More than seven in 10 Medicare beneficiaries didn't check or compare their health plans in 2018 for changes in drug plan pricing, Medicare Advantage plan costs, or provider networks for 2019 -- leaving them vulnerable to surprising price increases and reductions in the array of doctors their plans will cover.
That's according to a new report from the Kaiser Family Foundation (KFF), which also found that certain demographic groups who might benefit the most from comparison shopping were even less likely to check for changes in their plans.
For example, higher percentages of lower income or less well-educated patients, those in poorer health, residents in rural areas, or those in an older age bracket didn't look up their plans or survey their options for better, less expensive alternatives.
"This is a story that affects the majority of people on Medicare," report author Tricia Neuman, executive director of Medicare policy at KFF, told MedPage Today. "Most people simply do not compare their plans each year" during open enrollment, and end up surprised by changes they can't afford.
That trend is expected to continue this year, with 2022 open enrollment starting on October 15 and continuing through December 7.
The ramifications of the report's findings could be significant for physicians when beneficiaries suddenly find themselves unable to afford the drugs their doctors prescribed because the pricing structure (or "Tier" category) has changed. Or, they call their physicians desperately requesting cheaper alternatives that may not be as effective.
"Many patients, particularly those with serious medical problems, feel a close connection to their doctors, but may not realize that Medicare Advantage plans have provider networks that limit access to certain hospitals and doctors, and that provider networks may change from one year to the next," Neuman said.
In a separate poll released Tuesday, KFF revealed that one in five Medicare beneficiaries say they experience difficulty paying for their medications, including those with coverage plans. Also, for those seniors who are on four drugs or more, a quarter reported having difficulty affording them.
Deaths as a Result?
San Diego neurologist James S. Grisolia, MD, acknowledged the pressure doctors receive when angry, frightened patients ask that their prescriptions be changed to less expensive alternatives that don't exist. Some patients will alternatively skimp on doses or not refill prescriptions that cost a lot more.
"This happens now daily," he said, adding that "2022 will see patient deaths" because of it; for many conditions generics just don't work as well.
Particularly worrisome are brand-name seizure medications necessary for survival, for which some drug plans require co-payments in the hundreds of dollars each month, almost as if the patient didn't have any coverage at all, Grisolia said.
The neurologist blames the pharmaceutical industries' "institutionalized greed," and said that patient-focused disease-specific organizations are working on solutions such as more pharmaceutical support -- "but the cost of medication is frankly at a crisis level."
American Medical Association President Gerald E. Harmon, MD, said this about the KFF report: "Physicians want real-time prescription benefit information to help inform discussions with patients about drug selection to avoid coverage and cost barriers that could impact medication adherence."
That's being developed, he said, but as yet does not mesh or integrate with all electronic health record systems. Nor does it provide information for all patients to give doctors the tools they need to "guide useful discussions with patients about drug coverage and cost."
Mind-Boggling Choices
The report noted that a likely reason for beneficiaries not comparison-shopping is the array of choices. The average Medicare beneficiary has "33 Medicare Advantage plans and 30 Part D stand-alone prescription drug plans" to choose from -- a factor Neuman said is causing beneficiaries to be "overwhelmed."
They "don't realize there's a fair amount of variation" from plan to plan, she said. The plans are also terribly complicated with many moving parts. That's why, Neuman said, "it pays to shop."
The KFF report was based on an analysis of the Medicare Current Beneficiary Survey, which was conducted in 2019. Neuman said it sampled at least 10,000 of the 50.7 million beneficiaries who had the opportunity to change Part D, Medicare Advantage, or straight Medicare plans in 2018.
Doubling and Quadrupling Costs
Some Medicare beneficiaries who have looked up their Part D drug plan benefits, which were recently released through mailed notices or on the Medicare Plan Finder, are finding drastic price changes.
For example, a common Aetna SilverScript plan in California is nearly doubling its annual deductible from $250 to $480. It also is changing the pricing structure from a flat fee to a percentage for commonly prescribed Tier 3 drugs, which includes several brands of generic statins such as rosuvastatin and ezetimibe.
Instead of $104 for a 90-day supply of each of those two drugs, the plan will charge 17% of $925, or $157 for one, and 17% of $800-plus, or $136, for the other, according to this reporter's conversation with a plan supervisor about her own plan.
Those prices could increase in 2022, the supervisor said.
Additionally, a brand of an inhaler that now costs $105 for a 90-day supply will cost 17% of nearly $1,900, or $324.
Several counselors with that plan told this reporter they are bracing for calls from angry enrollees and are in training sessions on how to manage them.
A beneficiary in New York with Aetna SilverScript Choice also will see Tier 3 drugs go from $105 for a 90-day supply to 17% of the full price set by the plan. The less commonly prescribed but more expensive drugs in Tiers 4 and 5 will drop from 40% to 34% and from 27% to 25%, respectively.
Savvy Consumers Only
"The whole system is premised on active, savvy consumers reviewing and changing their coverage in order to get what is best for them, but obviously that doesn't happen," said David Lipschutz, senior policy attorney for the Center for Medicare Advocacy.
"The advertising we have seen in the last few years from the Medicare program promotes 'plans' without the nuanced distinction between Part D and Medicare Advantage plans, leaving many to think they should enroll in MA plans even if they are in traditional Medicare and doing just fine there," he said. "Insurance industry advertising is out of control."
A San Diego Medicare beneficiary and former business editor was asked to look up his changes in his Anthem Blue Cross MediBlue Rx Plus plan, and found that the monthly premium is increasing nearly four-fold, from $26.10 to $92, an increase he called "outrageous."
Tatiana Fassieux, education specialist at California Health Advocates, said calls from Part D beneficiaries indicate increasing premiums in most plans, with some doubling or more than doubling. And most plans are going to the $480 maximum for the deductible, she said.
Neuman and Lipschutz both suggested that one way to improve the situation is increased funding for State Health Insurance Assistance Programs, or SHIP, now supported by federal grants. Lipschutz said the Medicare program should engage in more outreach and education, and work harder to "scrub bias" that has consistently appeared in the thick, annual "Medicare & You" handbooks, whose paragraphs appear to steer patients toward Medicare Advantage plans over straight Medicare alone, or straight Medicare with a supplemental and a Part D plan.
Both mentioned that the array of choices can be mind-boggling to a senior citizen. "Sometimes there is such a thing as too much choice," Lipschutz said.
Lipschutz also mentioned the need for Medicare to eliminate underwriting requirements for beneficiaries who want to leave Medicare Advantage for traditional Medicare with a supplemental plan to pick up the beneficiary's 20% share of Part B costs. Those with certain conditions that supplemental plans consider "pre-existing," such as diabetes or hypertension, are frequently denied coverage. That change would enable beneficiaries to "actually have a 'choice,'" he said.
The KFF report broke down the data by plan type: 29% of 50.7 million Medicare beneficiaries overall compared plans while 71% did not; of 21.4 million Medicare Advantage enrollees, 32% compared plans while 68% did not and for those in straight Medicare, 27% compared plans while 73% did not.
Many said they never visited an official Medicare website or did not have access to the internet or had no one who could access it for them. Medicare's toll-free number and Medicare Handbook were also not widely used.
The KFF analysis also found a failure to compare plans among those in Medicare Advantage drug plans, i.e., 81% of 16.4 million enrollees, and for stand-alone Part D drug plans, 72% of 20.7 million enrollees did not compare plans.
https://www.medpagetoday.com/special-reports/exclusives/94997
