MORE PLAN D

The most important revelation in my investigation of Plan D is that it is NOT required.  I can simply choose not to subscribe.  That moves the consideration to a whole new level.  Also, according to the 2013 rules, a person who receives Extra Help can change companies anytime -- not just before December 7.  

The most discouraging aspect of this search has been that no matter WHOM I ask for help and advice, what I get is a pitch for or against “Obamacare” -- which is irrelevant.  They told me when I was doing public relations with the media that if someone asked me a question I either could not or did not want to answer, I should answer a question that was similar but not the same.  I hear this strategy among politicians and even doctors again and again.  Sometimes they don’t even do “similar.”  Just change subjects.

I will not depend only upon the advice of doctors about which drugs I should take, the same as I will not depend upon insurance companies to tell me which policies I should engage.  The influence of big pharma, the many instances of flawed studies and reversed recommendations, my hospital chaplaincy which gave me access to patient files and physician reviews, and my brief brush with statistics, have all told me that medicine is NOT magic, that what cures one person can damage the next, and simply perpetuating oneself is not the best goal.  I barely managed to resist the craze for estrogen replacement at menopause.  Everyone talks about testosterone as psychoactive -- try switching in and out of estrogen!  It’s being thirteen again.

So, where am I?  Personally, I mean.  What Plan D should I choose?

1.  QUALIFICATION:  I'm under the poverty line as currently defined.  It moves yearly.  I’m on the boundary and could be pushed out in a different year, but now I get Extra Help.

2.  DIAGNOSIS:  My only conditions are “metabolic syndrome” and “ocular migraine”.  That means age and behavior driven glucose and blood pressure levels that are marginally too high as well as tired eyes from obsessive reading and writing.  These are all best managed with diet and exercise -- very minimal medication.   But these latter must be monitored with formidably expensive lab tests.  Much of medicine now is based on these tests rather than direct observation of the body.  For a five minute conference with a nurse-practitioner, a blood draw, and multiple panels of statistics that showed the same figures as last time, I was billed $546, all paid for by Plan B.  NOT Plan D.  

At this “checkup” I asked for the new “shingles” vaccine but there was none on hand in the clinic (which means a new billable visit to get the shot) and no one knew whether it is covered or under which plan.  Ideal levels of glucose vary in the minds of various physicians.  Some say that slightly older people should maintain slightly higher levels.  Others think that lower is always better and will push a person close to the danger level, I discovered from experience.  One cannot relax vigilance. 

3.  DEDUCTIBLE:  This is the amount a person is expected to pay before the insurance  begins to pay.  On the list I’m looking at, most companies specify a little over $300, but if one is classified as “Extra Help” (meaning poor) then the deductible drops to maybe $65.  Some companies offer NO deductible. This is a good thing since the total cost of my drugs for the whole year is less than $300 -- at non-negotiated prices.  The cost of my YEAR’S drugs  if the insurance company has negotiated special very low prices for the meds is little more than $65.  Of course, the insurance companies owned by drug store chains have a lot of leverage for deals -- probably as much as a small African country.

4.  CO-PAY:  Some policies ask the patient to pay part of the cost of drugs, separately from the issue of what is deductible.  Co-pays, like deductibles, can be arbitrarily changed by the insurance company on the first of every year AFTER you have had the chance to change policies.  There is some kind of relationship which is meant to allow the insurance company to preserve its profit.  BUT a person with Extra Help can change any time.  No advisor knew this, though it’s in the Medicare book, which is about the size but not the helpfulness of my MAC OSX operator's handbook.

5.  MONTHLY PREMIUM:  In the beginning this was the essence of the game: put your money in the pot and gamble on whether you’ll need it.  Now it is the subject of negotiation and accommodation.  If you are poor enough, you will get Extra Help with your premium.  Extra Help also lowers your deductible.   Medicare “Extra Help” will not necessarily pay all your premium, but Montana (among other states) will pay what’s left, so possibly the total covers ALL the premium.  But don’t get to assuming there is NO premium, which is sort of my mistake.  Someone has to cover it and you’d better check out who is doing it or risk -- as I did -- neglecting $8.50 payments until it has become a $450 debt.  Since the insurance company made no fuss about it, I suspect there is some mechanism for the government to compensate for deadbeats like me.  (I AM paying off this debt.)  Plan B payment is simply deducted from your SSI check before you get it, leading to the illusion that there is no premium.

6.  GAP COVERAGE:  Another negotiating chip: as soon as this phenomenon was invented, it could be widened, discounted, redefined.   The idea is that if over time you exhaust a certain amount of insurance coverage, you are suddenly not covered.  Then at some late date you’re covered again.  Makes no sense to me.

7.  ACCEPTANCE OF GENERICS:  Some plans require generics, others require name brands.  There are enough small differences in formulation that some people don’t benefit from generics or vice versa.  Another wiggle point that benefits Big Pharm.

