Medicare change leaves gaps - Many scramble for drugs as pharmacies deny coverage

By Jennifer Latson

The Olympian

Olympia, WA - 1/31/06 - Some Thurston County residents who thought they were enrolled in Medicare’s prescription drug plan are finding that they don’t have coverage when they go to pick up their prescriptions.

It’s forced those people to pay for the medication themselves or to go without it. Affected people include elderly people who have canceled old prescription drug plans and signed up for Medicare’s new program, which started Jan. 1, and low-income people with disabilities who were kicked off the Medicaid drug plan but haven’t gotten onto the rolls of Medicare’s coverage plan. A safety net created to help those people by providing them with free emergency medications isn’t working, officials said.

Among them is Teresa Price of Lacey, who has been on Medicare and Medicaid for the past 15 years but discovered when she went to her pharmacy this month that she didn’t have insurance to pay for her prescriptions.

Her pharmacist found no record of her enrollment in the new Medicare drug plan, called “Part D.”

Price, 41, needs daily medication to control seizures and schizophrenia but won’t get coverage for those drugs until Feb. 1.
She’s been without her medication for more than three weeks now, and she’s starting to get desperate.

“I have no money. I’m out of meds,” she said. “I take seizure meds, psych meds and cholesterol pills. If my cholesterol goes sky-high, I might end up having a heart attack or a stroke.”

Price is not alone. About half of the 30 or so calls a day coming into Olympia’s nonprofit CHOICE Regional Health Network are from people who are having trouble getting prescriptions under the new drug plan, workers there say.

“I don’t think it’s an overstatement to say that the Part D program will result in people dying because they don’t have access to the prescriptions they need in time,” said Kristen West, executive director of CHOICE.

Sagging safety net

People like Price, who are eligible for Medicare and Medicaid, used to get free prescription coverage from Medicaid, which provides health care coverage for the very poor.

They are the people the new system is failing the most, say advocates
and state officials who are working to undo the damage.

“This is a population that, until Jan. 1, the state was taking great care of,” said Mark Rupp, the governor’s executive policy adviser for health and human services. “Suddenly that whole population is in a federal system, the state is paying the federal government, and now our people aren’t getting the medication they need.”

Medicare’s new drug plan replaced the Medicaid plan, and people on Medicaid were supposed to be transferred automatically to the Medicare plan, which offers low-cost drug coverage through private pharmaceutical companies.

But the volume of information that came with enrolling the state’s 1 million Medicare recipients — 100,000 of them eligible for both Medicare and Medicaid — caused computer systems to fail and backlogs to form. Enrollment information for many patients who did everything right never made it to pharmacists, according to Jim Stevenson, a spokesman for the state office that administers Medicaid.

“(Price) was supposed to be auto-enrolled into a plan, but because the feds’ lines and the drug companies’ lines have been so tied up, we haven’t been able to get information,” said Stevenson. “The pharmacist isn’t finding people’s enrollment information.”

Medicare recipients were promised a free, 14-day supply of medication in cases like these. That was intended to ease the transition into the new program, but the backup plan isn’t easy for pharmacists to use, and many aren’t.

“The law says the plans were to be set up to furnish those prescriptions in an emergency situation, but unfortunately, that’s not working right,” Stevenson said. “Pharmacists just aren’t set up to deal with the problem.”

Small pharmacies in particular are hesitant to pay for prescriptions themselves and hope the federal government pays them back, said Marika Bertolini, who works for CHOICE and is helping Medicare patients resolve their problems with the plan.

“Unfortunately, they’re just as overwhelmed as the consumers are, because they’re getting faxes daily, if not hourly, telling them what the latest problem is,” Bertolini said.

Price gets her prescriptions from the local Albertson’s store and was told she couldn’t get any free medication. She makes less than $700 a month in Social Security payments and doesn’t have enough left over to pay for her expensive medications.

“I got a letter from the governor, and she said they could help me for 14 days,” Price said. “(The pharmacist) said he wouldn’t do it. He said, ‘Who’s going to pay for that?’ ”

Wide scope

CHOICE officials could not say how many county residents have found themselves in situations similar to Price’s, but they know their phone lines have been clogged with calls from people.

“We’ve had a ton,” said Holly Detzler, CHOICE’s business director.

Representatives who run a help line at the state Insurance Commissioner’s office also have been swamped, officials there said.

And at the state Medicaid office, officials have sorted more than 2,000 calls from people in as bad a predicament as Price or worse.

One woman who, like Price, was dual-eligible for Medicare and Medicaid and has a mental illness, couldn’t get her prescriptions filled because federal records incorrectly listed her as dead, said Stevenson, the Medicaid spokesman.

A number of patients were told they’d have to pay the full price of their medications, and many of them simply couldn’t afford them. One patient who was unable to get his drugs wound up hospitalized because of it, Stevenson said.

But because the Medicaid office no longer has any say in how patients pay for their medicine, there’s not much they can do, said David Hanig, who runs the Medicaid call center.

“Just about everyone on the call center I’ve spoken to has had one or more calls where the client has said, ‘If I can’t get my meds, I’m going to die,’ ” Hanig said. “At this point, there isn’t a lot we can do. We forward them to the Centers for Medicare and Medicaid Services.”

But it’s nearly impossible to get through on the deluged Medicare hot line.

The governor has taken her own steps to resolve the problems. Two weeks ago, she sent letters to the state’s 100,000 dual-eligible patients to tell them that they have the right to free medication if they aren’t listed on one of the drug plans. About 3,000 of those patients live in Thurston County.

Last week, Gregoire spoke with U.S. Health Secretary Michael Leavitt, asking whether the federal government would pick up the state’s tab if it covered the cost of the interim medications. She didn’t get a clear answer, said Rupp, her executive policy adviser.

Social workers such as Bertolini are worried the confusion could last another month or longer, endangering some of the county’s most fragile people: the elderly and disabled.

Even when the system is working the way it should, officials say, it’ll still do a disservice to people like Price — people who have a very low income and are elderly or disabled, who qualify for Medicaid and Medicare coverage. Price, who has not paid for any medications for 15 years, will have to pay a co-pay of $1 to $5 a month for her prescriptions when she is enrolled in the Medicare Part D program.

Many people who are enrolled in the two federal health care programs have a dozen or more prescriptions. They average seven prescriptions per person.

“What Medicare Part D does is gives a break to Medicare beneficiaries who aren’t as sick, and it does that at the expense of those who are the most sick,” said West, the executive director of CHOICE. “The most fragile people are subsidizing a better deal for the less fragile.”

Jennifer Latson covers Thurston County and Tumwater for The Olympian. She can be reached at 360-754-5435 or jlatson@theolympian.com.