By Wendy Rhodes
Posted at 1:56 PM
Medicare
denies there is a problem, but Medicare advocates say something is amiss -
escalating costs are often inconsistent with typical fluctuations in drug
pricing.
WELLINGTON —
Joel Lieberman is a smart guy. A retired judge and trial attorney, he has tried
countless medical malpractice claims throughout his career.
He
defended doctors and hospitals in the Philadelphia area for eight years before
switching his focus to patients.
In
2001, Lieberman, 76, moved to Florida’s west coast then relocated to Wellington
in 2003. But in 2019, dreams of sunny days on the golf course gave way to a
battle he never saw coming: a fight for his own rights against the nation’s
largest health care insurer: Medicare.
“I
never expected that I would be a victim, because I was always out there paying
attention, yet I didn’t pay good attention this time,” he said of getting
locked into a Medicare Part D prescription plan that would quadruple the cost
of some of his drugs before the year was through.
Like
many people, Lieberman picked his prescription carrier using the Medicare Plan Finder,
a website consumers rely on to compare Medicare plans and prices. He had been
using Humana, but decided to switch to Silverscript in 2019 because the price
quotes were lower.
He said
the written quote through Silverscript for all seven of his prescriptions
totaled $98 per quarter.
But the
first time he went to CVS to pick them up in January, he was charged $147.
By the
second quarter, the cost had risen to $183. By the third quarter it was $224,
and by the fourth quarter the exact same prescriptions rang up at a whopping
$242, he said.
“I felt
like somebody was in my pocket stealing my money,” he said. “And I wasn’t going
to let it happen.”
Reliable
numbers?
He
called Silverscript to find out why the prices had increased so much. They told
him, he says, it was because the costs of medications were rising.
Lieberman
didn’t buy it. Frustrated and a little suspicious, he contacted the Department
of the Inspector General at the U.S. Department of Health
and Human Services, the government office tasked with identifying, combating
and preventing fraud under the Medicare program.
“They
told me there was nothing they could do,” Lieberman said. “So I asked, ‘Where
does this fall?’ And the lady said, ‘In a crack.’”
Shocking
as that response was to him at the time, Lieberman would discover it was not
far from the truth. And he is not alone in his frustration.
“100
percent,” said Medicare advocate Sue Greeno of how many Medicare beneficiaries
could be affected by any problems or misquotes with the Plan Finder.
Greeno
works for the Center for Medicare Advocacy,
a non-profit, non-partisan law organization that provides advice and legal
assistance to seniors struggling with the Medicare system.
She
reviewed Lieberman’s case and found that his escalating costs were inconsistent
with typical fluctuations in drug pricing.
“His
was going gradually up every quarter, so it seemed like there were other
factors at play,” she said.
In
Lieberman’s case, Greeno said the drug prices seemed to have been misquoted.
But she is quick to point out that increasing prices are not always indicative
of a problem with the Plan Finder.
Often
times, she said, people think they have been misquoted, when in actuality, drug
prices actually did increase or the subscriber simply does not understand the
normal fluctuations in costs over a coverage period.
“There’s
all kinds of disclaimers. (Medicare Plan Finder) is a snapshot in time, not a
guarantee that you’ll pay these prices when you go to the pharmacy,” she said.
That
explanation is not good enough for Lieberman.
“I’m
lucky I can afford it, but a large percentage of the population doesn’t have
never-ending funds,” he said, expressing concern for those he dedicated much of
his career to helping.
“The
drug-carriers have a responsibility to their members,” he said. “The world is
relying on the information they provide to make a choice.”
Plan
Finder ‘lacks transparency’
Whether
or not the Medicare Plan Finder is misquoting drug prices is up for debate.
Lieberman
said it is. Greeno said it seems to be in some cases. The Centers for Medicare & Medicaid Services, or
CMS, which is the federal administrator of Medicare, said it is not . . . and
it is.
“CMS
has found the Medicare Plan Finder to be delivering accurate information on
both drugs and premiums, and we’ve seen some inaccurate coverage on the new
Plan Finder,” a spokesperson said in a written statement.
