Medicare Part D: Learn from my mistakes

Following up on my piece on Medicare Advantage programs (Medicare Advantage: OK, it's bad for the country, but what about for me?, Dec 6, 2022), I wanted to add a piece on the Medicare Part D Prescription drug program. While others may be smart enough to not make the mistakes I have, I believe that the structure of the program and the behavior of many or most of the insurance companies involved in it encourage people to make decisions which are often not to  the person’s benefit (of course, they benefit the insurance companies!), so maybe others can learn from mine.

First, some clarifications about the last post, based upon comments I have received. Not all Medicare Advantage plans are equally bad or equally predatory. The for-profit ones run by insurance companies are the worst. Several not-for-profits are descendants of the original HMOs (from the time before they were called HMOs), which were real consumer cooperatives based upon the idea that if they could cut out the middleperson (the insurance companies) they could deliver more healthcare to members for the same money or at least the same healthcare for less money (these included HIP in NY, Group Health in Seattle, Ross-Loos in LA). Kaiser was not a consumer cooperative -- it was originally begun by Henry Kaiser for employees of his steel company -- but did function in a similar way as a nonprofit. Many of these were, however, bought out by insurance companies, venture capital (private equity) companies, and other profit-making organizations, and of course most of the Medicare Advantage plans that now exist were always for profit.

It should go without saying that when the “middleperson” (insurance companies) that you were going to cut out to benefit the consumer members takes over ownership, things change.  And, while many of the non-profits are less egregious in their exploitation than the for-profits, they share many of the same characteristics. So it is still “caveat emptor”, let the purchaser beware. Consider the idea that a non-profit Medicare Advantage plan may be better for you than a for profit, but it may still be a bad choice compared to traditional Medicare (TM). And certainly compared to what we should have – an improved and expanded Medicare for All.

Which brings me to Part D. Originally, Medicare was designed primarily to cover hospital care, then the most costly part of healthcare, and this, now called Part A, is the only portion covered by the Medicare Trust Fund from the money deducted from paychecks. Part B, the portion that covers outpatient care, is funded by general revenue plus monthly premiums paid by Medicare recipients to the government, which in 2023 will begin at about $164/month (for incomes below $97,000/year) and go up with higher incomes. Medicare Part C is what is now called Medicare Advantage, the substitute for TM (Parts A, B and D). Part D is the prescription drug plan. It became apparent in the decades since Medicare was created that prescription drugs were an increasing portion of the annual medical costs for Medicare recipients and that they were not covered was a problem for many people. So, eventually, under the presidency of George W. Bush, Part D was passed to cover them. But, of course, it was a “compromise”, which, as usual in government, means a compromise between meeting the needs of the American people and making a lot of money for the private corporations that ‘lobby’ (read: give money to) Congress. So, rather than covering drugs under the Medicare program, which would have done it pretty much at cost (traditional Medicare’s overhead is approximately 2%), it was farmed out to private insurers, some non-profit but mostly for-profit companies. Their overhead is a lot more, and they make a lot of money on this, as every Medicare recipient is required to have a part D plan (unless they are still working and covered by an employer plan or have a Part C, Medicare Advantage, plan that covers prescription drugs). Private for profit drug manufacturers also won another huge concession from Congress and the administration in the form of a prohibition on Medicare negotiating the prices of the drugs. As the largest purchaser of these drugs in the country, they would have great leverage and get great prices, and as a result the pharmaceutical companies would make less money. We wouldn’t want that, after having carved in profit for the insurance companies, so we don’t have it.

So let’s talk about me. When I retired and had to get a Part D plan I also needed a Medicare Supplement plan, to cover the 20% that TM doesn’t pay and other costs. I got the latter through my insurance company, USAA, and got a good policy for a reasonable fee. One thing Medicare does regulate are Medicare Supplement plans, which are identified by letters: A, K, F, G, N, etc. All plans offered by any insurer have to meet the standards – that is, the benefits for all type F or type K plans have to be the same-- so the competition is on price and service, which is absolutely the way it should be (but rarely is). However, USAA does not offer a Part D plan; they contract with Humana to offer their plans to their customers, so I chose a Humana plan. Unfortunately, the standardization that characterizes Medicare Supplements is NOT true for Part D; the different plans have all kinds of complicating and confusing characteristics. Both Medicare and the insurers offer “calculators” where you can put in the drugs you take and it calculates what they would cost you on each of their plans, adds the premium, and voilà, tells you the best deal for you. Maybe. If you trust them. But there turn out to be some hidden factors.

