Seniors must be wary of false claims in Rx drug bill

May 15, 2000|By Betsy McCaughey

Members of Congress have their marching orders: talk about prescription drug coverage for seniors.

So far, the debate has been short on details. But when it comes to health legislation, the devil is in the details. Some of the bills could restrict your access to newer medications.

If you are taking one of the "miracle" drugs such as Celebrex (arthritis), Prevecid (reflux), Aricept (Alzheimer's), Fosamax (osteoporosis) or Lipitor (cholesterol), keep reading. Here's what you need to know about the two front-runner proposals for drug coverage: President Clinton's Medicare Modernization Act of 2000 and House Speaker Dennis J. Hastert's (R-Ill.) alternative proposal.

The president's bill might not protect your choice of medications. It expands Medicare to include partial drug coverage for an additional Part D premium and relies on a single pharmacy benefit manager (PBM) in each region of the nation to administer the benefit.

PBMs already administer drug coverage programs for HMOs and employers. When you enroll, you would get a drug benefit card to take to the pharmacy. When you order a prescription, the pharmacist would call the PBM, check to see whether the drug is covered and then either fill the prescription or tell you that drug isn't allowed. Your choice could be limited.

Under the Clinton bill's risk sharing arrangement, PBMs would have a powerful incentive to limit you to the cheapest drugs. Risk-sharing means the PBM profits when your medication expenses come in under budget, and makes less profit if you are allowed to consume more. Doctors who treat arthritis already complain about what drug managers do to HMO patients. For example, some patients are forced to settle for Ibuprofin and are not allowed to use newer anti-inflammatories, such as Celebrex, which cost more.

The Clinton bill says any drug prescribed for you is covered if it is "medically necessary." Does that mean your doctor simply checks a box on the prescription pad saying it is "medically necessary," or would you have to wait for an extended appeals process? The White House needs to answer that.

One thing is clear. Under the president's bill, if your PBM keeps turning you down for medications your doctor orders, you have no place else to go. It's a monopoly. In each region, there is only one PBM, chosen on the basis of lowest bid.

In contrast, the Hastert proposal sets up a competitive system. Seniors are allowed to choose one of the drug plans offered by private insurers. All insurance companies try to limit costs by limiting covered drugs. But under the Hastert proposal, you can vote with your feet if your insurer isn't covering the drugs you need.

The Clinton plan would pay a maximum of $1,000 toward your drugs annually in 2003 and 2004 with gradual increases later. It would not protect you from the unaffordable expenses that come with cancer or chronic diseases such as arthritis until 2010.

Mr. Hastert's proposal would guarantee protection against huge expenses. The insurance industry has expressed reluctance to offer "catastrophic" coverage, saying future drug costs are too unpredictable. To solve that problem, Mr. Hastert's proposal includes federal government reinsurance to enable insurers to include high limit protection without assuming the whole risk themselves. That's important. About 4 percent of seniors need at least $4,000 of medications a year. They would be left in the lurch by the administration's bill.

Congress should help seniors who cannot pay for prescription drugs. Failing to provide that help will result in higher Medicare costs. Anti-coagulants often can protect high-risk patients from stroke. Anti-coagulants cost about $1,095 a year, a lot to pay out-of-pocket but a bargain compared with the $100,000 lifetime cost of a severe stroke.

Seniors need to speak out to ensure that whatever drug insurance bill is enacted provides access to the newest, most effective drugs, not just cheap older ones, and includes protection from the huge, unaffordable expenses that come with cancer and chronic illness. The administration's bill does not, but the Hastert proposal looks promising.

Betsy McCaughey is a senior fellow at the Hudson Institute and former lieutenant governor of New York.

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