8.  ACCEPTANCE BY DOCTORS:  Some docs will accept whatever Medicare pays and others won’t.  There’s a strong sense of entitlement on the part of the docs as well as a tendency to want to push the easy stuff off onto, for instance, nurse/practitioners.  When all they do is look at test scores and then follow the indicated formula, there’s not much difference, but there is a definite culture diff between the two levels of education as well as culture diffs within the medical profession, esp. if you include O.D.'s with M.D’s.  Only one nurse-practitioner, a man, has ever given me a checkup by really looking at me, checking reflexes, feeling my feet and so on.  Maybe one-third of docs (male or female) have done the same.  But the bills for service were the same.

9.  SPECIFIED FORMULARY:  Whole separate booklets specify what meds the insurance company will pay for.  I don’t get it.  I guess some treatments are considered ineffective or dangerous.  One suspects thumbs on scales.  Why the fancy word: “formulary?”

10.  LEVEL OF SERVICE:  The constant complaint when it comes to drugs issued by free clinics, whether it’s the Indian Health Service or a public health HIV-AIDS service, is that the drugs arrive after long waits, inaccurately provided, handed over with contempt, sometimes not in stock, and so on.  Of course smart drug store chains high-light good service since it is something they can require of their employees without extra investment of money. But somehow service provided to people who are needy is often given with contempt.  Isn’t it reasonable to give needy people MORE kindness?

11.  CONFLICT OF INTEREST:  And here’s where I balk and begin to think of just going without Plan D.  Big Pharma is involved with the politics of government health care and insurance -- like CareMark drug chain owns SilverScript.   Also, it is forbidden for insurance salesmen to pitch their plans to Extra Help people -- so who are all these “agents” who call instantly if I pull up an insurance company on the computer?  They are “licensed” -- that means nothing.  Maybe passed a test.  Semantics.

12.  SCARE-MONGERING:  Every person is in danger of dying at every moment of their lives.  A flaming piano could drop out of the sky on you before supper.  It’s not likely, but it’s possible.  We all are held taut between wanting to risk for the possible benefits and even for a possible increase in skill and experience, but wanting to stay safe enough to risk again on another later day.  Everyone has to find their own trade-off.

So I have to think about the likelihood of me needing much more expensive drugs in the future: cancer, heart, trauma.  I get a coupon for being such a clean living non-risker.  I also have good genes, for which I thank the precluded ancestors of myself who lived such hard, dangerous and probably defiant lives that they were killed early, thus removing their faulty genes from my pool.  There’s also something to be said for my mother who believed in cod-liver oil, farm food, and donkey labor by kids.

CALLING PLAN D, MEDICARE, SOCIAL SECURITY, AND THE PHARMA/INSURANCE INDUSTRY

All across the country every day huge pools of people sit down in cubicles, put on headsets, and straighten the three-ring notebooks in front of them.  Most of them are people of color, overweight women, and men who either are not equipped to or not interested in carving a career.  They answer questions all day, sometimes about a guarantee, sometimes a complaint, sometimes as customer service for orders and so on, and sometimes to explain government services.  Their computers, alongside their answer books, can pull up detailed information about you.

I once applied for one of these jobs and listened in with auxiliary headphones.  The people were calling because they had opened charge accounts and discovered that without them actively choosing it, they were paying for death and mutilation insurance policies on that account.  It would not pay them or their survivors, but rather the account.  The call center was supposed to discourage them from canceling the insurance. The interviewer considering hiring me thought I would be perfect for this because I had been a minister.  Many of the callers were distraught, clearly poor, and -- judging from accents -- in the Deep South.  I could barely understand them.  I withdrew my application.

When I worked for the City of Portland, I had the same sort of job but this time answering questions about city codes and regulations, which were recorded in a three-foot row of books with thin paper and fine print.  Sometimes they were about bad landlords or a wish to build something.  Many were about flood plain regulations, which are based on maps which were hard to interpret.  So one quiet afternoon I composed a one-page summary of answers and principles to send to callers.  At the top was the legal right to ask for a hearing on their problem.  The plans examiner who handled these determinations was a great libertarian and defender of rights, but my inclusion of the right to ask for a hearing set his hair on fire.  Visions of endless hearings rose in the smoke.  I had to throw my summary away.

No one’s hair is bursting into flame this time around.  If I feel it beginning to happen I’ll just run out and stick my head in the snow.  But I got up at 4AM this morning, determined to understand what is going on.  I’ve prevented further debt, thanks to BigSkyRX, and am not trying to challenge my $450 accrued owed premiums, but trying to understand the whole system.  On Friday the library will host “Navigators” who will try to answer as many questions as they can.  Every question I asked on my phone call journey sent the operator off for a conference with a supervisor because the question/answer was not in their book.

