My wife and I recently became eligible for Medicare’s prescription drug coverage, known as Medicare Part D. I am a retired lawyer who specialized in complex cases and Barbara has worked as a primary care doctor and associate professor at Harvard Medical School for many years. We assumed that choosing a plan would be a straightforward and easily accomplished chore. We couldn’t have been more wrong.
The odyssey — which it truly became — began as soon as we logged into the Medicare web site that “facilitates” drug plan comparisons. Our first inkling of trouble afoot was the abundance of choices, 25 of them, in Middlesex County, Massachusetts, where we live.
The website gives consumers numerous variables to evaluate: tier level, drug costs (before and after meeting deductible, in and after the “coverage gap”) and co-pays. It also lists deductibles and premium costs for each plan. We dutifully tried to prepare a spread sheet to more easily compare five plans, but then thought about trying to find answers to this question: What is the relationship between tiers, copays, and listed drug costs for four different medications?
I got some answers by chatting online with Medicare. The Medicare chatterer said I should ignore the drug tier and copay information and just look at the list of drug costs. The lawyer in me prompted me to ask this: “Why does Medicare list the drug tier levels and the co-pays on the first pages of the site if that data has no relevance to the consumer?”
“I don’t know,” the chatterer tonelessly replied.
Back to the Medicare website. We chose three prescription drugs we ordinarily use, such as Symbicort, plus several others we use less frequently, such as an inhaler for allergy season. But we had to abandon the latter because the site does not allow users to learn the cost of a medication used only once or twice a year.
To resolve the cost issue, I called two companies to explore the details of their coverage.
The conversation with Company One was a disaster. The representative was not very knowledgeable and it was difficult to communicate with him. We asked about Shingrix, the new shingles vaccine, and even after spelling it three times couldn’t get a clear answer. As we talked, the Company One representative disappeared for a few minutes at a time to talk to a supervisor, but would not let me talk directly with her.
I was finally told that getting Shingrix from Company One would cost $295 for each of the two vaccinations. The representative also told me, after several delays and numerous questions, that Symbicort, an inhaler, would first cost $365 and then $48 after the deductible was satisfied.
We had initially looked at Company One because its monthly premium was lower than the others, even though it received a rating of only 3.5 stars on Medicare’s comparison website. My phone call, along with what appeared to be higher costs for our medications, led me to call Company Two.
That company’s representative was easy to communicate with and answered all of my questions in about 15 minutes — a far cry from the 2.5 hours I spent talking with Company One. I learned from Company Two that the initial Shingrix shot costs $147 and the follow-up shot cost $37.
We quickly understood why Company Two got a 5-star rating on the Medicare site, and why the difference between 3.5 stars and 5 stars is substantial.
By this time, we had spent close to ten hours trying to understand and then choose a Medicare prescription drug plan and had examined only two companies.
We chose Company Two because the thought of exploring more companies was too painful and Company Two’s representative was clear, knowledgeable, and pleasant to talk to.
We knew we weren’t making a completely informed choice: We hadn’t compared the costs for all 25 companies and were relying on a good experience during a single telephone call with an individual in a company’s sales division. Would the experience be just as good if an issue with a medication arose later? We hoped so, but had no data to support that inference.
When we began to explore Medicare Part D, we wondered if people with few resources could navigate the world of Medicare and its drug programs. Our conclusion is that no one, no matter what resources they have available, can make an informed choice because the system is so convoluted.
All of us need a better system. Ideally, there would be one reasonably priced plan and subsidies for those who might struggle to pay for their prescription drugs. If the ideal can’t be realized, then reducing choices to facilitate the ability of participants to make decisions would be a helpful first step. If 25 companies want to bid for participation, then a state agency should select the best five or six plans and let Medicare recipients choose among these few survivors.
Reducing choices, however, is only a minor improvement. The present system confuses everyone — rich and poor, those with a lot of formal education and those with little — and doesn’t serve the interests of elderly patients.
We need a system for choosing Medicare Part D plans that is straightforward and easy to navigate, not one that is inscrutable, frustrating, and impenetrable.
Michael Altman was an equity partner in several Boston law firms and a law professor before retiring.
I choose the company that services you nationwide as I would like to travel. It also was accepted at my local drug stores where I would like to go. It had a low monthly premium, reasonable copays and all the deductibles were the same on the plans. I am not on any medications so saw no sense in high monthly payments with lower deductible. We shouldn’t be paying at all. If they can give illegals free health care should be able to give retirees free drugs.
I wonder why Dennis Byron needs to call me and others names and to become angry. He can keep insisting that the choice of Part D plans is easy but I have received scores of emails, in addition to the site comments, in which people express their struggles and frustration.
Kaiser Family Foundation sent me this:
Below is an email I got from a Medicare advisor confirming that many people struggle with the choices and urging further advocacy for change.
