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New Medicare Prescription Drug Plan -- Off To A Bad Start

We are sorry. We are experiencing higher than normal call level. Please call back a little later. Click. This was my eighth call in four hours -- none successful -- to one of the 15 health plans in New York for low income seniors or disabled adults.

Previously these New Yorkers had their drug prescriptions covered by Medicaid without charge. Now, thanks to the new Medicare prescription drug plan pushed through Congress by the Bush administration and put into effect at the beginning of this month, they have been automatically enrolled in one of 15 private health plans. They are now required to pay for the medications, sometimes full price.

In the short time it has been in place, the new Medicare Part D prescription drug plan has proven disastrous in state after state throughout the country. "Mix-ups in the first weeks of the Medicare drug benefit have vexed many beneficiaries and pharmacists," the New York Times recently reported. "At least 24 states have taken emergency action to pay for prescription drugs if people cannot obtain them by using the new Medicare drug benefit." One of those states is New York, as announced on January 13th by Governor George Pataki: "Hopefully," the governor said, "the federal government will resolve the difficulties so that all of our seniors and all of our disabled persons will continue to get the drug coverage they need." A follow-up editorial in the Times was entitled The Medicare Drug Mess.

The problems are legion -- inadequate coverage, computer glitches, inadequate training of pharmacists, long delays -- and they fall most heavily on the poor and the mentally ill.

Going Without Her Medication

One 57-year old woman in upper Manhattan, diagnosed as paranoid schizophrenic and a resident of The Bridge, a supervised community residence, came away empty-handed this month from the pharmacy that usually refills her eight different medications.

One medication, Provacol, for high blood pressure, was not covered at all, and she was told she would have to pay full price. And her psychiatric medication, Seroquel, was covered, but not in the prescribed amount.

Without enough money even for the copays, she left the drug store without any of her medications.

Her social worker at The Bridge, Karen Davidson Ruddy, spoke with the druggist; he agreed to provide a 15-day supply of Seroquel. The Bridge loaned the woman money to cover all the copays. As for the Provacol, Ruddy learned it could be covered by switching the woman to a different tier of the plan, but only if prior authorization was secured over the phone. For two and a half days, Ruddy and her staff tried unsuccessfully to get through by phone for this authorization.

"The machine kept saying 'We know your time is important so we will get to you soon.' After two days of hearing that," said Ruddy, "you start to believe that your time is not important to them."

The woman had now gone five days without her high blood pressure medication. Giving up on trying to reach the private health plan, Ruddy decided to check with the prescribing doctor at a walk-in clinic on West 97th Street. The doctor prescribed a drug that the plan would cover.

"Blindness or Stupidity"?

They are called dual eligibles--low income seniors or disabled adults, who qualify for both Medicaid and Medicare benefits. There are about 600,000 such dual eligibles in New York State. Dr. Harriet O'Hagan, medical director at the Bridge, thinks that 20 percent of her dual eligible patients have been running into difficulties.

"We checked the Web sites ahead of time and picked plans to cover medications," she explained. "but when they went to the pharmacy, there were still problems." And some of the problems have O'Hagan dumbfounded.

"Zyprexa, the most widely sold antipsychotic medication in America, is not covered," said O'Hagan. "Same thing with Abilify. And the antidepressant Zoloft--a widely used and highly effective antidepressant. I have no idea why these drugs are not covered. Another one is the Prolixin injection, one of the cheapest medications for psychosis. It is used for people who are noncompliant and it just costs pennies. Why is this not covered? It is blindness or stupidity."

In order to get these drugs for her patients, Dr. O'Hagan now has to produce evidence that she has already tried other medications, and she must prove that the client has been on this particular drug a long time.

"I have been calling the Medicare number, but I cannot get through to a human being," said O'Hagan. "I was on the phone for hours. Now I am calling the plans. I got through to one health plan for one person, but I have about twenty others."

She also found that the local pharmacist was not honoring the transition policy. "He does not believe he will be reimbursed."

Feeling the political heat, President George W. Bush has directed Medicare insurers to take immediate steps to cover 30-day emergency supplies of drugs for dual eligible citizens and the Bush administration insisted that low-income co-pays not exceed $5. Republicans and Democrats seem united in this decision to publicly bolster the transition policy. Meanwhile, the administrator of the Center for Medicare and Medicaid Services, Mark McClellan, has acknowledged the chaos, and said that his agency was working "around the clock" to fix the problems.