Somehow in 2011 I was moved from "Level 1" to "Level 4".  This reflects one’s relationship to the poverty level, which the lawmakers use as an index.  The idea is to measure the depth of your poverty and respond to it by the amount of help provided.  But the poverty level doesn’t stay put; it’s redefined according to some formula managed by Social Security.  I presume it’s probably involved in taxing as well.  You might be gratified to know that very rich people have extra premium payments.

Medicare is closely related to Social Security.  There are four plans:  Plan A is hospital stays and other serious and usually emergency things.  I've never used it.  Plan B is the general medical.  I mostly use it for my eyes.  It’s managed directly by Centers for Medicare and Medicaid Services.  I recently changed eye docs because the one I had been using kept pushing for things I didn’t need, esp. cataract surgery.  Also, he billed as soon as he prescribed rather than after the tests were delivered, so some of his payments were denied since the service had not been delivered.  My eyes are doing very well -- there is no increased diabetes damage though that was how the original diagnosis was made.  That same doc referred me to another doc who had been in court for double-billing Medicare.  She is no longer in practice.

I don’t use Plan C.  Plan D  is for drugs and I get two answers about whether it is voluntary -- yes and no.

What I needed to know this morning was the formulas for the four levels, but no one could answer that question.  Then I wanted to know why in 2011 I was moved from level one to level four, though my income only changed slightly due to COLAs.  So far I’ve talked to Social Security (they’re on the east coast which is why I called them so early), Medicare, Special Help, BigSky RX, and SilverScript.  I was interested to realize that CareMark, a pharmacy business, owns SilverScript.  (Walmart also owns a Plan D insurance company.)  I’m supposed to use a pharmacy in the “CareMark Network” which luckily owns the new ShopKO (previously Pamida) in Shelby.  Lucky, because Janet the pharmacist is really good at what she does and absolutely trustworthy.  

It strikes me that insurance companies owned by pharmacy chains are a conflict of interest.  In fact, the whole thing strikes me as a ball of snakes.  The big squeezers.  It is evidently the Caremark connection that is sending me all the chiding robocalls, ten-year-old sweet thangs on the phone, and computer letters, urging me to take more drugs.  Of course, they’re very persuasive to some nurse-practitioners and docs.  At least where I am most people are middle-class enough that our clinics and pharmacy chains are pleasant and clean.  But everyone is too unquestioning to suit me.

The most recent blowup over prescribing statins is only one python in the struggle.  Stigmatized patients are exposed to low-end providers in shoddy settings “because they’re just scum anyway or they’d get jobs.”  There’s a rising unwillingness across the nation to help people who are “not like us.”  More and more people are “not like us.”  More and more are immigrants, old, homeless, disabled, suffering from PTSD or brain trauma, and so on.  Some were here long before anybody else. (Native Americans -- remember them?)  Some churches feed on them, offering help and the assurance of prosperity in order to fill the pews with faithful people.  

On the hopeful side, I’m reading more and more analysis of society, new ideas, individuals willing to risk by uncovering the struggle, and the realization that nations, even the “democratic” ones, are being replaced by intertwined and international corporations.  A few, not so hopeful, are forecasting revolution.  There are already demonstrations in the streets.  Since so many young people are out of work and poorly educated but somehow idealistic, it is a good use of their time and an inevitable development.

BUSH'S VERSION OF OBAMACARE

This is NOT about Obamacare.  When I even say that word, people froth at the mouth, bleed from the nose, and become incoherent.  This is about Bush’s version of health care insurance, which was Plan D, a pass-through subsidy that greatly benefits the Mega Pharm industry entwined with the Mega Insurance industry, and helps a few real people along the way.  Former President Clinton reminds us that its start-up was as rocky as Obamacare’s, but not attacked so violently because it benefitted the rich as in corporations.  It is REQUIRED.  One can’t opt out.

Plan D is the insurance that pays for drugs, in my case Metformin and Benazapril/HCT2.  One pill of each (both low dose) once a day.  The justifying blood analysis in both cases is right on “the line” which is the score the doctors use to define who needs the drug and who does not.  If I walked a few miles a day and lost twenty pounds, I probably would not need either drug.  My diet is pretty irreproachable: no sugar, no white flour.  Lots of veggies.  My own muffins loaded with nuts and fruit.

Here I am, an active senior in a small Montana town with a trusted pharmacist who works at a big box store thirty miles away and is very alert about filling prescriptions and finding generics or -- when my compounded benazipril/HCT2 was not available -- finding an alternative (1 pill of the benazipril and a separate pill for HCT2) until manufacturing caught up again.  Since our roads in winter are often much more dangerous than either diabetes or high blood pressure, the store mails me my prescription on request.  But if I ask for it too soon, it’s denied by the insurance company. Access is controlled by a computer.  So is the money.  There's a little window of time.

