The following is a transcript of
"WomenMatter - Facts and Trade-Offs - Medicare Prescription Medicine Who Should Care?"
From December 10th, 2005



ANNOUNCER: WomenMatter Facts and Tradeoffs is the nonpartisan place where we can take one issue at a time and match what we do about it in our everyday lives to the facts of the bigger system we all live in and recognize that every idea for making it better has trade-offs.

Health care is every American’s chief concern. In an earlier show we took a close look at the shaky ground for Americans since health care insurance is often attached to jobs, and most employers – large and small – are shifting to give a lump sum of money to employees to buy their own insurance, or hiring someone whose spouse or partner has insurance coverage.

This show is about prescription medicines for the elderly and the disabled, and the dramatic changes the current administration has made to shift the system away from a government guarantee to their philosophy of more individual responsibility and more competition between private corporations.

Dr. Nancy Bauer, CEO and Editor-in-Chief of WomenMatter, takes this change apart with Susan Sargent, health care consultant with 30 years of expertise in advising both providers and consumers.

NANCY BAUER: WomenMatter is dedicated to making sure that there are no surprises when government sets standards that affect our lives and uses our taxpayer dollars to make changes. This radio show, Facts and Trade-offs, puts the spotlight on the system we have, and then takes apart the facts of possible government action and notes the trade-offs. That is, what’s gained and what is lost for all of us.

Our earlier radio show took apart the health care system we have, much of it based on jobs and much of it changing every day – because big employers can’t afford to pay for their retirees and entrepreneurs can’t afford to hire people who need health insurance. We looked ahead and asked women to decide what they want and tell their representatives.

This show is different. The big change has already happened. And most of us didn’t notice and weren’t told at the time two years ago, when it happened, what the details were. Now we’re in the midst of a giant experiment and a huge shift in philosophy, and we are told just to inform ourselves and choose.

WomenMatter: Facts and Trade-offs says that we also need to know the political picture of what we had, why we had it, and when and why the changes were made. With these facts solidly in mind, then we have a better chance of knowing how to judge this new system. And we’d better speak out to each other and to our representatives about whether it matches what we want for our citizens over 65. In a very few years, it’s going to be lots of us.

The title of this show is, “The Medicare Prescription Plan: Who Should Care?” As we will see through interviews with three experts on the issue, as citizens, as taxpayers, and current or future beneficiaries, the answer is all of us.

So Susan Sargent, health care expert, WomenMatter has said there are four ways to measure health care: quality; access, that is who gets it, when and where; choice; and cost. So in case we can’t remember what we already had, what is Medicare? Who is it for? And why did we get it 40 years ago in 1965, when Lyndon Johnson was president?

SUSAN SARGENT: Well it’s really interesting, Nancy. Medicare and Medicaid were passed at the same time. Medicare focused on the elderly and Medicaid focused on the poor – two very large voting blocs. And as we’ve discussed, that frequently drives a lot of the policy. And for the Medicare, for the seniors in the population, the focus was on providing a safety net. Hospitals were just starting to come into their own with new technology and it was getting more expensive, and seniors were complaining that something had to be done to provide them with a safety net – something to make sure that they didn’t spend their whole life savings on a hospital and their doctors.

And the thought was in the Johnson administration that if you pooled all of the seniors together that then you could share the risk. So in any given year, if one group of patients or seniors had to use the services, the others might not, and so the risk would be shared across this pool of seniors in the U.S.

BAUER: So what was the matter with it?

SARGENT: Well everybody’s jumped in the pool. That’s the problem. And the pool has gotten bigger. There were 41 million seniors in ’65, and now there are 77 million seniors, or will be soon, with all the baby boomers coming through. And they’ve also expanded the legislation to cover the disabled, and those are the chronically disabled. And people think of chronically disabled as physically handicapped, but it also covers individuals with long-term mental issues. So the chronically mentally disabled are also covered by Medicare- and medicine is very important.

The medicine has advanced fantastically since 1965. But you also have more imaging tests, radiology tests, X-rays, and MRIs done on a routine basis.

BAUER: Well that helps us to be diagnosed (earlier) so that when you go to the doctor they don’t have to spend so much time and pain being sick. When I was a kid you spent three weeks getting over something. And now if you have something the matter with you or you’re not feeling well, they can check to see, and they can even check to see what’s the matter with you before you feel bad.

SARGENT: Right, well and now what the medicine can do in many cases is keep people out of the hospitals. And so it’s more of an active, if you will, prevention system, which doesn’t make sense, but if people can pay for their medicine and get their medicine, then the chances are that the really expensive hospital costs and X-rays and MRIs can be avoided to some degree until they’re absolutely necessary.

BAUER: So the idea of taking medicine to stay healthy, or at least keep the body in balance, that makes sense. So we could put more money into Medicare, and just add medicines. I mean couldn’t we just do that if what we want is quality and access? That’s what the Democrats backed 40 years ago.

When government makes changes it does it with the majority vote and presidential agreement. All based on a philosophy of what’s most important to the people in power.

And with their winning in 2000 and 2002, the Republicans own enough votes in both houses of Congress, and the presidency, to pass any legislation they want. And they want less government and they want more private businesses competing for services. And they want individuals to make their own decisions about staying healthy.

So this new law was passed in 2003, just in time for the Republicans to run for reelection in 2004 and not leaving to the Democrats the idea that the Democrats were the health and education party. The Republicans wanted to make sure that they had major legislation in both of those fields. So they are the party that brings prescription medicine to the elderly, and Susan as you said, of course that means votes.

So what is the new system for prescription medicines? What makes it a Republican program?

