Hitting the Medicare doughnut hole early

Reading articles like this irritates me more than just a little bit. I have written extensively about the coming Part D doughnut hole already.

Furfaro, a disabled heart-transplant patient, hit the doughnut hole last month when he tried to fill a prescription for two medications. Instead of two $25 co-pays, the pharmacist charged him $661 and $329 for the prescriptions.

"I threw a fit," he said. "What am I supposed to do? I don’t have $661 in my pocket."

Stuff like this comes down to personal responsibility. As the person in charge of Medicare consultation at my place of employment, we killed ourselves educating people about the plan. We did everything humanly possible to 1) educate people and 2) help them pick the plan that was right for them based on their current drug therapy. From the perspective of my pharmacy, there was nothing more that we could have done to educate people and help them make the right decision. Nothing.

Millions of people and millions more family members are going to be experiencing this shocking and crushing problem,” Hayes said.

The Medicare doughnut hole is a strange compromise between lawmakers who wanted to limit the cost of the program and those who wanted it to cover as many people as possible.

While it is an "advocacy" group's job to push for more, more, more — there are limits, and these limits were advertised, and most importantly, there were and are plans which do not have a doughnut hole. A pharmacist cannot help it if someone didn't pick a plan that would suit their needs better. At some point, it must be the patient's responsibility to take care of themselves. It is not that pharmacist's issue that this patient happened to be on Prograf and that Prograf costs a lot of money, however that pharmacist does end up looking like the bad guy, even though he or she was just bearing the bad news.

The fact that plans exist without a doughnut hole is conveniently conflated with the basic plan that the federal government outlined about a year and a half ago, before the private sector finalized their plans. Perhaps it is because the journalist doesn't know, but more probably, it is because leaving this fact out tugs on the heartstrings that much more.

If his health deteriorates further, Furfaro said, he’ll just get admitted to a hospital and receive his medicine that way, as Medicare will pay all bills if he is hospitalized.

In Mr. Furfaro's shoes, I would do the same thing, and it is something that will be addressed as in a year or two. With the doughnut hole, some people will always run out of coverage through poor planning, catastrophic occurrences, or what have you, and they will go to the hospital to continue getting their medications. However it is in the government's best interest to keep people out of the hospital when they are picking up the tab, because it is more expensive to keep someone in a hospital bed than it is to pay for their medications at a retail pharmacy.

In the meantime, the current Part D plan has worked out astoundingly well, and it is certainly off to a very good start. Where the money will come from in the future to continue its funding is anyone's guess, though.

Update 12.26am: I forgot to mention that Part D providers are required to send monthly notices to their subscribers telling them how much of their benefit they have used up, so if Mr. Furfaro had been doing his due diligence, he wouldn't have been blindsided by the doughnut hole.

[tags]Medicine, pharmacy, Part D, doughnut hole, Medicare Part D[/tags]