Here We Go Again With Medicare!

On November 5, 2009, my grandmother celebrated her 97th birthday. She is in excellent health and still lives alone in her own home. She is able to do this because of the vast assistance from her family and various agencies, including our county's Home Health department, assistance with utility bills twice a year, Medicare, Medicaid, and her monthly Social Security pension of $759. I serve as her Durable Power of Attorney and handle all of her business transactions for her.

When the Medicare Part D Prescription Drug Plan was enacted in the fall of 2006, I selected what I felt was the best plan for my grandmother. Shortly after January 1, 2007, I discovered that Medicare had "switched" my grandmother to another plan without my knowledge - a plan that did not cover her prescription medications. It took some work and the assistance of a very helpful Medicare official in Dallas, but I was able to get my grandmother switched back to CignatureRx. This was not the end of the story... there were continual struggles with CignatureRx, because drugs they said were covered in 2006 seemed to mysteriously be "no longer covered" as the year progressed.

In 2007, I learned that CignatureRx was no longer a good fit for my grandmother, due to lack of coverage and the addition of premiums and deductibles. So I repeated the process to search for a new provider, and I chose Humana. I have to say, the folks at Humana were wonderful and very customer-friendly. They tried to tell me that two of my grandmother's most expensive medications were not going to be covered, but after hearing from her physician, they gave her a "lifetime waiver" on those drugs - she could receive these drugs for the initially-agreed-upon co-pay. I thought I was set! I learned in November 2008 that "lifetime waiver" was only good for one year - that in the insurance company's terminology, a "lifetime" equals one year.

Medicare employees confirmed to me in November 2008 that most seniors will have to re-apply for coverage EVERY SINGLE YEAR, due to changes in formularies, premiums, deductibles, and more. So once again, I am searching for an insurance provider that will adequately cover my grandmother's seven daily prescription drugs.
I know this is lengthy, but believe me, I have condensed it greatly. If you were to read my blog posts of February 2006 and November 2008, you would see some of the ordeal that has transpired:

• http://firecrackerbaby57.blogspot.com/2006/02/medicarerx-drug-plan-is-fiasco.html
• http://firecrackerbaby57.blogspot.com/2006/02/keep-your-fingers-crossed_10.html
• http://firecrackerbaby57.blogspot.com/2006/02/its-over-hopefully.html
• http://delisandwich.blogspot.com/2008/11/if-its-november-it-must-be-time-for-new.html

Aside from the obvious concerns over how this is handled... here are my issues with this plan. I am a 52-year-old former elementary school teacher with a MS in Education. My husband and I founded a magazine and publishing business. I know how to navigate "red tape" and make appropriate contacts, yet I still struggled with this one. If getting prescription drug coverage is this difficult for me, imagine what it would be like for seniors trying to do it themselves. They get through two pushes of the menu buttons (and there are dozens!) and they give up and go away. I figure this is the hope of many of these bureaucracies. As concisely as I can make it:

• Medicare Part D is another example of how convoluted our health care system is.* The average senior cannot figure this out on his/her own, and I seriously doubt most have advocates to do this for them. Even four years into this, I still have to call my Medicare connection in Dallas for clarification and confirmation. I got this contact because initially I complained loudly to everyone from then Governor Mike Huckabee to Congressman Marion Berry, both of my senators, and others. Most seniors won't have the resources - or patience - to do this. (See my first blog post link for info on the responses - or lack thereof - I received!)
  
• I try not to let my grandmother know how much is involved in getting this coverage each year; however, sometimes she is required to verify information on the phone for representatives, etc., so she does know there is work involved. One day she said, "I'll just not take those medicines." I quickly told her this was not an option! But I fear that this is indeed what many seniors are doing... rather than fight the phone menus, comparing plans, and more, they give up and forego needed medications. This system is designed to shoot them down quickly and frustrate the seniors into quick defeat.
  
• The Medicare Part D Prescription Drug system is not equitable. So far, because of her meager "income," my grandmother has qualified for a waiver on premiums and deductibles on certain plans. Many others do not, and those premiums and deductibles add up quickly for older Americans on a fixed income. And what happens when the plans get so out of whack that my grandmother and others like her no longer qualify for waivers on these fees, as well?


• The "donut hole" is ridiculous. The mother of my mom's neighbor had to have an extremely potent antibiotic last January. The doctor could have given her injections, which would have been covered somehow by the insurance provider as a "medical procedure" perhaps. Instead, he prescribed oral medication - to the tune of about $3000 per month. This meant that this lady was thrown into the "donut hole" in February! I have a sick feeling this is in no way an isolated instance. Yes, it was a mistake made by the physician, but it shouldn't be possible. Physicians need to be treating patients, not keeping up with which forms of certain drugs are covered by insurance companies - and how!

Thankfully, I am now semi-retired and have more time to devote to keeping my grandmother in the necessary assistance to sustain her in her own home. We've done three stints in nursing homes for rehab following injuries and illness, and that is not where she needs - or wants - to be. And frankly, keeping her at home is far more economical for the federal government, in terms of capital outlay for her care.

The bottom line for me is that this system is not working for our seniors, and it's almost as if - as a nation - we don't care! As I understand it, presently the government cannot regulate premiums, deductibles, and formularies for the pharmaceutical companies. I believe it is time to revisit this situation... and maybe this is where the public option could help... something that seniors could choose that would cover their medications without imposing these fees and restrictions. I wholeheartedly support the President's health plan, and I believe that, sadly, this fiasco with Part D coverage is only one small part of a much bigger problem. But it is one that desperately needs to be addressed.