SARGENT: Well I think it’s, just very quickly, important to say that the Democrats, when they passed this in ’65, said “government will do it for you, this is your tax dollars at work.” The Republicans are saying the same thing, but they’re taking the tax dollars and giving it to the private sector, as you said Nancy, to promote competition and to encourage individuals to make their own decisions.

So what’s happening right now is that private companies are getting money to offer prescription drug plans to Medicare recipients, whether they’re disabled or elderly, but there are some choice and cost issues that each eligible person needs to take into account. So what prescriptions are they on? Is it covered under the different types of private plans?

The private plans have what they call a formulary, which is a list of what drugs they’ll pay for. For the chronically and mentally disabled, and for many, many seniors who rely on anxiety medicine, that’s not covered. Well, you need to know that going in. And you need to know what pharmacies are going to be participating and which ones aren’t. And if you’re currently receiving free medicines under a pilot academic program or a program that your doctor is participating in, that may not be covered. And all of a sudden you’re going to have to be paying for medicine that you’re now getting for free.

The bottom line is that each person who might be affected by this, whether it’s an elderly person or chronically disabled person, or somebody who loves and cares for these people and is helping them make the decision, has three major responsibilities. The first one is they have to be responsible for their own health. They have to know what drugs they’re on, what medicines they’re taking—

BAUER: [laughter].

SARGENT: —what their health care plan currently pays for. If they’re paid by an employer prescription medicine program, what’s covered and what isn’t? And then finally, since nothing is perfect, and you have to assume that some of the Medicare prescription medicine program will have to change, boy do you have to be talking to your elected officials and making sure that they know that you vote.

BAUER: So WomenMatter interviewed three people who understand this new system. The first is a woman from the American Association of Retired People, the organization that first supported the new plan and is now lobbying and asking its members to change it. So note that we have been talking about a prescription plan outside Medicare, an add-on. And that’s different, by the way, from a program called Medicare Advantage, which is not Medicare but rather a private HMO that includes prescriptions for which you have to leave Medicare and get a combination of people helping you manage your health, the regular HMO, and prescription medicines.

This is a little complicated Susan, because everybody uses the term “Medicare.” So there’s what the government now calls original Medicare plan, what we already have, and Medicare Advantage, they’ve put the name Medicare into everything, so Medicare Advantage is the HMO. And then there is prescription plan, Medicare plan D, which is just medicines in addition to Medicare.

SARGENT: What’s really interesting Nancy, is that with Medicare passing in 1965, there was another piece of legislation passed in 1973 that promoted health maintenance organizations, or HMOs. And originally their focus was on young, healthy people, because that’s who they could afford to take into HMOs. But since 1965, people are living a lot longer. The medicines are better, and they’re staying alive and thriving much longer. So now Medicare is saying, “Well gee, maybe we could take that HMO philosophy and apply it to people who are 65 and older, because they’re living another 20 years, and they can benefit from some of the prevention programs that HMOs historically had.”

BAUER: So in addition to the woman from AARP, Cheryl Matheis, we’re going to hear how they see it, since they represent so many and they also sell insurance, of course. And then we’re going to hear from two people most of us will turn to for advice instead of all the advertising on TV and in the mail that are coming from private insurance companies and companies that make medicines.

We’re going to hear from a neighborhood pharmacist, not one of the big conglomerate pharmacies that can negotiate better prices. A neighborhood pharmacist is the one who knows not only what medicines we take, but what they cost.

And then we have an interview with a doctor who has specialized in elder care, or geriatrics, for 30 years. And he raises the question about who knows what an individual needs, and what choice she should make. So what do we listen for when we listen to these practitioners, Susan?

SARGENT: Well I think that the three interviews are superlative. They are just really right on target in terms of not endorsing the Medicare prescription legislation, but not discouraging people from signing up for it. They keep coming back to, from all different perspectives, what each individual has to make a decision about – how they have to get smart for themselves. No one can make this decision, or if you’re making it for a loved one or on behalf of a loved one, what are the key things you need to know? And it’s right down, exactly to what you need to know.

BAUER: Yes, let’s now see what they have to say.

* * *

BAUER: It’s my pleasure to introduce our WomenMatter audience to Cheryl Matheis, who has the amazing title of Director of Health Strategies Integration in the Office of Social Compact for everybody’s best known geriatric organization, the American Association of Retired People, which is both our favorite lobbyist organization for the elderly, and an insurance company that provides health insurance and other kinds of insurance, as well as trips around the world, to people who are as old as I am. So Cheryl Matheis, I welcome you to WomenMatter.

CHERYL MATHEIS: Thank you Nancy.

BAUER: And our show, Facts and Trade-offs. So you’re a lawyer.

MATHEIS: I am.

BAUER: And you’ve been at this, in this whole field of how retired people are affected by government and by health care, for all the phases that we’ve been through. So you were a lobbyist, and then you worked at the state level, and now at the national level.

MATHEIS: Well that’s right and, yeah, I’ve seen it all and I think we’re seeing it come around again.

BAUER: And tell me, as you look back over the years, are we getting smarter?

MATHEIS: Oh I sure hope so, I really hope so. I mean I think it’s very frustrating for those of us who work in the public policy arena, because a lot of times what we see is the same question we grappled with five years ago, 10 years ago, and sometimes 20 years ago. And I’m sure there are people who were dealing with it even before then. So it’s tough to have to come to terms with the same question over and over again. I think what we hope is that perhaps we’ve made some progress in the interim.

BAUER: Well so we’ve had this philosophical debate in the country – how much individual responsibility is a person supposed to take for his or her own health –

MATHEIS: Mmm-hmm.

