americans while

putting the brakes on rising costs.

Dowling is not alone. About 6 million people with severe medical

problems and low incomes face similar threats from the same source.

Nobody wants it to happen, but so far at least, no one has come up

with a solution.

And Dowling's plight is an early sign of an even larger problem: The

healthcare needs of the disabled, the elderly and the poor are complex

and the systems serving them huge — 90 million people, $600 billion in

annual expenditures.

As Washington struggles to maintain the programs while dealing with

seemingly unsustainable cost increases, the law of unintended

consequences is likely to strike again and again.

Dowling and others like her fall into a netherworld where Medicare and

Medicaid overlap. They are what the government calls " dual eligibles "

and, because of their financial situation, receive benefits under both

programs — drug coverage from Medicaid, which primarily serves the

poor, and hospital and doctors' care from Medicare, which primarily

serves the elderly.

In January, for the first time, Medicare will offer a drug plan that

is to operate quite differently from Medicaid's system, which provides

comprehensive, virtually cost-free prescription coverage. Medicare's

plan will rest on competition among private insurance companies and,

hoping to save money and streamline the system, Washington has decided

that patients such as Dowling will automatically be switched to the

Medicare drug system.

The new program was not created with people like Dowling in mind, however.

The private plans that patients will be required to use under Medicare

will emphasize reliance on generic drugs and other measures designed

to cut costs. Medicaid gave doctors virtually free rein when it came

to choosing drugs.

Advocacy groups and experts say that after the switch to private

plans, there's no guarantee that Dowling and other " dual eligibles "

will be able to keep exactly the same combinations of drugs they now

receive under Medicaid. That could upset the delicate balance among

the drugs upon which Dowling and others depend.

" My biggest concern is making sure that people with specialized

medical problems are not shortchanged, " said Sen. Gordon H.

(R-Ore.), a supporter of the new drug benefit. " It's really the most

vulnerable population we have. "

No part of the country faces a more challenging transition to the new

coverage than California, with nearly 1 million dual-eligible Medicaid

beneficiaries, more than any other state. Medicaid, a federal-state

partnership, is called Medi-Cal in California.

Even California's ethnic diversity could become an obstacle in the

switch. Just communicating will be difficult since Medi-Cal

beneficiaries speak at least a dozen major languages, including

Spanish, Farsi, Cantonese and Armenian.

For Dowling's multiple problems, doctors spent months making

trial-and-error adjustments before they got the combination of drugs

that seems to work for her.

She takes a painkiller to help her get out of bed in the morning. She

uses a combination of asthma drugs for breathing. Another drug helps

the circulation in her legs.

Together, the drugs make it possible for Dowling to live on her own in

the San Francisco Bay Area with a service dog named Little Maggie,

four cats and a van equipped with hand controls, in addition to her

motorized wheelchair.

Even a small setback — unexpected new side effects, for example, or a

lower level of effectiveness — could render her unable to function and

force her into a nursing home.

That would cost the system more money, and Dowling is horrified at the

possibility of losing her freedom. " I have fought many years to live

independently, and I'd rather be dead than go into a nursing home, "

she said.

Under the new Medicare program, instead of simply picking up her

prescriptions at the pharmacy, Dowling would be asked to choose from a

number of private insurance plans, which would offer differing

benefits, including different lists of drugs. They would be free to

change the list of covered drugs.The idea is that Medicare patients

would get help with their drug bills, and competition among the

insurance companies would act as a brake on prices — a boon to

overstretched federal and state healthcare budgets.

Some of the hoped-for savings are expected to come from the greater

use of generic drugs and cheaper drugs that are similar to the most

costly versions.

That may work for most patients. But Dowling and others like her fear

that they will not be able to find plans willing to assure them of

receiving exactly the same combinations of drugs that work for them now.

For some who depend on multiple drugs to manage complex problems, the

subtle differences in formulations of nominally similar drugs can make

significant differences.

