This is an important distinction, because after you enter the donut hole, you pay more for all<\/em> of your medications, not just brand-name drugs.\u00a0 I am now responsible for 25% of the $441 paid to Bristol-Myers Squibb for my monthly supply of Eliquis, and 37% of the $76 paid to Rising Pharmaceuticals for a 90-day supply of my generic blood-pressure pills.<\/p>\n In the Sea of Donut Holes (with the Blue Cross Meanies)<\/span><\/p><\/div>\n I will remain in the donut hole until I have paid $5,100 out of my own pocket <\/em>for drugs, which is not going to happen this calendar year.\u00a0 So my fall into the donut hole will cost me an additional $303, assuming there are no medical surprises.<\/p>\n Shame on me, someone who is reasonably well-versed when it comes to what I pay and what I get, for not paying more attention to my benefits statements.\u00a0 The donut-hole rules, as complicated as they are<\/a>, should not have come as a surprise to me — but I’m still taken aback at how much money the drug companies get for my medications, even the generics.<\/p>\n You may have read elsewhere that provisions in the ACA (it’s alive!) will finally close the drug coverage donut hole in 2020.\u00a0 But here’s the thing, as Joe Biden likes to say: closing the donut hole on paper does not<\/em> mean I will pay the same copays all year long.\u00a0 The fact that I paid (only) $37 for Eliquis before I hit the donut hole is best thought of as a benefit of my particular plan — by law, I was “responsible” for up to 25% of the cost even before I reached the donut hole.\u00a0 Under some other plan, I could<\/em> have been paying $111 a month from the outset instead of that $37 copay.<\/p>\n Confused?\u00a0 I know I am, and I’m not alone<\/a>.\u00a0 Wading through the explanation of costs and coverage on medicare.gov<\/a> calls for a lot of patience if not an accounting degree.\u00a0 As far as I can tell, not a whole lot is going to change for me in 2020.\u00a0 I will start out with low copays, but once my total drug costs reach $4,020 (the new threshold), I will pay 25% of whatever price the drug company asks.\u00a0 I will stay in this (ghost) donut hole until my out-of-pocket costs reach $6,350 (a $1,250 hike from 2019), after which I will pay 5% of the retail price for my medicines.<\/p>\n As there is no standard Medicare drug plan, I can’t predict what all this means for others.\u00a0 If you take even one non-generic drug, read your coverage documents carefully.\u00a0 Not that this gives you a lot of choice.<\/p>\n \u2022 \u2022 \u2022\u00a0<\/p>\n One last item, about the politics of all this ridiculousness.\u00a0 Paul Krugman pointed this out<\/a> in 2005, when Medicare Part D was signing up its first participants:<\/p>\n Republican Congressional leaders who rammed the bill through in 2003 weren’t actually trying to protect retired Americans against the risk of high drug expenses.<\/em>\u00a0 Their purpose was purely political: to be able to say that President Bush had honored his 2000 campaign promise to provide prescription drug coverage by passing a drug bill, any drug bill.<\/em><\/p>\n Once you recognize that the drug benefit is a purely political exercise that wasn’t supposed to serve its ostensible purpose, the absurdities in the program make sense.\u00a0 For example, the bill offers generous coverage to people with low drug costs, who have the least need for help…\u00a0 Meanwhile, the people who are actually likely to need a lot of help paying their drug expenses were deliberately offered a very poor benefit.\u00a0 According to a report issued along with the final version of the bill, people are prohibited from buying supplemental insurance to cover the doughnut hole to keep beneficiaries from becoming “insensitive to costs” — that is, buying too much medicine because they don’t pay the price.<\/em><\/p>\n This has always been conservative dogma: if we make health care easy to get, people will use too much of it; if we force people to pay for it, they will reconsider whether they really need it; and if we let health care prices seek their own level, that will effectively ration it.\u00a0<\/p>\n It is easy to spot the flawed premises here.\u00a0 It presumes people like<\/em> going to the doctor and taking medicine and would seek<\/em> out <\/em>such activities if there were no restraints.\u00a0 It presumes ordinary people have the means to shop for health care as well as the expertise to judge its cost-effectiveness.\u00a0 It presumes that cost-sharing by patients is an appropriate way to get patients to use lower-cost drugs — when the only real choice most patients have is whether to get their prescription filled.\u00a0 And it equates health care with consumer goods, in that some people can afford the best and some can’t and that’s the way it oughta be in America.<\/p>\n Maybe conservatives would like to talk about cost-sharing with people who take Revlimid for multiple myeloma.\u00a0 (Medicare spent $3.31 billion on Revlimid in 2017, more than any other drug<\/a>.\u00a0 Eliquis came in second at $3.07 billion.)\u00a0 The copay for one dose of Revlimid is often $7,000 or more, which would immediately push a patient through the donut hole.\u00a0 Or maybe conservatives should ask people with chronic hepatitis C whether they can just live with it — after all, even the new generic version of ledipasvir<\/a> costs $15,000 per course.\u00a0 Finally, with respect to so-called lifestyle diseases<\/a>, maybe conservatives would like to share their evidence that forcing people to bear the financial burden of past unhealthy behaviors serves to deter those behaviors.\u00a0 (I think it only serves to punish them.)<\/p>\n The Medicare Part D approach to prescription drug coverage is based on false premises and should be scrapped.\u00a0 Health care should be a societal burden, not an individual one;\u00a0 yes, we should all live healthier lives, but no one I know asked to have atrial fibrillation or multiple myeloma or hepatitis C.\u00a0 Every patient should receive the most cost-effective treatment that has been shown to be medically effective and respects her quality-of-life.\u00a0 The patient’s personal financial situation and the type of insurance she has should not be factors in selecting her treatment.\u00a0 This implies no more deductibles, no more donut holes. No more misguided incentives placing burdens where they don’t belong while failing to address the real causes of outlandish medical costs.<\/p>\n So here is where I part ways with the “Medicare for All” and “Public Option” proponents. Medicare may be better than other alternatives but it isn’t good enough.\u00a0 I am waiting for other presidential candidates besides Bernie Sanders to step up and say so.<\/p>\n _____________<\/p>\n “Have you had a fall recently?” my doctor asks these days.\u00a0 Well, Doctor, yes I have.\u00a0 I fell into a donut hole.\u00a0 I didn’t think I was that feeble.\u00a0 And I never saw it in front of me. I wasn’t … Continue reading ![\"\"](\"http:\/\/chcollins.com\/100Billion\/wp-content\/uploads\/blue-donut580.jpg\")
<\/a>* U.S. Patent 9,326,945<\/a> was issued May 3, 2016 to Jatin Patel et al<\/em> and assigned to Bristol-Myers Squibb.\u00a0 The next drug God should create (with help from Dr. Patel) is an over-the-counter anti-inflammatory that one can take with Eliquis.<\/h5>\n","protected":false},"excerpt":{"rendered":"