I chose the Humana plan with the cheapest premium, Humana Wal-Mart, not because I expected to buy my drugs at Wal-Mart but because it was the cheapest. My drugs, you see (I take 3 prescription drugs) are all available generically. They are (relatively) cheap. And so Humana does not cover them. So I pay out of pocket. Until and unless I meet my deductible; then they pay, maybe. But what I discovered in the first year is that any drug I get that is a lower price that the supposed retail price doesn’t count toward my deductible. Humana’s justification is that they have negotiated lower prices, and I am benefiting. It sounds possibly plausible, except all  insurers have pretty much the same lower prices. And usually more than you’d pay with GoodRx®. But it means that I can never meet my deductible and thus they never pay anything. But I pay them a monthly premium. That is a good deal – for them. Sounds an awful lot like a protection racket!

Because I just kept the same plan in my second year, I thought I’d do the same in my third, and didn’t go online to choose a plan during open enrollment. I then got my bills and my premiums went up from about $17/mo to $57/mo! When I inquired (irate) they said I didn’t elect a plan, and the exact plan I had had (the cheapest) was no longer available, so they decided for me that I’d be best off in their most expensive plan! Two things to note: 1) while my premiums went up (and I had to keep this plan for a year), they still paid nothing, so I just contributed more to Humana, and 2) they did have a cheap plan, which cost even less than I had been paying ($14/mo) but of course they didn’t think I’d want that.

The next year, I took it, and have had it for a few years. The premium has crept up, from $14, to $17, to $22. Last year I paid $272 for drugs and they paid $21. That, I think, was for a vaccine. This year the premium is going up to $30, nearly a 50% increase. But I didn’t notice that until they sent the payment book. It took me two days to look, call Humana and discover from them that the increase was just, well, an increase, no reason other than they want more money and can do it, and that when I went to Medicare.gov there were companies offering plans for as little as $7.40/mo. I would probably get no benefit from them either, but a lot lower premium. Sadly, for me, I found this out December 8, and December 7 was the end of the open enrollment period.

I won’t forget next year. I have no loyalty to Humana, and think they are unscrupulous predatory profiteers. Of course, most all of them are, but Humana seems to be worse than many. Luckily, the premium difference won’t break me, but since I will get no benefit, there are about a thousand different charities I’d rather donate the money to than the Make Humana More Profit Fund.

US government programs should exist to help the American people. Some good reforms would include allowing Medicare to negotiate drug prices and standardizing Part D plans the way Medicare Supplements are. Real reform would be to have a single universal program covering all health care (inpatient, outpatient, drugs, mental health, vision, dental, etc.) and eliminate profit from healthcare.

Sorry it is too late for this year. Be careful during open enrollment next year. I will be.

 

 

More important than our circadian rhythm: Creating a society that is safe and has health care for all

The New York Times, in addition to covering world and local news, has a lot of “feature” type news, generally appealing to educated, urban, and often higher income people, especially in New York, who are a large percent of its readers. Obviously its Arts coverage reflects the enormous NY arts scene, but also frequently seems to be more in-depth, designed to appeal to an even smaller group. Similarly, while its health coverage often includes news and opinion pieces on the social inequities in health care, on community risks (such as gun violence), and on policy issues, it also includes pieces aimed at what might be called “individual health self improvement”, sometimes involving new(ish) research.

An example is the recent front-page piece on “Circadian Medicine”, that reports on research about following our “body clocks” to get the greatest health benefits from how we do things like eat, exercise, etc. It starts with a look at the effort to move toward permanent daylight savings time and how this affects our personal and work lives.  Of course, this is ultimately a sociocultural issue; the amount of light and dark each day is unchanged, but the question is when our particular area decides to do things. Farmers and ranchers, for example, do not work based upon the time it says on the clock. If we wanted to, we could work from 9 to 6 instead of 8 to 5 rather than changing the clocks.

What is actually more important about this piece, to me, is that it goes on to emphasize how individuals can (possibly) improve their health by choosing the correct time of day to do their health-inducing activities. It is thus yet another effort to look at what each of us can (provided we have the education, autonomy, money, and time) do to make our individual selves healthier. Maybe. Such emphasis is not wrong per se (except, of course, when it is wrong, as has been, for example, our obsession with taking vitamin supplements when we are not vitamin deficient, as see F. Perry Wilson on Medscape, “It’s official: vitamins don’t do much for health”). The real issue is that it is a distractor, in that it focuses upon something that is perhaps slightly beneficial for some people (or not) but will not have a major impact upon the health of the public or the populace, taking our attention away from focusing on the very many major serious things that do have a significant effect upon the health of the public, and that we, as a people, could do something about.