From: Joseph R
Date: 1/1/20 17:22 (GMT-05:00)
To: [email protected]
Subject: Medicare Article
My name is Joe R and I enjoyed reading your article and fully understand your frustration with the Medicare system. I’m a SHIP counselor in IL. SHIP is a national organization that provides free, impartial counseling to seniors who need help with Medicare. You’re correct that there are too many choices whether its Medicare D drug plans, Medicare supplement plans or Medicare Advantage plans. Each year seniors are expected to compare their current drug or Advantage plan to the many other plans which can be an overwhelming task especially as they age. Consequently, many seniors forgo plan comparisons and stay with their current plan even though there may be better plans in terms of costs and benefits. It’s unfortunate that Medicare makes it so difficult for seniors and I encourage you to continue to be an advocate for a simpler system.
All these responses are so heartfelt. They display our frustration and some of the causes of our outrage (e.g., we deserve it and they don’t, it’s our job to figure things out, asymmetric information is the way of the world so why should this be different, etc.). Maybe “advocating” in the form of Letters to the Editor, to AARP, to our congressional reps, etc., is just not enough. Here in GA, the state supports a network of knowledgeable folks to explain Medicare issues to those who ask; there are about 5 or 6 for the entire STATE, I believe. Maybe other states do as well. But most folks I know on Medicare do not know to ask: they have not heard about that service, don’t understand what it does, can’t get to the local ‘council on aging’ (where that knowledgeable and patient person works). So, what then does “advocacy” consist of? I’d bet that many of us on STAT have run projects in our disciplines managing people and dollars and lives and futures. We have, like Liam Neeson says, “certain talents.” And most of us believe in one way or another we are tasked with caring for others, with repairing the world. We darn well know what we would do if we were getting paid in dollars for fixing this if we were working. Well… Do we now sit and watch? Merely do our scientific observations and calculations and write a paper or two? Folks we know and love are being hurt. We didn’t let that happen in the ER or the ICU when that was our lives. So… what’s the plan? What are the outcomes? How do we get there? How do we know when we arrive? What is the plan? Like it was said 1800 years ago, just because we can’t complete the task does not free us of the responsibility of beginning it.
I do not disagree at all. How would the health insurance companies (“chatterers” #1 and #2, and more) respond to your very legitimate frustration and your objections? How would Seema Verma? How would Alex Azar? How would Milton Friedman have answered you from a free market perspective? How about, say, Doug Badger at The Heritage Foundation (from their website today: “Health care reform should be a patient-centered, market-based alternative that empowers individuals to control the dollars and decisions regarding their health care”), who is one of their resident experts on healthcare policy)? Unless and until we can anticipate and respond appropriately to the very folks who have caused our shared concerns with the ethos, logos, and pathos this problem demands, there are tens of millions of Americans who might THINK they are ‘making a choice’ but really are being nudged in one direction or another by the next TV ad or morning TV show ‘expert’. Perhaps these days, in a democracy, that illusion is sufficient?
More plans mean more choices. Each part D plan users different pharmacies and most will have preferred pricing at certain pharmacies. The Medicare Advantage plan can be a great plan for those who can’t afford or qualify for a Medigap plans. , there can be underwriting for the Medigap plan if you do not have a guarantee issue enrollment period. A good agent will verify your needs. If you are looking at a Medicare Advantage plan they will verify your doctors and hospitals are in the network and what happens if you have to or want to go out of the network. With all plans I encourage you to look at your current prescription and medical needs. You can change every year. Also with most of the the Medicare Advantage plan paying less gives you greater benefits. There are even plans that give you back some or all of your Medicare Part B premium
Yes! I’ve got a PhD and my wife has a PhD in economics. I’m professor of medical informatics and I’ve written a lot about healthcare policy. I’m also a senior fellow at one of the nation’s leading healthcare economics institutes. Nevertheless, I found spelunking through the medicare options absurdly complex. The CMS book for my state displays: 1. the many companies; 2. the plan levels for each company (e.g., a, b, c, etc); 3. but also has the counties covered by those companies in often odd patterns (e.g., counties 3, 7, 5 vs counties 1, 2, 4, 7). The latter element makes it even more of a labyrinth.
Of course one can create a spread sheet to help organize the options, including the needed medications. But the status of these medications (generic vs. brand name vs. replacement products) are unknown and usually unknowable.
We do know from thousands of reports that the supplemental plans exist to give US tax funds to the insurance industry, which can lower costs to consumers. But consumers are forced to negotiate this labyrinth with limited understanding of their options and of forthcoming price changes.
Or working backwards, since you can only live in one county, what does it matter what the choices are in the other six counties? You’re about the fourth or fifth wealthy person on this comments thread claiming something that 40,000,000-* of we middle class seniors have no problem with is complicated. What is really the agenda?
