Medicare: Medi - was?

'It's scary every day': Medicare members left out of plans aid and worry about future

Charleston Gazette, via NewsEdge Corporation:

Feb. 27--GRANTSVILLE -- Although the new Medicare drug benefit helps many seniors afford their drugs, it may leave Ruth and Bob Fitzwater without their medicine.

As of Jan. 1, Medicare recipients can buy their medicine through plans offered by private insurance companies. Beneficiaries choose plans based on what they can afford and the drugs they need. Medicare will help pay drug costs. People with significantly low incomes can get financial help from Social Security.

But the Fitzwaters belong to a portion of beneficiaries who have too much to get help from the government but cannot afford a drug plan.

With a combined monthly income of about $1,900, the only way the Calhoun County couple could afford the $900 in drugs they need each month was through low-cost drug programs run by pharmaceutical companies. Many companies plan to close the so-called patient assistance programs, or PAPs, to Medicare beneficiaries in the next few months.

"I don't see why life is worth living for us anymore," Ruth Fitzwater said, her 64-year-old eyes red and brimming with tears. "You think you have somewhere to turn and someone to help you when you get old. ... You ever wonder what it's like to never have a life, to hurt, to wonder where the medicine is coming from? It's scary every day."

The couple's dream home manifested four years ago as a roomy but modest log cabin near Grantsville, more than two miles down a curvy, half-paved road. Mounting medical costs -- including a $2,000 hospital bill -- forced them to re-mortgage the house, Ruth said.
"They want everything the old people have," she said. "I'll be damned if the government will step in and take my home."

The first letter came in October from Bristol-Myers Squibb, informing Ruth and Bob that they were off that company's PAP if they chose a Medicare plan. Others followed with the same message or just cut them off completely.

Ruth takes four medications, most for arthritis. She nonetheless takes care of 72-year-old Bob -- bathing him, feeding him and helping him in and out of the wheelchair he got, compliments of several strokes. She tends to him around the clock because his dementia means he cannot be left alone, she said.

But when it comes to paying for the 13 medications that keep Bob's diabetes, lupus and Parkinson's disease at bay, the only things she can do are worry and hate a system she says provides for prisoners, but not seniors.

"We would have been better off had we gone and killed somebody," she said, letting out a loud laugh. "You really got to laugh. It's a big joke. I just wish Mr. Bush could come here and just try to live like us for six months. I guarantee he wouldn't like it."

The federal government said drug companies could not keep Medicare patients on assistance programs, said Ed Sagebiel, a spokesman for Eli Lilly and Co. The company's Lilly Cares program closes to Medicare beneficiaries March 31, even if they have not enrolled in a Medicare plan.

But Medicare's federal stewards, the Centers for Medicare and Medicaid Services, or CMS, put out a special bulletin saying drug companies could keep beneficiaries on PAPs as long as those drugs do not count toward the $3,600 in out-of-pocket expenses (minus plan premiums) most recipients are expected to pay each year, said Lorraine Ryan, a spokeswoman for CMS.

"They're wrong," Ryan said of the drug companies' take on the Medicare rules. "It was never CMS' intent to disallow drug manufacturers from helping people through patient assistance programs. Our only concern was making sure there was no room for fraud and abuse."

Still, nearly every letter distraught Medicare members have brought to Brian Cunningham of the West Virginia Primary Care Association -- a trade group for nonprofit health centers -- cites the non-existent federal guideline, he said.

"It's almost like they are apologizing for this bad decision by the [government] when the drug companies know darn well that is not the real reason. It's dollars and cents," he said.

Eli Lilly gave out $400 million in drugs through PAPs in 2005, Sagebiel said. The company is looking into a way to help people who fall between federal aid and self-sufficiency.

Other drug firms such as Pfizer always said PAP coverage would end for people who signed up for Medicare, said spokesman Jack Cox. Pfizer joins several companies that will keep people on PAPs as long as they do not get a Medicare plan.

That sounds great, assuming all the drugs a person needs come from Pfizer, Cunningham said. If a person also needs a medication from GlaxoSmithKline for instance, which will remove all Medicare-qualified people, then what?

Cunningham helps Medicare members get through the often-tricky enrollment process. For middle- to upper-class people, the drug program indeed saves money, he said. For poor people who can get federal assistance, the benefit gives them a stake in their health care, he said.

"When it comes to your life and your health care, we, as a society, would expect them to pay a couple hundred dollars a year for their drugs," he said. "You get a better outcome from health-care products when people do have to take some responsibility for part of the cost."

Federal guidelines, however, draw a thin line between those who get help and those that do not. People who might make only $4,000 over the limit get nothing.

The standard benchmarks for Social Security help go up to a monthly income of $1,197 for single people or $1,604 for married couples. Assets, such as savings accounts or investments (but not your house) cannot be worth more than $11,500 if single or $23,000 if married.

"When you're talking about drugs, $4,000 is nothing," Cunningham said. "For people who already live check to check, there's no way in the world they are going to be able to come up with $600 every month" for a Medicare plan.

Joanie and Bill Stuart would easily spend $3,600 each year for medication if they joined a Medicare plan, Joanie said. Together, they need about $1,200 worth of drugs each month, she said.

Like the Fitzwaters, the Greenbrier County couple relied on PAPs until their companies told them to use Medicare instead. With $900 in regular bills, $17,000 in outstanding medical bills and an income based only on disability payments, the Stuarts need to decide what they need more, Joanie said -- food or medicine.

Former drug addicts, Joanie, 50, and Bill, 42, worked even during their wild years until her bipolar disorder and his schizophrenia put them out of commission, she said.

"I worked my butt off to be sober and clean and productive," said Joanie, who has been sober for 13 years. She estimates that she averaged $50,000 per year between the ages of 15 and 37.

"Bill and I have worked very, very, very hard to be stable. We want to be productive citizens. We want to work," she said. "I've never not worked until I got sick and then I tried. I just couldn't hold them down. I get frustrated and confused and have panic attacks."

Unlike heart patients or people with migraines, if Bill or Joanie forgo their medication, the result could be ugly for everyone.

"I end up in a psych ward or in jail because my behavior's really off the hook. I have a mean streak in me a mile high," Joanie said during a telephone interview. "[Bill] gets extremely loud, uncontrollable voices in his head telling him to do whatever. Hold on, let me ask him ..."

From the background of their Smoot home, Bill answers, "I would kill somebody."

Joanie, like Ruth Fitzwater, seemed suddenly lost for words when asked how she would get the medication she needs without help from drug companies or money for Medicare: "I have no freaking idea, sweetheart. I really don't.

"I'm real happy having a simple life, but I'd like to have a simple life and be sane, too," Joanie said. "That would be wonderful."

Lancelot