In the interim, Dr. O'Hagan instituted her own emergency program: She has been giving her patients medication samples sent by drug companies. "We're giving those out, but they are going to run out soon." The effect of not taking medication for a few days or weeks on people with mental illness can vary, according to O'Hagan. "Some people decompensate (deteriorate physically or psychologically) within days," she said. "For others it is months. I may be forced to make substitutes for some of the medications and that may not be appropriate. There may be side effects. It feels kind of third world."

Computer Glitches And Unnecessary Hospitalizations

The Coalition of Mental Health Agencies, an umbrella organization that advocates and assists nonprofit agencies caring for the mentally ill in New York City, reported many of the same problems coming into their Medicare Part D telephone Helpline.

Bill Zeiser of the coalition had a caseworker tell him about a 57-year old mentally ill client from the Bronx with HIV who was about to run out of his AIDS medication. Due to a computer glitch, he was being asked for high co-pays for both his psychotropic and HIV medications. One particular medication was going to cost him $180--and he is on several different prescriptions. The last Zeiser heard, the caseworker was exploring the possibility of having his client admitted to the hospital to get the medications.

Hospitalization was "one of worst case scenarios that we had envisioned," said Zeiser, "but now we see it come to fruition. The grim reality is that people have to do what they have to do to get medication.

"The irony," he continued, "is that it is so much more costly to have these people checking into hospitals to get their medications than if the Medicaid benefits had carried over in the first place."

Pharmacists Want To Help

At a small pharmacy, Price Wise on West 81st and Broadway, the pharmacist on duty, Anthony Mladinov, reluctantly broke away from his work to talk for a few minutes about the drug plan. "This is the first chance I've had all day to catch up." Mladinov estimates he is staying an extra two hours every day to manage all the work.

"Some people come in without an insurance card," he reported, "but there are things we can do to help." He heard that if you go into one of the [chain drug stores] without a card, they tell you to come back when you have it.

The most common problem are customers finding their prescriptions are not on their plan. "Of course, if they did their homework beforehand," the pharmacist said, "and checked online three months ago, and called the plan back then, back when you could reach them on the phone, then they would know which plan to be on. Now you cannot get through to an HMO." For the most part, though, he was optimistic. "It will all be straightened out in a week or two."

"I certainly think things will improve," said Karyn Krampitz, director of Special Projects at the Coalition for Voluntary Mental Health Agencies. "The fact is that the pharmacists for the most part want to help, but they were not properly trained in time and many of them are not going to dispense medications unless they have some assurance that they can bill someone for it."

Social worker Ruddy recommends to her clients that they go to small independent pharmacies rather than the large chains. "They know us and they work with us," she explained. "If you have a good relationship with your pharmacist, the hope is that you can muddle through this together."

Long Term Issues

Even if many of these short term issues are resolved in the coming weeks, Bill Zeiser sees long term systemic problems that need to be addressed, such as the dual eligible copays and the complexity of the system. "What we want is for the Feds to ensure an uninterrupted supply of necessary medications for dual eligibles," said Zeiser. "After the transition period, a dual eligible would be at square one, still unable to get the medication they need from their plan, which doesn't cover it. In many cases, a thirty day supply will simply not be enough to hold someone over while they navigate the process."

Many fear that copayments may discourage mentally ill clients from taking their medications. "My clients say, 'OK, I'll take the medications,'" said Ruddy, "but when we tell them they have to pay for them, they don't want to do that."

"Some of the mentally ill would just as soon not take their medications" stressed Karyn Krampitz "So any reason that disrupts it, they just do not take it, and that is a major problem."

Related Resources

Medicare Part D Plan Finder
Good comparison tool for health plans.

A private company that has their own interactive online tool, which allows an individual to compare formularies.

Government source for basic Medicare Part D info

New York State Long Term Care Ombudsman's office
For individuals in long term care facilities who have problems getting medications, no matter what their diagnosis.


Medicare Rights Center

Coalition of Voluntary Mental Health Agencies
The Coalition's Part D Helpline: 212-742-1873. Available Tuesdays and Thursdays from 10 AM - 5 PM

New York Chapter of NAMI (National Alliance for the Mentally Ill)

The Department of Aging has centers around the city where volunteers and staff will help people. A person need only call 311 and say "I need help figuring out Medicare Part D" and the operator will refer them to the nearest DFTA Center.



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