*20,000,000 poor seniors get both the drug plan and the drugs basically for free and I they somehow make a mistake (e.g., pick a plan that does not cover a drug they need), they can change the plan four times a year
My husband and I are two recently retired physicians who have experienced the same scenario. I’m glad you wrote the article so now I don’t have too. And next year you can go through the same process after the premium for the chosen Part D plan doubles.
This year our new Part D plans have lower premiums than our plans from before. You do need to go to the Part D Plan Finder every year and search for Part D plans to see which is the cheapest for the year (including everything, not just the lowest premium). It doesn’t take very long to do this.
Picking a plan is easy if you use a licensed insurance agent. That is what us medicare specialist do everyday. There are several things you have to keep your eyes on. Your pharmacy, types of drugs, and so on play a part but isn’t that hard with a little help. I’m surprised a lawyer wouldn’t know that because they wouldn’t advise someone to go to court with just a website. Plus, it doesn’t cost anything to the client because the agent gets commissioned by whatever company they ultimately choose. By the way, the agent gets paid the same no matter which company is they go with so that they won’t choose a higher cost plan.
Or as another commenter explains, free totally unbiased advice is available at all senior centers in Massachusetts. In Massachusetts, the SHIP program is called SHINE
As a licensed health insurance agent specializing in Medicare, I have one complain about the SHINE program. In my experience, and I’ve talked to many SHINE representatives (they hunt me down at health fairs to argue) they are the ones that are usually biased on the plan in which they’re involved with (since most SHINE volunteers are already on Medicare themselves). An Insurance agent that’s a broker gets paid exactly the same no matter what plan they put you in. Plus, we seem to have a lot more experience in showing people the ins and outs and being unbiased. Of course, that’s my opinion.
Excellent article by Mr. Altman. This is what the whole USA population needs to understand the largest problem with Medicare part D. The circuitous phone information makes it difficult for the Medicare population to understand, even for a retired surgeon.
Dear Mr. Altman,
I am curious if you are looking into Medicare Advantage. My husband and I were duped into this program that includes free premiums, free dental and vision. Just a few months later my husband suffered a subdural hematoma from a fall and was in and out of intensive care, rehab facilities and eventually the psych ward where he was receiving the care that he needed. After being there for two weeks, our Medicare insurance said he could no longer stay in that hospital and continue that treatment against the opposition of his doctors. It was here that I found out from the hospital social workers that it was because he was under Medicare Advantage and the final decision was from doctors employed by the Med Advantage policy. It virtually guaranteed that there was going to be no further treatment to help and the only other avenue was to enter a memory care facility where he died four weeks later. I conferred with a geriatric lawyer to help understand how this all happened to a healthy 75 year old. He said without doubt the Medicare Advantage is a disadvantage because, even though so many benefits are at no cost, it is traded for a panel of doctors with the goal to drop expenses to Medicare. I think the elder population are not only being hoodwinked by this ‘Advantage’ which compromises a patient’s rights and their doctor’s ability to make the best decision for their patient. I am on Medicare now and I definitely did not sign up for this ‘advantage’. I would like very much for others facing Medicare choices have the facts before they make a very serious decision for their continued health.
Hey Margot. I’m a Medicare specialist and insurance agent. Your complaint is valid but not what is being discussed. Stand alone Part D plans are drug plans for people with Medicare Supplement plans not Medicare Advantage. Part C, are Medicare Advantage plans which include Part D. Supplemental Insurance, in my opinion is far superior to Med Advantage, but are useful for people who don’t have a lot of resources.
1. If you were “duped into” a public Part C Medicare Advantage health plan, you have until March 31, 2020 to get off it and go back to Original LBJ Medicare with all its high co-pays and deductibles and lifetime limits. Public Part C is about 20 years old. It is now the most popular way by far for people fully signing up for Medicare for the first time to get their benefits. But Part C is not for everyone
2. Most public Part C Medicare Advantage plans have a premium. If you chose one that does not have a premium, perhaps that is your issue (of course, no or lower premium means lower benefits–just like anything else in life). You can also upgrade between now and March 31, 2020 (more often if you qualify for a variety of assistance plans, which cover 80% of us on Medicare in Massachusetts if we choose them)
3. The experience you described with having rehab limited is the same no matter which type of Medicare you choose. The benefits in both Original Medicare and public Part C are the same
In the event you need help with choosing your Medicare Part D or have any Medicare questions, please contact your local SHIP office. The Senior Health Insurance Information Program (SHIIP) is a health insurance information program that provides free one-on-one counseling, education, and information to individuals with Medicare of all ages. Just Google SHIP for your state and you should find a list of offices. SHIP offices are staffed by volunteers and are only interested in helping you find the best plan for you.
Comments are closed.