BAUER: And how much do we have as an entitlement? Medicare was passed in 1965 for everybody, all of the older citizens, whether you could afford to pay for it or not. So that people who could afford to pay for health care were actually getting their health care out of taxpayer dollars. And now this is up for major discussion in this new program, where there is much more individual responsibility and there is much more attention to differences in costs and who’s going to get covered, and for what.

What are the political factors that you see that cause political parties to pay attention to this? After all, everybody wants to be healthy when they get older, and everybody gets sicker as they get older. Everybody needs more health care as we age.

MATHEIS: Absolutely. But clearly, where somebody stands in the political spectrum and how they feel about public funds being used for individual benefit has a big influence on how they want to see this health care delivered.

Medicare, as you said, has been around for 40 years, and it was probably just as controversial when it was first enacted as the Medicare prescription drug benefit is today, and probably even more so, because at least we have a basis for it.

BAUER: Right, so this idea then of having to decide, and that it’s public money. And there are people who say it’s the government’s money or it’s my money, but actually it’s our money—

MATHEIS: That’s right.

BAUER: Because the government’s money is my taxpayer dollars, and when I put it in the pool with other people it’s because I want to, I don’t want to go out and fix the pothole in front of my house by myself. So the idea is that if we pool our resources through our tax dollars, we’re supposed to get more than what we could get as an individual.

MATHEIS: That’s right, and I think people very much like Medicare personally, regardless of their political leaning. But people feel very strongly about how these services should be delivered and how individuals should contribute to them. And because of these strong feelings, and because there was a desire to add a very important prescription drug component to the medical care offered in Medicare, that drug component comes in looking a little different, because it’s more configured the way the majority party right now thinks these benefits should be delivered.

Meaning, it’s more voluntary, it requires individual choice, it’s dependent on market forces to bring prices down. And it’s sort of a grand experiment in taking a social program, a social insurance program like Medicare, and seeing if you can apply these market force theories to it, and if it can thrive under that.

BAUER: And of course we’re going to find out if it doesn’t thrive, [laughter].

MATHEIS: We will find out.

BAUER: We’ll find out. AARP has been in a particularly interesting position on this one, as we all know. That you all supported the bill when it was passed, and I admit that I’m a member of AARP and in your age category, and I got the mailing that said would I please tell my congressman to change the bill.

MATHEIS: Right, well—

BAUER: Please petition and get it changed. So can you describe—

MATHEIS: Sure.

BAUER: – how you all see all of this? –

MATHEIS: Well I think we see it as an evolutionary process. We made a very pragmatic decision to support the bill, and this was two years ago now when it was enacted. And the decision was that we worked with both parties and we were working not for a particular party but for a goal. And our goal was to make sure that prescription drug coverage, which is the basis of most medical care today, would be included in Medicare. And so that was the ultimate goal we had. And we said we would be willing to consider different ways of getting to that goal.

And so we worked with both parties. We basically ultimately supported a bill which probably is a little bit different than the one we would have chosen had we been drafting it ourselves, but we supported it for the basic reason that, that was the way it was going to get enacted or it wasn’t going to get enacted at all.

BAUER: And so when it was passed, as I understand it, nine Republicans voted against it and 14 Democrats voted for it, and people stayed up all night to get it passed.

MATHEIS: That’s right.

BAUER: So that certainly Congress knew that they were looking at a Catch-22. That is, a real example of the title of this show called “Facts and Trade-offs.”

MATHEIS: Sure.

BAUER: That here are the facts, and there were trade-offs. And they realized, as you pointed out, that on this question of quality which everybody’s concerned about, that they put less emphasis on quality and more emphasis on choice and cost.

MATHEIS: Well I think clearly the emphasis became on choice and cost. And also on the method of delivery – delivering Medicare through private companies. So it became more a public-private partnership, which is something that fiscal conservatives are very interested in. They’re interested in seeing if market forces can bring prices down, whereas the other view would be that bulk purchasing and regulation can bring prices down. So the key is, everybody wants the price to go down, but there are completely different views of how you’re going to accomplish that.

BAUER: And interesting that the way in which they (are asking), or (helping) the market to get into this game – maybe game is not a nice word – but into this service, is to subsidize it. So our taxpayer’s dollars have gone to private corporations, have they not? As well as to insurance companies, to get them to offer choices.

MATHEIS: That’s right.

BAUER: So that our taxpayer dollars are actually subsidizing the market to make money off of what they do so that they will compete with each other. Is that a fair way of describing it?

MATHEIS: That is. There are significant subsidies in the program, at least up front, to try to entice private entities to come in and offer a program within this. Whether those subsidies will need to be continued, of course, is something for the next Congress and the Congress after that to think about. But it is very true that this is not pure market forces, because Congress decided that market forces were so unusual in this type of situation that they felt the need to put in some type of subsidy to encourage the market.

BAUER: Do we have any idea how much money our taxpayer dollars are going to this? I mean what’s the total on subsidies, do you know?

MATHEIS: Well the total cost of the program is projected to be close to $800 billion.

BAUER: I heard the budget director, the Office of Management and Budget talking, and they said originally it was going to be $400 billion over 10 years?

MATHEIS: Yes.

BAUER: But now it’s really $800 billion over—

MATHEIS: Yeah, $700-some is the latest projection.

BAUER: Projection, and so the question is, which 10 years?

MATHEIS: That’s right, and as you can see, if the estimate can change so quickly, it just shows that we are not very firm about how we are able to determine really what something is going to cost. Hindsight is always better, and we’re trying to do it ahead of time.