In the snail mail I’m always getting six or more pages from my Plan D Silverscript Insurance provider which was evidently bought by CareMark Insurance Company at some point.   There’s so much of it and I’m so passive about such things, I’ve always ignored them.  Until I realize now that I had racked up a bill with these people that exceeds $400.  I’m below the poverty line and have both Medicare Extra Help and BigSkyRX, which in theory pay all of my premium of $8.50 a month.  Evidently when CareMark acquired Silverscript, that ended -- not the subsidies, which continued, but where they were sent which changed from the company to me.  I just deposited them.  Now that I understand what’s going on, they go to the company as they did before CareMark.

My deductible at Silverscript is $325 a year, which I will not reach in 2013.  It used to be $76 or so.  My premium would be $31.50 if I paid it myself.  “ExtraHelp” from Medicare lowers the premium to $8.50.  I also get Big Sky RX which would pay the rest except that I’ve just kept the money, sorta wondering what it meant.  So I have racked up a bill with Silverscript of about $400.  They are happy to arrange payments, no interest.  Until I have a payment agreement with Silverscript, I will not be able to change companies.  There are several companies with deductibles about $30, even NO deductibles.

When Silverscript was bought out by Caremark there was a huge jump in the number of their clients plus records had to be migrated from one system to another.  I have experience with this challenge and INEVITABLY the information is corrupted and some of it is lost.  In fact, the problems with bookkeeping were so severe that Silverscript is “just emerging” from being sanctioned by Medicare.  They cannot take new clients.  It appears that because I made no proactive choice of Plan D company, I was assigned to Silverscript which has a deductible higher than the public cost of my drugs in a year.  Metformin would cost me privately about $40 a month and the Benazapril would be much less.   I called Silverscript to see how much THEY paid for my drugs . They are paying $2.71 for Metformin and $.47 for Benazapril PER MONTH.  Less than four dollars in return for a premium of $8.50.  Basically, my only benefit is that I get a negotiated price for meds.

It’s my own fault.  I have not been taking care of my own business in the way that a mature person ought to.  I’m not senile, I’m negligent.  In the end it was not the money that got my attention, though looking back at this pile of paper, I see that it’s all documented and I could have figured it out.  What got me focused was what I blogged about earlier:  they began to call in person, robocall, and mail letters accusing me of not taking my meds.  That was irritating.  They are not my doctor.  Their business is to pay, not to prescribe.  How is it that they can nag me about taking my pills but can’t call or write to see why I’m not paying my premium?

Now the tiny once-a-week Valier clinic, which I use because my little old pickiup doesn’t have many miles left on it and the roads are risky in winter, has lost its latest doctor.  This is not unremarkable except that this time there is no new doctor.  Instead we have a nurse practitioner.  That’s fine.  But she is young and, like many young women around here, still in school mode. (The schools here are orderly but not progressive.)  She looks at my blood test scores, sees that they’re borderline and doubles my meds as well as adding a statin.  I monitor this stuff closely.  No one has tested me for the side effects of Metformin. (I take B6 sublingually to compensate, though the doc was happy to give me shots).  The nurse-practitioner was not aware of the present controversy over statins.  

The doc, whom I liked, took the view that one could overmedicate pretty easily, esp. when old, and that the emphasis should be on diet and exercise.  (I’ve never smoked and don’t drink except for champagne at weddings and expensive Scotch on great occasions.)  She left with her physician husband without notice, which is not unusual.  (Doctors in Montana are a different blog to write some day.) 

I cannot tell you how suspicious and paranoid I am about Big Pharm.  IMHO it’s a racket preying on the unsuspecting with the collusion of Big Insurance and -- ultimately -- Big Government Oversight.  That last word is the tricky one -- a double-meaning: supervision or ignoring. 

My first task was to stay sane.  I envisioned Silverscript/Caremark somehow taking my debt out of my monthly $800 Social Security check, leaving me only a few hundred dollars to live on.  Don’t tell me this wouldn’t happen -- similar draconian decisions have been made in the past.  But a woman poorer than me said, “Oh, all they’ll do is put it on your bill.”  Not so long as they have a regular check to garnish, even though there may be safeguards on things like that with Social Security.  And the national climate is beginning to change in a harsh way:  we are bringing back debtor’s prison.  Once again it’s a crime to be poor.

My second task was to work the phone, which is what I spent the morning doing.  The number on the back of the Medicare booklet that directs one where to call for help was a total bust.  It went to a local office staffed by volunteers who wouldn’t talk to me.  The call to Silverscript was certainly enlightening, though the person who answered clearly didn’t expect the kind of questions I asked.  BigSkyRX was terrific.  At last someone who would draw back the curtain and stop trying to diddle my Social Security.  The next step is to negotiate payments with SilverScript so that I can change to a different company before December 7.  That’s a whole new blog post.  I'm not in danger of running out of material.