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Drug Co-Pays




Medicare Dóa Failing Grade for the Poor and Disabled

(Published as Drug Co-Pays Could Devastate the Disabled in the Hartford Courant 11/11/05)

Charles Atkins, MD

As the January 1st go-live date for Medicare D (The Prescription Drug Benefit) barrels near, Iím increasingly angry over the devastating impact this will have on the poorest and most disabled. Let me explain; Iím a psychiatrist who has spent his professional life working with people who have severe mental disabilities such as schizophrenia, treatment-resistant depression and bipolar disorder a.k.a. manic depression. As a result, Iíve had a first-hand view of a Medicare population that is different from what one normally thinks about i.e. people over 65. Itís easy to forget that Medicare is not just for older individuals but also for those with severe disabilities, both physical and mental. Within this group, many live at or near the poverty level and so are also eligible for Medicaid. In healthcare jargon these are the "dually eligible" i.e. they receive both Medicare and Medicaid. There are roughly 65,000 dually eligible people in Connecticut.

Under the current system, Medicaid, which is half federally and half state funded, has covered the entire cost of medications for the dually eligible. In the recent past an attempt was made to have small co-pays for each prescription. This was rescinded as people whose lives depended on their medications began to go without. Under Medicare D not only will the dually eligible once again be faced with co-pays of between $1-$5 per prescription, there will no longer be the shameful way out of telling the pharmacist, "I donít have the money", which under the old system obligated the pharmacist to fill the prescription (s). With Medicare D, if you donít have the cash for the co-pays you will not receive your medication.

Now some might think $1-$5 isnít so bad. Of course if weíre on 6-10 medications that control our blood pressure, schizophrenia, prostate cancer and cholesterol weíll make choices. Do I take my medicine or do I buy groceries? Do I take some of the pills, maybe the antibiotic for my bronchitis, but do I really need the lithium that prevents me from having suicidal depressions that can last over a year? What about the HIV medications, there are so many of them, maybe I could just take them every other day, or just take one.

So whatís the big deal? The fact that going off medications is the number one reason why people with schizophrenia get hospitalized is a good place to start. Or that inconsistent use of antiviral and antibiotic medications leads to the emergence of drug-resistant strains should give pause for thought. Itís strange to realize that these seemingly insignificant co-pays are going to have such a devastating impact on peopleís lives. While it will be exceedingly difficult to prove direct causation, I believe there will be deaths. Not to mention the financial burden weíll all share with increased hospitalizations and Emergency Room visits. If someone actually believes these co-pays will save money; itís a perfect example of penny wise, pound idiotic.

It gets worse, and the complexity of Medicare D is far beyond the scope of this essay. Suffice to say that if you, or someone you care about, is a Medicare beneficiary or a dually-eligible beneficiary you need to get educated about whatís coming down the pike. To touch on one additional piece is the still unclear nature of the Prescription Drug Plans (PDPs) that all beneficiaries will be enrolled in. At last count 17 insurance companies have signed up to offer these plans. My suspicious nature tells me that anytime 17 companies want to do something, they intend to make money at it. That aside, each of these PDPs will have a formularyóa list of medications that theyíll cover. Each formulary will be different and if a medication youíre taking is not on their formulary you either have to pay full price, switch formularies, or pursue an exceptions process. As a physician, my blood runs cold at the thought of keeping track of the different formularies, and just how many forms will be involved with these exceptions processes?

So whatís to be done? As the clock ticks down Iíd encourage anyone whoís concerned about the fallout of Medicare D on the dually eligible to contact their legislators and make their voice heard. The co-pay issue, if not rescinded at the federal level, needs to be covered locally. Itís a Ďpay me now or pay me laterí scenario, but our cost up front will be far less than the bill weíll get after January 1st when impoverished patients with severe disabilities will be asked to pay for medications they simply cannot afford.

-The End-

Resources to learn about Medicare D:

The National Alliance for the Mentally Ill (NAMI) 1-800-215-3021 www.nami.org web site. This organization, along with several other advocacy groups for people with disabilities is currently asking for a Special Legislative Session to address this issue.

The Center for Medicare Advocacy 800-262-4414 www.medicareadvocacy.org web site

Medicare. 1-800-MEDICARE www.ssa.gov web site



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