Rat Poison & Medicare's Part D Doughnut Hole

The Kasier Family Foundation paper, "The Medicare Part D Coverage Gap Costs and Consequences in 2007", by J. Hoadly, E. Hargrave, et al., August 2007, analyzes Medicare beneficiaries' doughnut hole experiences in 2007, the first full year of Part D operation. Twenty-six percent of Part D enrollees reached the coverage gap (half by late August), which left them to bear the full cost of further 2007 prescriptions within the doughnut hole, and fifteen percent of these individuals went on to reach catastrophic coverage. Tha authors found that 15 percent stopped taking their medication, 5 percent switched to an "alternative drug in that class" and 1 percent reduced their medication use. 10 percent of the diabetics who reached the doughnut hole coverage gap stopped taking their medication, 8 percent switched to an alternative and 5 percent cut down on their medication use. The authors also noted that monthly outlays by the doughnut hole patients jumped from $104 to $196 during the gap.

One method, often and emphatically recommended by insurers to save money, is to purchase generics which are theoretically "bioequivalent" to branded products. Coumadin, the branded anticoagulant, is far more expensive than warfarin, the generic. As I mentioned in an earlier blog, an instance in which a patient returned a bottle of warfarin (a form of warfarin is used as rat poison) to a local pharmacy as "ineffective" (meaning, there was no discernable anticoagulant effect by blood test), sent a complaint to the Food and Drug Administration, and had no response either from the pharmacy chain or the FDA to the complaint, raises the question of whether the advice to purchase generics is always prudent. Compounding this specific warfarin problem was the recognition by some physicians in the area where this took place that warfarin supplied by the same pharmacy chain had provided inadequate anticoagulation to their patients.

So patients are in a bind. Spend their limited retirement funds on branded products which will place them in the doughnut hole sooner and aggravate their financial problems, or take "alternatives" which may yield suboptimal benefit and ultimately lead to uncomfortable, dangerous and expensive morbidity and possibly mortality. Or, they can just stop taking the medicines they can't afford to buy, perhaps using prayer rather than science to get through without bankrupting debilitation or death.

Of course, Congress could order Medicare to negotiate pharmaceutical prices for Part D patients, insuring product quality and affordability and ameliorating this unfortunate situation.

Obama Really Didn't Talk About Health Care Did He?

Obama's speech accepting the Democratic party nomination was short on plans for health care. He described his cancer-ridden mother's battles with insurers over benefits. He mentioned a plan for Americans which would give them Congress-like benefits. He spent a lot of time embracing, holding, and beaming at his family. But there was nothing of substance which could help 250+ million Americans understand whether he really has any health plan at all. We were entitled to more.

He could have said that he favored a single payer system with a available supplmentary coverage similar to the Medigap insurance that seniors on Medicare can purchase. He could have said a few words about setting up a truly competitive healthcare insurance environment in which qualiy and efficiency of health care can be measured to maximize benefit. He could have said a lot of informative things about his plans for health care. But he didn't.

How much money was spent by corporate health care interests to fund the Democratic Party convention? Will the big spenders be at the table designing the health care system that meets their organizational and financial/profit requirements without serious regard for public benefit? Will it be a glossed-over "business as usual" fix to our bloated, expensive and inefficient system? Or will Obama, if elected, and the Congress to be elected, get serious about fixing our ailing health system?

A number of years ago, at a meeting in Sacramento, the Senate President Pro-tem told me (and a few others from a powerful health trade association) that money did not buy his vote. He followed that statement by making it clear that money buys access to him and subsequent comments inferred that it might favorably dispose him to vote, some of the time. The rules haven't changed. Pay attention to who is funding the political parties, and their members, to gain access and influence opinion. If you do, you will be able to predict what our health system will look like in two years.

Fannie Mae, Freddie Mac & Your Family's Health Care

America is in a severe economic slump. Concurrently, the nation's health care costs, for a growing and aging population, are increasing. When the denominator (gross domestic product or GDP) shrinks or stalls, and the numerator (health care costs) grows, we will devote an increasing percentage of the gross domestic product to health care, giving politicians an excuse to vote against meaningful health care reform with health services for all Americans. I expect to hear the refrain "we don't have the money just now" from state capitals and Washington, coupled with the inference that health care is taking too big a bite out of America's economic apple.

The collapse of Wall Street, the exposure of our government to default on $5.2 trillion in mortgages (which you, the taxpayer, will be expected to underwrite), the lack of overall government credibility with its effect on individuals' and business' purchasing plans, and dismal newspaper headlines all affect the GDP denominator. A decrease in preventive medicine, early diagnosis and treatment, childrens' services and health technology, coupled with accelerating pharmaceutical costs, will eventually inflate the numerator.

As we move into the Democratic and Republican conventions, listen critically for realistic discussion of serious health care reform. It's your family's health and well-being they won't be talking about.