BAUER: So AARP finds itself both advancing the cause like Joan of Arc, and [laughter] being castigated for not making it perfect the first time around. But there are people and WomenMatter is particularly interested in how an idea or, or a philosophy, becomes a bill. This is in addition to how a bill itself becomes a law. And clearly as the majority party has a philosophy that it is actually using, it’s a very interesting experiment in whether or not you can literally make this difference between the majority philosophy on medicines under Medicare as only a first step – and the Medicare law as it has been.

And what will happen? Will this destroy Medicare, as the market competes with Medicare for—

MATHEIS: Oh, I don’t think its going to destroy Medicare at all. this is just one part, and it’s prescription drugs.

BAUER: Mmm-hmm.

MATHEIS: And it will either be successful or, and this is my opinion, Congress will change it. I don’t think Congress is going to let it fail. So we have a situation in which, there was an objective. The objective was to get prescription drug coverage into the law so that people would have it.

BAUER: And no Congressperson would want to be against that I suppose, so that even if they didn’t like the method they were probably asking themselves, “how do you vote?”

MATHEIS: Well some obviously, as you saw, did vote against it. But it’s a very tough thing to be against because it’s what everyone else has in their health insurance. So you have this there and you have it in a certain way, and the law requires it that way, but frankly, what the American public is very good at doing once they settle on an objective, is if the means they’ve chosen doesn’t work they simply go and find another means, they don’t scuttle the objective.

BAUER: And of course that is indeed the hope. And there are those who feel that this is on its way to some kind of a combined national plan. That as General Motors and the other companies that can’t afford to compete with China and India with their retirees drop people out of their coverage, we’re going to get something national with the private insurance companies and the private pharmaceutical companies built in.

MATHEIS: Well, that is really the question, that you’ve posed. What will be the impact in private companies dropping their retiree coverage? And are we all moving toward one program for the whole country, or not?

BAUER: And of course, if we’re all in the pool together, the sick and the well, the young and the old, that does share the risk.

MATHEIS: Well it does, and it should enable us to get the best deal if we do it the right way.

BAUER: Aha, so that quality, access, choice and cost are still the four things that we need to look at, and this relationship of individual responsibility that doctors and everybody’s talking about: how to get us individual older people to pay attention to our weight, our smoking, our exercise, and if we know what the pills are that we take anyhow. What’s AARP going to do about education?

MATHEIS: Well we’re actually spending a lot of effort on education, because we figure that that is really the key to this success, of this or any other health program. So we have offices in every state and we have lots and lots of volunteers who are trained to go out and help educate people, both about the Medicare prescription drug benefit, but also about healthy behaviors, things that people should do to help themselves stay, basically out of the hospital, out of the sick-bed. And we’re doing a lot of that. And I think that what we’re hoping to find is that we can measure success from our efforts, so that we can help other groups replicate them around the country.

BAUER: I think that that may be individual responsibility through real education, and that’s where WomenMatter fits as the nonpartisan information and education service. We need to educate ourselves. You can’t browbeat people into this; they’ve got to figure it out for themselves. But this cumbersome program you’ve described, and this transition plan, we’ll monitor it carefully and see whether or not the individual voter gets smarter, because the voter and the patient and the citizen are all one in the same person.

MATHEIS: They’re all the same, yes.

BAUER: Well Cheryl Matheis, thanks a lot for a very interesting time. And we will, together, watch what happens in this country, and get women to mobilize themselves and to continue to educate themselves on the details of how this whole thing works, so that they can tell their Congress people what they want done. Because there are 34 million women out there that didn’t bother to register to vote, and if they being to pay attention to the details every week, we can all make a difference for both parties.

MATHEIS: I think so Nancy.

BAUER: And thanks very much for this.

* * *

BAUER: I want to introduce our WomenMatter audience for Facts and Trade-offs to Fred Weissberger, pharmacist, who’s been part of a family-owned pharmacy that’s had 75 years in the same neighborhood, moving only within two blocks, serving the same people. And if I may call you Fred?

FRED WEISSBERGER: Yes, that’s good.

BAUER: Since everybody in the neighborhood does. Tell me Fred, the new prescription medicine plans that we’re hearing all about, what we’re hearing is that it’s voluntary and it’s based on people choosing. That is, this is what the administration wanted. How much do your clients, your patients that come to you, how much do they know? They have to make a choice.

WEISSBERGER: Do you mean what do they know about the program?

BAUER: What do they know about the medicines they’re taking?

WEISSBERGER: Well they’re aware of what they’re taking, and what they’re asking now, because many of them are on some type of a prescription plan, they’re asking what the costs are. So they want to know whether they should go with the new program or stay with what they have.

BAUER: Do they understand what the different medicines do?

WEISSBERGER: They should, yeah.

BAUER: I mean, do they ask you?

WEISSBERGER: Yes, we’re part of that when we counsel the people.

BAUER: And how often—

WEISSBERGER: They have to request it. In other words, some don’t care, some do.

BAUER: And do most people want to know?

WEISSBERGER: Yes. If it’s something new for them and it’s something out of the ordinary- they know if they’ve gone for a cold it’s an antibiotic- but if it’s something more functional than that, then they’ll ask.

BAUER: I see, so that it’s sort of a three-cornered thing. There’s the patient, there’s the medicine they’re taking, which they got from the doctor’s prescription.

WEISSBERGER: Correct.

BAUER: And then there’s the plan that they are under, the insurance plan.

WEISSBERGER: That is correct.

BAUER: And do they understand their plan?

