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Sick seniors facing Medicare coverage barrier

Dominika Osmolska Psy.D.'s picture
Sick senior citizen

The good news: chemotherapy might soon be more widely available in a pill. The bad: you may not be able to afford it. A story out of the Associated Press today highlights the struggle seniors on Medicare face when put on expensive cancer-fighting prescriptions.

The news expands on our previous report about cancer treatments becoming unaffordable even for the medically insured. The new, cutting-edge medications may offer a bypass to the traditional IV-infused chemotherapy treatment protocols – and their excruciating side effects. The problem is that many of these sometimes experimental medications can leave patients bankrupt, as total co-payments can exceed $500 a month.

The study last month in the Journal of Oncology Practice found that nearly 16 percent of Medicare beneficiaries did not fill an initial prescription for pills to treat cancer, a significantly higher proportion than the 9 percent of people with private insurance who did not follow through.

In the case of Medicare, a senior can suddenly be faced with a $2,400 monthly bill. Medicare prescription plans are allowed to charge steep copayments for the latest cancer drugs, which can cost tens of thousands of dollars a year. About 1 in 6 beneficiaries are not filling their prescriptions, according to recent research that suggests a worrisome trend. Medicare officials say they are ‘not sure’ what happens to those patients who are seemingly abandoning their medications. They speculate that they might either fall back on more traditional cancer treatments, or they may simply give up.

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Private insurance companies that deliver the Medicare prescription benefit say the problem is that drug makers charge too much for the medications, some of which were developed from taxpayer-funded research. The pharmaceutical industry faults insurers, saying copayments on drugs are higher than cost-sharing for other medical services, such as hospital care. Other experts blame the design of the Medicare prescription benefit itself, because it allows insurers to put expensive drugs on a so-called "specialty tier" with copayments equivalent to 25 percent or more of the cost of the medication.

It is sobering to find that forty-six percent of Medicare beneficiaries faced copayments of more than $500 when that number has been shown to be a critical one for the abandonment of treatment. Are close to fifty percent of seniors with a major health condition on the brink of walking away from their treatment?

Ironically, it is not the most desperately poor that are hit the hardest. The prescription plan is designed so beneficiaries who are poor or near poverty face only token co-pays. For the rest, President Barack Obama's health care law gradually closes the coverage gap known as the "doughnut hole." This year, the new law provides a 50 percent discount on brand name drugs for those in the gap. The gap starts after Medicare recipients and their insurance plan have spent $2,840 on medications. After that, seniors are responsible for roughly the next $3,600. Once total spending reaches about $6,440, Medicare's catastrophic coverage kicks in and beneficiaries pay only a small amount.

You read that right: $6,440. If your prescriptions exceed $2,840, you will need to shell out $3,600 out of your own pocket before the catastrophic coverage goes into effect. If you are retired, chances are slim that you can afford it.

Yet even that health care law could be struck down by the courts or repealed if Republicans win the White House and Congress next year. Even if the law stands, assistance after seniors end up in the gap doesn't take away the initial shock at the pharmacy counter.

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