How Do You Picture Health Care?

Our usual perception, when asked to visualize health care, is a television image of an emergency room, a physician, a sympathetic nurse, and perhaps a paramedic. In reality, our images symbolize a failure of health care and its end-stages. We should be visualizing poor quality unsanitary food, poor quality housing, cultural conflicts, gang warfare, excessive (and often underage)alcohol use, poor quality water, poor quality and insufficient quantity of preventive health services, poor environmental conditions, the prenatal visit not done within the first trimester, the mammogram not done in the vulnerable woman, the testicle not palpated in the adolescent male who has a cancer mass which could be found and successfully treated, the school nurse whose services have been lost because of insufficient funding for our children.

Health care is a lot more than physicians, nurses, hospitals and ambulances. The determinants of health are often those issues which are arrogantly dismissed by politicians and planners because their political contributors don't want them to pay attention to those complex issues, and it is easier to provide political benefit to wealthy voters and their corporate allies than to the poor, nonvoters and our kids.

After all, how many minutes of political advertising, or seats at a campaign dinner, can the poor and children buy?

Obama: Does "Americans" Mean No Health Care For Uninsured Immigrants?

On August 5, 2008, discussing Barack Obama's health plan, I quoted his web site's language ("Obama will make available a new national health plan to all Americans") and commented "This still leaves states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally".

A recent publication, The Impact of Immigration on Health Insurance Coverage in the United States, 1994-2006 clarifies the significance of Obama's omission. This August, 2008 report by Paul Fronstin of EBRI (Employee Benefit Research Institute) describes and analyzes the 1994-2006 impact of immigration on health insurance coverage. (ebri.org/pdf/notespdf/EBRI_Notes_08b-20081.pdf).

In 1994 36.5 million persons in the U.S. were uninsured and that number climbed to 45.4 million under age 65 in 2006. While most uninsured in the U.S. are native-born Americans, Fronstin reports that in excess of 46 percent (more than 12 million) of foreign-born noncitizens were uninsured in 2006 (as compared to almost 20 percent among American citizens who were foreign-born and 15 percent among native-born individuals.

The report notes that California, Texas, Florida and New York are the states where the greatest numbers of the uninsured immigrants live.

Fronstin has helped to clarify the dimensions of the impact of immigration on uninsured health care in the U.S.

Obama's health plan will still leave states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally. His plan perpetuates an expensive cost-shift to cities, counties, states and their taxpayers and employers.

As a Harvard Law School Law Review editor, graduate and lawyer, Obama's choice of words and particularly his ambiguities, are significant. Words do count.

Obama: A Health Plan or Weasel Words?

Barack Obama's web site (http://www.barackobama.com/issues/healthcare/) neatly encapsulates his health plan. I have taken the liberty of interlineating comments (in bold).

Barack Obama's Plan
Quality, Affordable and Portable Coverage for All

* Obama's Plan to Cover Uninsured Americans: Obama will make available a new national health plan to all Americans This still leaves states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally, including the self-employed and small businesses, to buy affordable health coverage that is similar What does "similar" mean?to the plan available to members of Congress. The Obama plan will have the following features:
1. Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions Will full benefits apply immediately upon enrollment or will there be a waiting period?.
2. Comprehensive benefits. The benefit package will be similar That word again. to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential Who defines "essential"? Right now, it may be a clerk in an insurance company's office who is not a physician or otherwise qualified to make decisions about essential care. Sometimes, it is patients' families whose expectations may not be consistent with standards of reasonable medical judgment. And as we saw a few years ago, sometimes Congress jumps in to make decisions concerning "essential" care. medical services, including preventive, maternity and mental health care.
3. Affordable How is "affordable" defined? premiums, co-pays and deductibles.
4. Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan. Will they be able to purchase a plan which has a comparable network of providers and pays its network of providers the same amount as other plans?
5. Simplified paperwork This was the promise of HMOs, too. The paperwork was replaced by the requirement that physicians, other health care providers and hospitals spend hours on the telephone trying to get authorizations. and reined in health costs. What does "reined in health costs" mean? Does it signify that services will be cut in order to control costs?
6. Easy enrollment. The new public plan will be simple to enroll in and provide ready access to coverage. If experience is of any value, such plans have neither been simply to enroll in and financial constraints have made access problematic.
7. Portability and choice. Participants in the new public plan and the National Health Insurance Exchange (see below) will be able to move from job to job without changing or jeopardizing their health care coverage. This may be a major benefit. However, some employers may find that portability means that some talented individuals leave their employ because they are no longer constrained by a family member's uninsurability.
8. Quality and efficiency. Participating insurance companies in the new public program will be required to report data to ensure that standards Such standards are not described. Where will the bar be set? for quality, health information technology and administration are being met.