WEISSBERGER: Most of them don’t because it changes from day to day, and that’s one of our biggest problems, because sometimes they can get a 90-day supply, sometimes a 30-day supply, sometimes a 14-day supply depending on what the medication is. And many of them ask, “Three months ago I got a 90-day supply, why is it switched to 30 days?” Well I’m sure they’ve gotten some paperwork on it, because the insurance companies are supposedly not allowed to change these programs without notifying the people, but it might be buried in five pages of paperwork.

BAUER: And there’s a lot of talk about the fact that the government wants people to get their medicines in the mail rather than coming to you. Is that true?

WEISSBERGER: At times it is.

BAUER: Why is that?

WEISSBERGER: Well it’s the insurance plans that are doing it along with what they call the PBMs, which are the companies who do the paperwork for the insurance companies. And they say it’s less expensive but in actuality there’s more waste to it.

BAUER: So there’s an insurance company, which is an HMO, there’s the pharmacy benefit manager, which is a separate company that manages the paperwork for the insurance company.

WEISSBERGER: That is correct.

BAUER: And then there’s the pharmaceutical company that makes the medicines, all trying to get their word out. Do you find that the doctors have already told the patients who come to you what the medicine is for and how it works?

WEISSBERGER: In many cases they have, in other cases they haven’t. And some people just want to get out of the doctor’s office so they’re not even listening.

BAUER: How many people a day do you give advice to? Or information to?

WEISSBERGER: Maybe it’s only 10 percent of the prescriptions we fill, on a regular basis. In other words, if 100 people come in, maybe only 10 ask for advice. Or even on a new medication, some are interested and some aren’t. Some just want to get out of here too.

BAUER: So they trust the doctor, they trust you.

WEISSBERGER: That’s correct.

BAUER: But now they’re going to have to trust themselves.

WEISSBERGER: If it’s mail order, the patients have to call in to find out. The mail order companies have people on staff that will go through some of the stuff, but it’s not face-to-face.

BAUER: So as far as you’re concerned then, is this new plan going to benefit people?

WEISSBERGER: Well the real benefit is to those using over $5,000 worth of drugs a year.

BAUER: Aha. Is that a lot?

WEISSBERGER: No, it’s not. Even though people think they have, that would be over $400 a month, and it’s a small number of people.

BAUER: Do people know what their medicines cost?

WEISSBERGER: Some do, some don’t care. Until instead of paying a $5 co-pay, they have to start laying out 50 or 100 dollars.

BAUER: And then do they object?

WEISSBERGER: Some do, some don’t.

BAUER: But the idea is that they don’t have a say-so in that. When do they find out that the co-pay is going up?

WEISSBERGER: When I fill the prescription, in other words, I can’t tell by just looking at somebody’s card what the co-pay is. And some plans vary if it’s a brand or generic; some vary according to the time of the year because they have to meet a deductible.

BAUER: Aha, so where do you have all that information?

WEISSBERGER: Well when we fill a prescription it comes in through the computer to tell what we have to charge Mabel Jones, or whoever it is.

BAUER: So that every person who comes to your pharmacy, you have them on the computer.

WEISSBERGER: Or they’re brand new, and we get the information when they present their card, yes.

BAUER: And the card is from their insurance company?

WEISSBERGER: That is correct.

BAUER: And so you put the card in the machine and it tells you--

WEISSBERGER: Put the information in, right.

BAUER: So that, therefore they haven’t really had to know before.

WEISSBERGER: Well some do if, I mean, it’s available in the literature they get from their benefits people, but some don’t want to go through to read it, they just know they have coverage. And to what extent- I mean I’ve had people who’ve had a thousand dollars worth of coverage and it cost them $840 a year to get $1000 worth of coverage, which means they have next to nothing.

BAUER: And they didn’t know that.

WEISSBERGER: Well, they thought they did. No, they knew it, but they’re telling me how great it is. Well to me, for $160 I don’t want to have to lay out 100. In other words, they have to pay $840 to get a $160 worth of benefits. You know, it’s just not--

BAUER: So what advice do you have for the women who listen to WomenMatter, what advice do you give them?

WEISSBERGER: You mean for the new program?

BAUER: Yeah.

WEISSBERGER: Well if they’re on a monthly basis spending over $75 a month, then the new program is to their advantage. If they’re spending under that then it’s up to them whether they want to take the risk that they might need it. But they can always get it later on, just pay a penalty.

BAUER: And the penalty of course, gets greater every month--

WEISSBERGER: Yes, but then again too they save each month that they don’t go on it .

BAUER: Aha. So the idea is that they’re going to need to be more aware along the way. Do you think this is going to be more work for you or less?

WEISSBERGER: Oh it’s a lot more work. Any time, I mean any time you have to enter all the information and they weren’t on anything before. The thing of it is the number of people that the government is saying that really need it is nowhere near what is really needed. In other words, it’s only maybe 30 percent of the actual retirees over 65 because in our particular areas, most of the people have some type of program already, and only 30 percent have nothing at all. Anywhere from Medicaid, meaning where they’re in the lower socio-economic income, all the way up to somebody– my father being a prime example – who never took a prescription in his life and he died at 97.

BAUER: That’s way of getting even with your son as a pharmacist, right?

WEISSBERGER: Yeah that’s right. But many people have – my neighbor in particular – has a program from where he had worked, where he retired. He knows not to go with this new program because he’s paying two dollars for each prescription. Then you have somebody in Pennsylvania which is on the PACE program, which is a better program than this because it covers them from day one. Then you have people who are on Medicaid. And like I said the people who have programs from where they had worked. There are also the people who don’t have coverage, but they don’t take anything, and there are senior citizens who take nothing at all, it’s a small percentage And then you have people who can afford it if they had to lay out $5,000 a year. You know, going from the low end to the high end of what you have financially.