Some advocates have urged the federal government to slow the

transition to the Medicare drug benefit for the poor and disabled,

instead of switching all of them on Jan. 1 as planned. Several

advocacy groups have called for guaranteeing Medicaid for a year as a

backstop.

Yet the Bush administration and many supporters of the Medicare

benefit are loath to reopen the issue, fearing that the fragile

political coalition that approved outpatient drug coverage for all

senior citizens could unravel.

Instead, the federal Centers for Medicare and Medicaid Services has

encouraged states to authorize a three-month supply of drugs as a

bridge for poor and disabled " duals. " is urging that it be

extended to six months.

The Medicare agency says it is doing all it can to avoid problems.

Poor and disabled Medicaid beneficiaries will be automatically signed

up in one of the new drug plans to prevent anyone from losing

benefits. Every private plan will have to have a written transition

strategy for Medicaid patients, including a way for them to appeal

coverage denials.

Moreover, plans will be required to cover " all or substantially all "

drugs in six critical categories, such as anti-cancer agents,

HIV-

AIDS drugs and anti-psychotic medications. And the government will pay

more to drug plans covering sicker patients.

That still may not be enough.

" Even if [Medicare] is 99% successful, with 6 million people, you

could still have more than 60,000 losing their medications, " said

M. , president of the Medicare Rights Center in New York.

" To us, that is why it is immoral to let political fears block a

Medicaid transition safety net. "

Such rhetoric solves nothing, said Mark McClellan, a physician who

once practiced in California and now runs Medicare and Medicaid.

" I want to be very clear, " McClellan said. " I am not focused on any

political fears here. I am focused on how to get effective Medicare

coverage to people of limited means…. We haven't spent a lot of time

focusing on would've, could've and should've with the law. We are

focusing on how to implement it as smoothly as possible. "

McClellan said those with the least ability to pay have the most to

gain from the new Medicare benefit. As an additional safeguard, they

will be able to switch drug plans at any time, he said.

California officials say they are guardedly optimistic.

" Right now, [Medicare] is addressing all of my concerns regarding the

transition, " said Stan Rosenstein, the state's deputy director of

medical care services. " That said, this is a massive change, and we

all have to be vigilant to do everything we can to avoid breaks in

coverage. "

California will continue covering some tranquilizers that Medicare

will not pay for. And to ease the change, the state will keep in place

a policy that allows patients to receive a 100-day supply of most

drugs, Rosenstein said.

But advocates are unlikely to get the commitment they're seeking for

the state to cover any drug that the private plans won't.

" The state claims it's broke, " said Jeanne Finberg, an attorney for

the National Senior Citizens Law Center in Oakland. " But I don't think

the Legislature is aware how big a change this will be, and how their

constituents will be affected. "

Frail patients now covered under Medicaid should not be required to

change medications because of cost, pharmacology experts say.

" Economics is not a medically appropriate reason to switch a patient

from a drug if they are doing well on it, especially if it's a patient

with a chronic condition, " said Larry Sasich, a pharmacist who teaches

drug policy at the Lake Erie College of Osteopathic Medicine's School

of Pharmacy in Erie, Pa. Drug plans say they will handle the disabled

with care.

" If you have a chronic condition and you're stabilized … we're not

going to cut people off, " said Phanstiel, CEO of PacifiCare

Health Systems Inc., which is bidding to provide Medicare drug

coverage in all 50 states.

In some cases, a plan pharmacist might call a doctor using high-cost

drugs to treat a patient when cheaper alternatives are available. If

the doctor doesn't want to change, " end of story, " Phanstiel said.

That's doesn't sound so reassuring to Marta .

A Medi-Cal beneficiary from Van Nuys, is disabled because of

cerebral palsy.

" What I get through Medi-Cal in California is because of years of

advocacy by various groups to see that the benefit is generous, "

said. " Private companies … are going to be looking to make a

profit off me, and that is a whole different structure. "