 Like what? Let’s start with some data that should be scary: Among wealthy countries, the US is the only one that has seen a leveling-off and decrease in life expectancy, as reported by “Our world in data”. I have reported on this trend several times previously (Lower life expectancy in the US: A reflection of racism, classism, and social inequity April 29, 2022, Decreasing life expectancy in the US: A result of policies fostering increasing inequity, November 29, 2019) and examined some of the various proposed explanations. Case and Deaton, among others, suggest that the increase in the death rate (particularly among less affluent whites) are “deaths of despair”, mediated through the use of substances (alcohol, tobacco, opioids and other drugs). No doubt these are major contributors, but there are also others. One that has many people very concerned, as it should, is the ubiquity of gun violence in the US. This is a major contributor to death rates in populations such as young males, where suicide and homicide are very important causes of mortality. Most of us can reel off the names associated with major episodes of mass shootings, especially school shootings like Columbine, Sandy Hook, and Uvalde, but these are the tip of the iceberg. An interactive story in the Times documents the 63 “mass shootings” (four or more people shot) in May 2022 alone, and there were 65 in June, and 25 in July -- and as of only July 8 when this was published! And this does not count the many more deaths where “only” one to three people were killed! In the wake of Buffalo and Uvalde, Congress finally passed a very weak gun law. It did break an impasse, but in the minimal amount of restriction it places on gun ownership and carrying, it reinforces the idea that “America is a gun”, as in Brian Bilston’s poem. Any other country with only one major mass shooting has reacted much more dramatically and effectively. While articles continue to appear, such as the Op-Ed of Patti Davis describing the reaction (in her) and lack of reaction (in the nation) to the shooting of her father, Ronald Reagan, 41 years ago, we still are in thrall to the gun lobby and to folks who truly believe that they are at risk if they don’t have and carry guns that they make it easy for those who are going to create major violence and death.

And what about when we get sick? We – Americans – are as a group less able to access care than people in those other countries because we don’t have universal health insurance or access. Dr. Aaron Carroll, in an Op-Ed on July 7, emphasizes the impact of health insurance deductibles, noting that it is not just the uninsured but the underinsured, for whom deductibles are a major obstacle (along with other inappropriately-designed out-of-pocket payments) who suffer from not being able to access medical care, especially in time. The numbers that he cites for deductibles, and for co-payments and co-insurance, are amazingly high, as is the impact that it has on the health of those affected. For example, “The good news is that the A.C.A. limits these [out-of-pocket expenses] in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family,” and for people in Medicare drug plans “a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23% decrease in drug consumption.”

The fact that it is the Medicare drug plan (Part D) that is cited here is not coincidental; it, along with both Medicare Advantage (Part C) and the newer REACH (formerly DCE) program implemented by CMS (the Center for Medicare and Medicaid Services) are the portions of the Medicare program focused on providing profit to investor-owned companies rather than health care to American seniors. A recent report by the Urban Institute on Geographic Predictors of Medical Debt, in Health Justice Monitor, shows, unsurprisingly, that those areas with the highest concentration of poor, uninsured and underinsured people, and people with chronic diseases have the highest level of debt. And the lowest level? Those areas with the highest concentrations of people over 65. This, of course, is the only part of the general US civilian population that has essentially universal health insurance, despite the efforts of the programs above to decrease or dilute it. Although this seems worth mentioning, the Urban Institute did not; maybe they thought it was obvious.

But in this country nothing is obvious to most people and needs to be pointed out.  This includes our legislators, federal and state, to whom often the only thing that seems obvious is who is contributing to them. With all respect, we need to be focusing less upon our body clocks and circadian rhythm and more on the things that made a real difference in our nation’s health.

We need to decrease the availability of semi-automatic guns with high-capacity magazines. We need government policy focused upon creating well-paid, good-benefit jobs that will decrease “deaths of despair” rather than maximizing corporate profit. And we need high-quality universal coverage and access to health care for all our people. What we do not need are more programs like Medicare Advantage, Medicare Part D, and REACH that channel public tax dollars to private enterprises as profit.

What we do need, we needed long ago, and we need it now.

No way to run a business: the US healthcare system is not about caring for you!

The most distinctive and defining characteristic of the US healthcare delivery system is how poorly it serves people, and the number of hoops, obstacles, and downright obfuscation people need to work their way through to get care. The most important problem is that we have worse health outcomes and more premature death than any other industrialized country, and the excessive cost of achieving those worse outcomes (the only place where we’re #1!). But the sheer difficulty, pain, and low yield of going through the information needed to make the wisest decisions (actually wise, we will see, is virtually impossible in our system) takes a – completely unnecessary – toll on all of us.

The reason for this situation, very simply, is that the healthcare system in the US is not structured to deliver maximum health benefit, but to deliver maximum profit to the major players – and that is very few of us. It is absolutely critical to remember this core fact, because every other characteristic of our healthcare system derives from it. Worried about surprise medical bills when some of the doctors at your in-plan hospital are out of plan? Worried about paying for the wonderful new medicines advertised on TV that promise you cure for thousands of dollars a month? Worried about whether you can afford the premiums for the plans your employer offers, especially if you need to cover your family? Or the premiums for the better ACA-plans? Whether you can bet on your current health status, if it is ok, continuing into the future? Whether you can survive until you are old enough to get Medicare? And then, when you are, whether Medicare will cover enough of your bills, or if you need – and can afford – a Medicare supplement plan? How about choosing a “Part D” drug plan? Why are the websites and information so opaque and difficult? Is there any plan that is truly of value? And even if “of value”, can YOU afford it?