BAUER: And so Medicare was an entitlement for everybody whether you could afford, to pay for it or not. Now we’re breaking it up into who needs what and what you’re saying is that—

WEISSBERGER: If I don’t take any medication why should I pay them $31 a month?

BAUER: Until the day that you need it.

WEISSBERGER: Right, right, that’s right.

BAUER: So that it is, we’ll see what happens to this amazingly great number of choices that people have to make.

WEISSBERGER: Well the other thing is too, what I’ve seen over the last two years or so is that the drug companies have raised the prices beyond what they normally would have raised the prices, not knowing what’s coming. And they’ve gotten away with it. And it was raised a little bit beyond what the cost of living was, which they always try to adhere to. And they did it not knowing what this law was going to bring. Well the law didn’t stifle drug raises; the government didn’t put the brakes on the raises from the drug company, so people are going to be paying more for drugs coming down the future.

BAUER: When the prices are higher does the pharmacist make more money?

WEISSBERGER: No, we get the same. [laughter]. You know I can fill a $10, or I should say I can fill a $50 prescription or a $1,000 prescription – the amount of difference is peanuts.

BAUER: Really? Because who pays you? Do you get paid by the insurance company?

WEISSBERGER: Well we either get paid by the individual, but it’s all at the discounted price set up by the insurance company. Some people have to pay us, they get reimbursed, or some people only pay us $5 and I, say, get the other 95 from the insurance company. Or the PBM.

BAUER: And so that, therefore do you have to negotiate with every one of those—

WEISSBERGER: I can’t negotiate with anybody. We’re almost the- we’re not strong enough. If I have $100 million dollars to fight then they have $110 million to fight me. And if I got together with other pharmacies, they’d call it collusion and we would be in court. You have no say in the matter.

BAUER: So everybody needs to understand the importance of what you do in this three-cornered movement as well.

WEISSBERGER: Yeah, are we going further because. . .

BAUER: No this is fine. Thank you very much Fred Weissberger.

WEISSBERGER: Oh you’re welcome. OK thanks a lot.

* * *

BAUER: I want to introduce our radio audience to Dr. Gerald Phalen, who practices family medicine and geriatric medicine in Philadelphia, Pennsylvania. And he’s been at this for 30 years. And Dr. Phelan, everybody says that this has come about, this idea of a Medicare prescription medicine plan, in a philosophical debate over how much individual responsibility the individual patient should take, and how much should we all do together because we live in a society where older citizens ought to be taken care of.

But it seems to WomenMatter that the most important thing is what does the individual patient really know, and where are they going to turn for advice? And it strikes us that they’re going to come to you.

GERALD PHELAN: Well I think you’re right, and I think, hopefully most of my colleagues will familiarize themselves with the Medicare D prescription plan. But equally important, they also have to be familiar with their patient’s prescription plan in order to help the patient make a comparative process.

Most of my experience in the last week or two has been that most of my patients have a plan better than Medicare D. Medicare D seems to me to fit into the needs of the socio-economically disenfranchised group of people. And for those people in the middle class who, because they did not work for a big corporate entity, have no prescription plan now.

BAUER: Aha, so that the idea of going to get the people who really needed it, it’s going to be tough for the ones who already have it.

PHELAN: Just in the last week I’ve had two experiences where two large corporations, one international and one local here in the Philadelphia area, have told their employees that they will no longer be eligible for pharmacy benefits beginning January 1st of ’06. This has been a very traumatizing experience for this group of people, because now they have to go back and look at the literature. We have 59 different prescription plans in Pennsylvania and it’s really going to be impossible for this group of people. And there also is the fear of being penalized if they don’t do something.

BAUER: And if they don’t do it by May 15th, then it’ll cost them every month for the rest of their natural lives.

PHELAN: That’s right, so they feel there’s this big hammer over their head, and they’re not sure really why this happened.

BAUER: It’s interesting that this has been going on. The bill was passed in 2003 and so a couple of years later everybody’s waking up because it’s actually happening. And maybe we all should have thought about this sooner.

Let me ask you this: How much do your patients really know about the quality of the prescription medicines that they take, or the quality of the care that they get, if they had to make these choices?

PHELAN: I think most of the consumers of health care in America are functionally illiterate about the quality of care they’re getting, and the medications they’re getting.

Part of that’s because there has not been enough emphasis on the part of the health care system to encourage the patient to take a larger part in their own care. And part of it’s due to the medical profession over the last hundred years, and I hope that’s starting to change, where we have felt that it was our purview to make the decision and the patient would just merely go along for the ride. I think that’s starting to change.

We need more and more education. We need more education on the hospital side, when the patient is leaving, and we need much more education on the ambulatory side, teaching patients that yes, that blue tablet has a name, and what is it called and why do you take it?

BAUER: But that takes time.

PHELAN: It does.

BAUER: And so the idea that WomenMatter has been saying, there’s the quality piece that everybody’s got to know about. Then there’s this access, which is, “Can I get to a doctor when I need it?” And those of us who are lucky enough to be able to get to a doctor when we need it, either because we can afford it or we worked for a company that can afford it, that we have a doctor that can do it. But you get there and some doctors are only taking seven to 10 minutes, and they run a lot of tests.

PHELAN: Unfortunately, you’re right. That’s the average in the HMO side of health care, and I have a number of good sources, local academic professors at Jefferson, the physicians I’ve talked to – it’s about six to seven minutes. And if you talk to the online physician, by about three o’clock in the afternoon, they hate whoever they have to see for the next two hours.

