Drug plan won't cure all ills

Even after wading through the confusion of myriad plans, people may still find themselves unable to afford all of the medications they need.

Most of Dr. Edward Langston's elderly patients have no insurance coverage to pay for their prescription drugs.

Langston, a trustee of the American Medical Association, asks his patients about coverage. He tries to prescribe generic drugs. He knows some of them make choices about what to sacrifice: medicine or other basics. Like food.

"It's a real issue for many of the seniors," said Langston, a family practitioner in Indiana.

So Langston believes the new Medicare prescription drug benefit will do more than help his patients' wallets. He thinks it will also help make them more likely to get the medicine they need.

But questions remain about how the new benefit will affect seniors' care. The new plan requires seniors to choose from plans offered by private insurers and other groups, and many complain that it's confusing.

That confusion could affect whether participants can get the drugs they need, said Dr. Anne B. Curtis, chief of cardiology and director and CEO of cardiovascular services at the University of South Florida College of Medicine. People with heart disease take so many drugs today that it's hard to keep them straight, she said.

As an example, Curtis reeled off six different drugs that a heart failure patient might take.

A tricky choice

She is worried that many patients will have a hard time sorting through the different plans to see which of their drugs are covered and may wind up picking a plan that doesn't offer enough.

The new drug benefit will provide help for many people who don't have any drug coverage now. In that sense, it has to be an improvement.

"For those folks using a lot of drugs, if it makes that cheaper, it increases your access to those drugs," said economist Etienne Pracht, assistant health policy and management professor at the University of South Florida. "From a medical standpoint, it gives physicians more choices in helping their patients."

That should be especially helpful for people with low incomes. They can enroll in plans that have low - or no - monthly premiums and pay $5 or less to fill a prescription.

But others say the Medicare drug benefit could have helped people more had it been set up as a more traditional government plan. One critic, Dr. Sidney Wolfe, health research director at the national advocacy group Public Citizen, said the plan is so confusing and costly that it is "doomed to fail."

Wolfe's biggest issue is that Congress banned federal officials from negotiating with drug companies for lower prices. That will affect people's health care as well as their wallets, said Wolfe, who co-wrote the book Worst Pills, Best Pills.

"If you spend more per prescription, you get fewer prescriptions," Wolfe said. "It's as simple as that."

But now that the plan is in place, the big question is which drugs are covered, said Arthur Levin, director of the Center for Medical Consumers, a New York advocacy group.

"People who can't afford to buy any drugs now - are they any worse off in this plan than any other?" Levin said. "The critical issue has been cost. The next issue is going to be what restrictions are going to be imposed on anyone who enrolls in a specific plan."

Different plans offer different lists, or formularies, of what drugs are covered.

There's also the possibility that after people have signed up for one plan, it could change which drugs are covered and drop a needed drug.

"You might enroll in a plan and six months later find they've changed their formulary," Levin said.

Rules require that each plan cover at least two different drugs in each category of medicine. Federal officials are supposed to keep tabs on changes in covered drugs, Langston said.

"CMS says they'll be watching to make sure there's no bait-and-switch going on," he said. "On paper, it looks like it ought to be a good deal."

The question, he said, is whether the plans will work as advertised.

The "doughnut hole"

Health experts also worry about how the coverage gap, or "doughnut hole," will affect participants. Under the new drug benefit, seniors will have to pay a monthly premium, and sometimes a $250 deductible each year. After the deductible is met, the plan will pay for most of the drug costs up to $2,250 each year.

After that, the patient is responsible for paying all costs up to about $5,100. Then the plan kicks back in, paying 95 percent of drug costs.

That means that people are protected if they get a catastrophic illness that requires buying many costly drugs. But people with chronic diseases who have to buy many drugs may find themselves hitting the "doughnut hole" of no coverage each year.

"I'm very concerned about that," said Philip Johnson, pharmacy director of H. Lee Moffitt Cancer Center & Research Institute in Tampa. "There are going to be a lot of cancer patients who fall into that."

It's not just the drugs that attack tumors, but those that manage treatment side effects that could be at risk, Johnson said.

"A lot of medicines are supportive care - to treat anemia, or pain or depression," he said. "Those must be available too."

Some plans are designed to provide additional coverage, so there is no hole. But those often have higher premiums. Some experts worry that people will find themselves in a familiar situation toward the end of each year: having to choose between buying drugs or paying other expenses.

"It may be that unless you have cash in your pocket, to pay in the doughnut hole, we'll be back to the future, where people are not taking the drug for chronic conditions because they can't afford it," Levin said. "There are consequences to stopping medicines. Some medicines can't be stopped too quickly and too readily."

Curtis has the same worry. If patients suddenly stop taking certain heart drugs, such as beta blockers, they might have heart attacks or a heart rhythm problem that results in an expensive hospital stay, she said.

"People need these drugs," she said. "When they stop, people can have a deterioration . . . that leads to higher medical costs."