Confused?
You’re not alone.
“For
all things Medicare, it doesn’t matter if you are a doctor or lawyer — it’s
complex stuff,” Greeno said. “It lacks transparency and is extremely hard for
people to understand.”
Medicare
seemed to acknowledge the issues in a November 2019 statement.
“This
year we overhauled the Medicare Plan Finder because it needed it,” it said.
“Advocates, beneficiaries and oversight agencies told us that. And they were
right.”
But
then, it goes on to deny any problems:
“CMS
has been distressed to see media coverage talking about ‘glitches’ or
‘malfunctions’ in the Plan Finder. ... It displays the most current and
accurate information on premiums, deductibles and cost sharing that Medicare
Advantage and Prescription Drug Plans provide.”
Unfortunately,
it is virtually impossible to quantify how often drug prices may be misquoted
through the Plan Finder because, unless someone prints and saves the original
quote and all of the input data used to compile it, it can never be accessed
again.
“There
definitely are cases where you’re getting a price that just doesn’t make any
sense,” said Jack Hoadley, a research professor emeritus at the Health Policy
Institute at Georgetown University in Washington, D.C. “A counselor that looks
at this regularly can see a red flag, but to a regular consumer, that is not so
obvious.”
If the
Plan Finder truly displays the most current and accurate information,
Lieberman’s drug prices should drop in 2020.
The
same seven drugs this year are estimated to cost $130 per quarter, which is an
86 percent decrease over the last quarter of 2019, but a 28 percent increase
over the same period last year.
“I
expect that the bait-and-switch is going to happen again,” Lieberman said of
the little faith he has that the quarterly price will remain as quoted. “It’s a
gamble. I think I could get screwed again.”
Misquoted
or misunderstood?
Greeno
said it is difficult for Medicare beneficiaries to know if they were misquoted,
because drug pricing often changes for legitimate reasons and insured patients
can have trouble understanding the complexity of the way drugs are priced.
She
gives a basic overview:
Prescription
plan coverage and pricing varies depending upon the carrier and the pharmacy.
Plan
deductibles range from zero to $435 a year.
Once
any deductible is met, plans go into the “initial coverage” phase. During this
period, the insured typically pays a co-pay or flat fee based on a five-tiered
system — tier one represents lower-priced drugs and tier five represents the
highest-priced drugs.
When
the total paid by both Medicare and the insured reaches $4,020, the plan goes
into the “coverage gap” or “doughnut hole” phase. During this period, the
insured pays roughly 25 percent of the price the selected plan has negotiated
with the selected pharmacy.
Once
the total out of pocket drug costs reach $6,350, the plan enters the
“catastrophic phase,” which is when the insured pays an average of 5 percent of
the negotiated cost or a low fixed copay.
Because
of the different phases, and because drug prices do fluctuate, an insured can
experience dramatic price variations throughout the year due in no part to
misquotes on the Plan Finder.
“This
is extremely complex,” Greeno said. “Every person’s situation is so different.”
Help is
available
Despite
its denial of problems with online drug pricing, CMS said they “want to ensure
that beneficiaries are confident in their decisions and happy with the coverage
they choose.”
The
organization encourages anyone who needs help choosing a plan or has questions
about pricing to call 1-800-MEDICARE. “Special enrollment periods” after the
normal Dec. 7 cut-off are available to those who believe they have been
misquoted or for a variety of other issues.
Consumers
may also contact SHINE, a non-profit, free service through the Florida Department of Elder
Affairs that can help navigate the complex world of
Medicare.
SHINE
has locations throughout the state, including 11
offices in Palm Beach County. They may be reached at
866-684-5885 or via FloridaShine.org.
Greeno
stresses the importance of taking time each year to shop for the best plan for
your unique situation.
“What
you have one year may look very different next year,” she said. “I’ve seen
people save thousands of dollars by changing their plans.”
Lieberman
isn’t one of them. Despite his grievances, he signed up with Silverscript again
for 2020.
“I’m
stuck,” he said. “When I went to look for other pricing, they’re still within
the cheaper range.”
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