BAUER: So you should always make your appointment early in the morning. [laughter].

PHELAN: Yeah, you don’t want to go after lunch.

BAUER: All right. So when you have a geriatric practice like yours, what do you do about how long can you spend with each patient?

PHELAN: Well I’m very fortunate that I’m older and I remember the appropriateness with which care used to be delivered. With the HMO pressure in the training system, in the hospitals and the health care system today, I’m not sure that our young health care practitioners – nurses and doctors, although nurses more than doctors are certainly upset about what’s going on – really understand that getting back to the old medical model, you must sit and talk with the patient. Because if you talk with the patient, the patient, 90 percent of the time, will always tell you what’s wrong. You just have to listen and talk. And filling out forms and sophisticated algorithms do not necessarily tell you what’s wrong. They might help you with treatment on the other end of the scale, but in order to get the data, you have to sit and talk with your patient. You have to have a rapport.

BAUER: The patient really can describe it, given enough time.

PHELAN: Absolutely.

BAUER: Without the technical language, and that you can interview them the way that I’m interviewing you, that is that as I get the chance to listen to you talk and to say that an algorithm is a fancy formula for figuring out if the patient has X and needs Y and that maybe you should prescribe Z.

So this question then of choice – how much does a patient need to know about choice? And should choice be related to cost? The thing that is of concern is that if they are trying to reduce costs to the government, or in the country, in the richest country in the world, by asking people to make choices that are less costly, they have to measure that then, do they not, against what the blue pill does? And who do they turn to for that advice but to you?

PHELAN: Well I think primary care physicians more and more today are wearing multiple hats – social service hats, financial advice hats, cost-of-living advice, end-of-life decisions. I think that if we really wanted to talk about the fundamental processes of the country, we need to have a single-payer health care system of health. Everybody knows that who’s not in the for-profit mode of health care. As long as we have 59 prescription benefit plans in Philadelphia, the cost of managing those plans will basically cannibalize the health care system. A single-payer health care system would cost six percent of the dollars allotted to the system. Presently we’re spending 30 cents of every dollar on administrative costs.

BAUER: So the idea is that there are people who signed onto that bill who didn’t like it, but who thought, “Well we’ll sign on and then we’ll make it better later.” But at least the party that wasn’t in favor of Medicare at the beginning is behind this law. After all it was the Democrats who provided Medicare but it was the Republicans who wanted this particular bill. And the idea is, now we’ve got both parties interested, and we can make it better later.

But what’s happening is another assumption. There are people who are saying, well this is so burdensome, it’ll fail out of its own weight, and then we’ll get something for everybody. And there are others who feel that, as we’ve said on an earlier talk radio show on health care tied to jobs, and as you pointed out, the corporations are going to drop people because they can’t afford to compete with the Chinese and pay for retirees as well.

PHELAN: Exactly.

BAUER: So it’s their fault for keeping us alive longer –

PHELAN: [laughter].

BAUER: – along with the pharmaceutical companies who have indeed developed medicines that help. But this idea of how are you going to help your patients realize how much responsibility they should take.

PHELAN: Well that’s always a difficult issue. I’ve been trying to master that for 30 years. The doctor-patient relationship is a very complicated process. Not all people are capable of making those decisions and so in some cases the physician has to try and encourage the individual to move in a particular way. That’s probably the most difficult part of health care you’re talking about now. And it cannot be legislated. I do think it can be trained early in the health care provider system. And that’s every health care provider.

BAUER: But it is interesting that among some of these plans they’re saying they will charge you less for your co-pay if you go to a fitness center and we’ll get you a membership.

PHELAN: Right.

BAUER: We’ll charge you less for your plan if you will join Weight Watchers. There are some plans actually doing that. Is this something that, I mean we’re talking about people who smoke, people who are overweight, people who have addictions all being in the pool together, and this individual responsibility, certainly this new law and this new plan is focusing on that. Is this something that the doctors and the nurses are going to have to take responsibility for?

PHELAN: I think so, I think so. And of course this is just one more way of trying to make an overburdened health care system now provide a service that nobody wants to. We have created a monster in health care. And right now it’s being driven by the for-profit system, which was probably the biggest mistake. That occurred back in 1973 when they allowed the HMO act to have a profit motive in it.

So a lot of these ideas are very good, and they’ve got good data to support them. We know that if people move more, eat less and don’t smoke, they’re going to be healthier. That has nothing to do with the hands-on process of the physician. But getting that information out to people is something that’s going to be the burden of the health care provider.

BAUER: And this is where the physician is the counselor and does understand. And maybe there’s enough pain in this plan so that people begin to pay attention. But WomenMatter certainly will combine with other services, we’ll make it possible for that information to continue to get out and it is enormously helpful to have had this opportunity, Dr. Gerald Phelan, to talk with you.

PHELAN: Thank you Nancy. Always my pleasure.

* * *

BAUER: As we discussed earlier, the four ways we measure health care are cost, quality, access and choice. We heard from Cheryl Matheis of AARP that the current plan focuses on cost and choice to the exclusion of access and quality. Let’s take a look at how we got to where we are and the political reasons that the plan looks now the way it does.

So let’s remember the political timetable. The important thing we have to know is that in this country when we vote is that winner takes all. One over half gets you all the decision making in both houses of Congress. And then if you have, as the Republicans do now, they have won both houses of Congress and the presidency,(And then if one party has won both houses of Congress and the Presidency, as the republicans do now,) if they can get all of their members to agree, they can pass any legislation they want.