These questions just touch the surface. Then, you actually need to access healthcare services. Then it gets worse. Primary care doctor? Can you get an appointment? Use urgent care? Is your problem on the list of things that they can competently manage? Emergency room? Wait until you are so sick they have to take care of you? And what about those drugs…?

The specific problems that this system creates for individual people are often overwhelming, and become the focus of people’s lives when they do have chronic diseases or ongoing health needs. Politicians and their policy advisors who keep talking about addressing them one at a time are at least intellectually corrupt (setting aside the question of whether they are also financially corrupt) in believing that a patchwork of – patches – can make people, at least temporarily, think that they are doing something to help while maintaining a predatory structure. Let’s just look at a few recent examples and stories.

The Upshot in the NY Times recently had a piece on how the pandemic has increased the use of telemedicine, and how this might lead to better access to emergency care, citing a very positive study done by the Veterans Administration. The study shows, among other things, that same-day access to primary care can obviate the need for emergency care. Beyond that, having a regular source of primary care, and being able to get in when you need to, decreases hospitalizations and mortality. Of course, it is important to remember that the VA is (like the military) a single-payer health system and works better than the rest of US health care within the constraints of continually decreasing funding, part of a general Congressional and executive effort starve it for funding, specifically to ensure it doesn’t work as well as it could. Those same legislators then blame the VA rather than themselves for veterans not getting the best possible care, a tried-and-true tactic for evil politicians. Except the VA, and military health care, do work better than the private sector. (For more on the VA, see the excellent article “Shaping the Future of Veterans’ Health Care” by McCauley and Ramos in the New England Journal of Medicine, Nov 5, 2020, which requires a subscription.) The comments by the brilliant and incisive Dr. Don McCanne, found at the above link to the Upshot article, clearly makes these important points. And why can’t you get same day visits, or even prompt visits, with your primary care provider? Remember the key factor in all US  healthcare; it is usually not that your doctor is unwilling; it is that they also work for a corporation whose policies are about maximizing income and profit, not about improving your health.

In a recent conversation with a friend – also a senior citizen knowledgeable about health care policy, who was long on a medical school faculty and now lives in a relatively rural area – we discussed the best choice for a Medicare Part D plan. I noted that in 2020 I had assumed that my insurer would, absent my making a change, continue me in the lowest-cost plan as it had the two years previously. It didn’t; it automatically bumped me up to the highest-cost plan. With no added benefit, because of Catch-22 – I could never make my deductible, and thus have the plan kick in, because all of my drugs were “tier 1” and didn’t count (the calculators offered are only of use if you use high-tier high-copay drugs like those advertised on  TV). This year I made sure to change back to the cheap one, so I can pay $17.50 instead of $55 a month for no benefit. My friend agreed and will choose the same plan. But did note that if a family doctor and a health economist had trouble figuring this out, it might be hard for a lot of people! It is this characteristic of our health insurance system that makes the claims of those who advocate for private health insurance because it gives you, the consumer, “choice” are completely bunk. Almost no one can read, digest, understand, and utilize the information that is (sometimes) provided, in all different places, to get to a decision on what will work best for them. And, for the few who can, it usually turns out not to be very good! Remember: this is not some quirk, it is how our healthcare, and health insurance, system are purposely set up: To be confusing, opaque, and beneficial only for the sellers, not the consumers.

My friend and I also talked about several interactions he recently had with the health system his primary care doctor is part of. One involved his receiving (as an ex-smoker) a scanning CT scan and suggesting that they obtain an older one, from the medical school where he used to work, to compare the new one to. “We don’t do that,” he was told by the person at the other end of the phone. Another was about finding out how he could get documentation to be in an early group to get COVID-19 vaccination when it becomes available, given that he is high-risk not only by age but by having chronic diseases. They don’t do that either. These are unacceptable answers, as he told the office of the vice president he complained to, and who agreed to make things happen. This is not a flaw in the system; it is how it is structured, for everyone. Most people, you see, will not complain, and thus will, well, get screwed. But it saves the company money. This is a core way health insurers function. The higher the bill from a doctor, the more routine it is to just deny it, making the doctors work to prove they should get paid. Clearly, this is a particular issue for surgeons, who usually have staff who routinely fight with the staff of the insurance companies to appeal these denials.

There is an old saying that “this is no way to run a business” But, for most companies involved in health care – insurance companies, pharmaceutical manufacturers, long-term care companies, hospital systems, and increasingly large physician groups owned by corporations, it is the way they run their business. And it is a very profitable way to do it.

It is just no way to provide healthcare.