On November 3, the Boston Herald ran one of those typical healthcare-insurance-companies-suck sob stories written by its "house lefty." But this healthcare-insurance-company-sucks sob story had a twist. The healthcare-insurance company in the Herald story was not one of the usual for-profit Republican bad guys but the good old Democratic-party bureaucracy, the Centers for Medicare/Medicaid Services.
The alleged "Medicare victim" is a former pressman (I'm guessing that's someone that worked in newspaper publishing back when it used presses) with rheumatoid arthritis (RA). In the story, the victim is of an age not specified, and has been on Medicare of a “part” not specified, for a length of time not specified. The Herald story did say where the Herald’s victim lived in Massachusetts (Millis) and that he needed Enbrel, the drug of Phil-Mikelson-pro-golfer fame, to control the RA. Supposedly it used to cost the Herald's "Medicare victim" $42 a month under Medicare back in some time period unspecified and now – starting in July 2011 -- it began to cost him $600 a month instead.
We'll probably never know the whole story about the Herald's "Medicare victim" unless he wants to go public. But the Herald did a disservice to seniors by publishing a story that made no sense to anyone that studies Medicare drug coverage. And unneccesarily scared the shit out of hundreds or more seniors who use it.
Thankfully, as inaccurate and as misleading as the Herald story is (kind of like former Illinois Senator Obama claiming that a healthcare insurer denied his mother cancer-care coverage), the Herald article provides a teachable moment. Lefties love teachable moments. The potential teachable-moment statements in the Herald article are underlined both above and below. I will follow up with detail on each in future blog posts as appropriate and if I feel like participating in a teachable moment. But in summary
1. The Herald said:
"(The victim) says Medicare has changed its deal for covering... (Enbrel)"
Medicare did not change "its deal" for covering Enbrel or any other drug. (Note how the Herald says the victim said this. That way, the Herald is not responsible for the inaccuracy.)
2. The Herald said:
"(Enbrel) kept him working for 10 years with increasingly severe rheumatoid arthritis."
This calls into question the story line of the Herald "house lefty" that something that Medicare had been supporting for 10 years (a low co pay) was then recently and abruptly changed drastically "by Medicare." Medicare has only had Part D drug coverage for five years. Worse in terms of the teachable moment, we don't know what 10 years the Herald house lefty is talking about.
3. The Herald says in a November 4 follow-up article that its Medicare victim is on an unnamed Tufts Medicare Preferred plan. It does not appear that either Tufts (the actual insurer) or Medicare (the accused insurer that is actually only a payer, just like EMC or Raytheon or probably the Herald) changed anything for the Medicare victim assuming he is the guy from Millis that turned 65 in 2010, that he was not disabled by the RA (the story implies he was working fairly recently), and that he used Tufts.
4. The Herald said
"Enbrel used to cost him a $42 per month co-pay."
My guess is that the "Medicare victim" received some bad insurance advice, possibly from Tufts. Good advice would not have changed his cost situation but it could have better prepared him and possibly helped him find assistance if he qualified. (I can think of at least one other scenario. Possibly he was disabled by the RA when he was in his early 60s, went on Medicare two years later but before he turned 65, and belonged to some Tufts health plan before 2010 -- like a Medicare Part C HMO -- that covered Enbrel better than Tufts' 2010-2012 Medicare plan lineup covers it.)
5. The Herald said
"Now it costs him $600 a month."
"Now" is the clinker in this claim. The monthly average under the likely Tufts plan for 2011 would have been around $400 a month (assuming he is using a local CVS or Rite-Aid), not $600. There are less expensive Medicare Part D plans in Millis that would have lowered his cost to about $330 a month on average. That lower price from other insurers will be about the same in 2012. But maybe there was another good reason to be on Tufts.
Enbrel is expensive medicine. Every case is different but, on an annual basis, the typical Enbrel Medicare user gets $22,000 worth of the recommended dosage of Enbrel for as little as $4,000.
- That's pretty good especially compared to before 2006 when there was no Medicare prescription coverage.
- That’s better proportionately than you getting your annual fix of brand-name blood pressure or chloresterol medicine on Medicare, retailing at $4000 but costing you $1000 out of pocket (a monthly $50 co-pay until you fall into a little bit of the donut hole and pay 50% of the drug's cost).
- And -- at least in Massachusetts -- there was and is a state program that helps substantially mitigate even the $4000 (or $1000) for senior-citizen couples making as much as $36,000 a year. With no asset test or spend down required.
6. The Herald said:
"So ("the victim") stopped taking Enbrel four months ago."
This statement is the one that really makes no sense to people that research such things because June/July 2011 was when the Herald's "Medicare victim" would have been coming out of the donut hole and have been eligible to buy Enbrel for only $95 a month for the rest of 2011.
I'm not defending the donut hole mind you but its effect is
- to keep annual drug costs very low for most seniors without specialty drug needs, and
- to provide benefits almost immediately after the policy begins without high up-front out of pocket expense
7. The Herald said:
"... he is far from alone. At a recent (Massachusetts) State House hearing, doctors, patients advocates and patients themselves told lawmakers that not only is Medicare changing prescription drug rules, private insurers also have demanded high patient payment for some of the more expensive drugs treating cancer, heart disease, HIV/AIDS, hemophilia and multiple sclerosis."
Again, Medicare is not "changing" and has not changed anything. IF anything related to the victim's Medicare drug coverage changed, and I cannot find that it did, it was one insurer that changed something.
Nor does a private insurer "demand payment" of anyone. That's not the way insurance works. (And most healthare insurance programs including Medicare are run by private insurers, despite the Democratic-party-line dig at "private insurers.")
And I don't think the Massachusetts legislature can do anything about Medicare drug coverage so it is grossly unfair of the Herald to imply the pols could help to its Medicare victim and other seniors. That just victimizes him twice, to use a favorite expression of the left.
I also don't think the Massachusetts state legislature can pass a law that would have an effect on those with employer sponsored insurance where the employer is self insured. Counting all Massachusetts residents where Medicare and self-insured employers are the payers, 75% of the people in Massachusetts are unaffected by anything the state legislature does when it comes to healthcare insurance.
The Herald sure packed a lot of teachable moments into a small article.
-- Dennis Byron