What happens then is once they’ve won, in the next election that’s the party that owns the health care message. So the Democrats owned the health care message when Medicare and Medicaid were passed, and the Republicans own the message now that we have the new prescription medicine bill and Medicare Advantage HMO.

So what they do is to use our tax dollars, and this is what the new plan does, they want to make sure it can’t fail. And as we pointed out earlier, what they’ve done is to take some of our taxpayers dollars and pay the insurance companies and the manufacturers money to make it possible to get in without losing a lot of money, to get in and compete with each other for all of these Medicare aged people and see if they can get them into their programs.

So it’s a use of public money for private enterprise based on a philosophy of if they can get these private companies to come in and compete with each other that the prices of medicines and the prices of coverage will actually come down.

It is a winner-take-all system that we have in this country, and when we vote we need to remember that, and that it’s not just voting for an individual or trying to be independent. What you want to know is that when you vote, your vote’s going to make a difference to a political party, which will organize the Congress and can make things happen.

So this is a party that believes that our profit-making system is the best way to go. And the tax dollars are used then to lessen the risk to employers, insurance companies, manufacturers, who are guaranteed that the government would not negotiate a price if the pharmaceutical companies, who are afraid of price controls, would get in and support this system. And the pharmaceutical companies are afraid, of course, that with price controls they would not make as much money, which they need to invest in new medicines, in research and development.

So politically that’s the story. And where is this going? Is this the best policy? Is it where we want to go Susan?

SARGENT: I think as Cheryl Matheis mentioned in her presentation, it’s a start. The philosophy is to go back to the safety net for seniors. And the safety net has changed shape. Number one, there are more seniors. There are also the chronically disabled. And the goal is to make sure that you’re promoting prevention. And prevention in this case is taking medicine and under Medicare Advantage, and doing things such as exercise and having a nutritional counselor that will keep you healthy. And that philosophy is hard to argue with. It’s a great philosophy. It should be extended to the rest of the population, perhaps.

But the quality and access issues are substantial. And I’m probably closer to having to be sensitive to this than I’d like in terms of being a baby boomer. But over time you have to be concerned about what medicines, as I said, are on the formulary, but then also how often are you going to have to refill them? And for some private insurance companies they’ll say, “Well we want you to have to refill it every 15 days, or every 30 days, or every 90 days.” Well, if the only pharmacy that’s participating in your insurance plan is across town that is an access issue, because you may or may not be able to get there. And the quality of the medicine: some people don’t like to take what they call generic medications, which are those that are not patented and protected under a private label. And for them that may be a quality issue. It may also be a quality issue as to which pharmacy you go to. People have very strong relationships with their pharmacist, as we heard.

So that I think that those are issues. The mentally ill, the chronically mentally ill have major, major issues in terms of whether their prescriptions will be available and easily accessible. They have lots of other barriers than most seniors in just getting access to the medicine and remembering to take it on a regular basis.

BAUER: So one of the real strengths of the program, of course, is that it is enforcing us to take responsibility for ourselves. We’ve got to know more and then we’ve got to think about preventing trouble. Because if we get into trouble there is, (and we haven’t talked about it and it’s something that everybody will learn as we look at our choices but up to about, two thousand, two hundred and something dollars any one year, we can be covered. But then there is this thing called the donut hole, which is the next $3,000 or so of what it might cost in any one year, you have to pay for yourself. So we’re actually being told that if we’re going to get really sick in any one year, we’re going to have to have money saved to pay for our medicines.

That is, there’s a point at which you have to pay for it yourself. Then if you’re in something catastrophically horrible, then the program, the national program, kicks back in and pays for a large percentage of catastrophic care. But picture yourself getting a little bit sick or deciding, “I don’t care about what I eat, I don’t care if I exercise, so I didn’t take my medicine for a couple of days, or I took it too long, or I borrowed it from a friend” – all of those dumb things that a lot of us do, we’re going to pay for that. Not only with the health situation, which we always have paid for ignoring our bodies, for not educating ourselves, but now we’re going to pay for it out of our pocket books. So that this new plan has tied education and prevention to our personal money and personal decision making, and there’s a lot that people are going to have to know.

So our research has now shown what many women would suspect – that the philosophies of both parties appeal to women. The facts are that in terms of health care we want it all. We want quality, we want affordability, cost, we want to make choices of our own, and we want to get the help we want when we want it, as quickly as possible and in a convenient place. But of course we know that each policy has trade-offs.

So how do we decide which policy to support? Each of needs to understand the facts and trade-offs of different plans and then pay attention to how they actually play out and the effect that they have on our lives. All of us need to pay close attention to our own choice and that of our families. When we turn 65 or become disabled, what do we want for ourselves? How concerned are we for others in our communities? Can we really think about the whole country and everybody as a part of a larger community? Or do we just think about ourselves or our immediate family or a particular group?

We need to know what we believe is right, match it to what actually happens, and then tell our representatives exactly what works and what we want for the future. Women of WomenMatter, don’t just wait to be told. Register now and vote in 2006. Communicate now with other women online on WomenMatter.com. Don’t just wait for the election time. Keep up to date on the issues, and we can do this on WomenMatter, we do this every week. Get in touch with your representatives now, by taking action on the website.

As the Medicare prescription plan has shown us, policies are often put into place years before they actually affect us, so the time to take action is now.

ANNOUNCER: WomenMatter.com will track what happens, making sure that we know the facts and understand the effects of the trade-offs. WomenMatter is the safe place to think through the details so that we can judge what is best by what each of us values and look carefully at the persuaders who only present the features they want us to know. Armed with information, we can judge quality, access, choice and cost for ourselves.

For WomenMatter’s Facts and Trade-offs, this is Victoria Jones.