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HealthCarePrescriptions for Californians : Is There a Train Wreck Ahead


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Title: HealthCarePrescriptions for Californians : Is There a Train Wreck Ahead

HealthCare/Prescriptions for Californians Is
There a Train Wreck Ahead?
  • UAW
  • Tuesday, April 10, 2007
  • Margie Metzler
  • 916-921-5008
  • Website

This program operates under a grant from the
California Wellness Foundation
Issues Facing Americans
  • The Uninsured 47 Million and growing!
  • Fixing Medicare Part D
  • Other Prescriptions Drug Issues Errors and

Uninsured Americans
  • 41 million uninsured nationally and 7 million
    Californians (and growing) most in working
  • Why?
  • Companies reducing benefits to save money
  • Cost of private insurance impossible for many
  • Cost of COBRA ballooning (1200 for a family of

Why is Being Uninsured so Dire?
  • Emergency rooms shutting down (Hospitals are in
  • Doctors dont take cash patients
  • Costs for cash patients way higher than cost to
    insurance companies
  • You cant get insurance if you are old or sick
  • Most people let conditions worsen till they are
    much sicker
  • 50 of bankruptcies are due to medical expenses

California Year of Healthcare Issues
  • 4 Plans
  • Sheila Kuehls SB 840
  • Governors Proposal (no bill yet)
  • Perata Plan
  • Nunez Plan
  • Republican Plan

Gray Panthers Supports Californias SB 840,
Single-Payer Healthcare!
  • Security - All California residents are covered
    for life.
  • Choice - the freedom to choose your own medical
    provider. Delivery of care will continue as now
    to be private and public.
  • Comprehensive Benefits - includes all care
    prescribed by a patient's health care provider,
    including hospital, medical, surgical, mental
    health dental and vision care prescription
    drugs and medical equipments, diagnostic testing,
    hospice care and more.
  • High Quality - The plan invests in needed health
    care infrastructure such as electronic claims and
    reimbursement systems and statewide medical
    databases that improve health care quality.
  • Efficient Administration - one comprehensive
    insurance plan saves the state, patients and
    providers billions of dollars each year.
  • Shared Responsibility - Payment of an affordable
    premium by employers, employees and individuals
    supports the health care system we all need at
    some time.
  • Fair Reimbursement Cost Controls

What is the Medicare Part D?
  • The Medicare prescription Drug, Improvement and
    modernization Act (MMA), Dec. 2003
  • Most sweeping change in Medicares 40 year
  • Administered by CMS and SSA
  • CMS RX Program
  • SSA Extra help for low income

Structure of Standard Benefit
  • Monthly Premium
  • Varies average is 31
  • Can be deducted from your SS check or paid
    directly to plan
  • Annual Deductible
  • In 2007, cant exceed 265 (was 250 last year)
  • Initial co-payment
  • 25 of covered costs between 265-2400
  • No coverage during donut hole (2401 - 5,451)
  • Still pay premiums, even though no coverage
  • Catastrophic Coverage
  • After 5451, 5 of covered costs

How Does it Work?
  • You figure out which drugs you take now and which
    you'll need all year.
  • Go to CMS, online or by phone, to register. You
    research the 55 different plans offered by 23
    companies (Or contact HICAP). You choose a plan
    based on the drugs they cover (formulary). You do
    this every year because the plans change every
  • You pay a monthly premium. If you didnt sign up
    by May 15 you pay a penalty for life.

  • Donut hole When the combined total cost (net
    cost, not co-pay,) reaches 2401, you are in the
    donut hole and for pay all costs for all your
    drugs for the next 2850. You are still paying
    your monthly premiums.
  • There is a new donut hole and new enrollment
    period every year. This year it ended Dec. 31
    the next will be Nov. 15-Dec. 31, 2007.
  • Turning 65 you can sign up 3 months before your
    65th birthday and youll have 3 months afterward
    to enroll. If you enroll after that youll pay a
    1 penalty per month for life.

Other Issues
  • No negotiating for best prices like VA and
  • States cant regulate insurance plans
  • Late Enrollment Penalty 1 penalty per month and
    the penalty lasts forever
  • Some retirees lost their creditable coverage for
  • Originally, insurance companies could change
    prices, formularies, co-pays, deductibles at
    will, but you couldnt change until Nov.
    enrollment period. Your complaints caused the CMS
    to force companies to keep you on the drugs you
    need until the next enrollment period.

Whats new in 2007?
  • Donut hole coverages have changed. Most companies
    still give no coverage, and some that do now
    cover only generic drugs.
  • Formularies may have changed.
  • Co-pays may have changed
  • The maximum deductible has risen from 250 to
  • Premium may have changed.
  • There are more plans available.
  • Two companies (Marquette National Life Insurance
    Company and PacifiCare) have dropped their plans.

We deserve these improvements
  • Waive premiums for any month a senior is not
    receiving Medicare prescription coverage. Those
    in the donut hole should not be required to pay
    for goods not received.
  • Count ALL drug costs incurred in the donut hole,
    not just expenses for those on the insurance
    plans formulary, provided by an in-network
    pharmacy. Every out of pocket cost should count
    towards catastrophic coverage.
  • Allow seniors to receive prescription drugs
    directly from traditional Medicare, not through
    an intermediary insurance company. This would
    reduce confusion and offer a simple, one step
    plan with affordable drugs.

More Improvements
  • Eliminate the lifetime penalty for seniors
  • Increase funding to provide counseling and
    education to beneficiaries and caregivers

Medication Errors Types
  • Institute of Safe Medication Practices Major
    Causes of Medication Errors
  • Critical patient information is missing
    (allergies, age, weight, pregnancy, etc.)
  • Critical drug information is missing (outdated
    references, inadequate computer screening, etc.)
  • Miscommunication of drug order (illegible,
    incomplete, misheard, etc.)
  • Drug name, label, packaging problem (look/sound
    alike, faulty drug identification)
  • Drug storage or delivery problem
  • Drug delivery device problem (poor device design,
    IV administration of oral syringe contents, etc.)
  • Environmental, staffing, workflow (lighting,
    noise, workload, interruptions, etc.)
  • Lack of staff education
  • Patient education problem (Lack on patient
    consultation, non-compliance)
  • Lack of quality control or independent check
    systems in pharmacy
  • Physician knowledge is lacking (when a drug comes
    to market that replaces an existing one or
    several ones, i.e., a combination drug may mean
    that a person takes it once a week instead of

No More Vioxxes!
  • Register all clinical trials and make results
  • Regulation of industry marketing
  • JAMA standards
  • Litigation (PAL)
  • Best Buy Drugs (
  • Drug Effectiveness Review Project (DERP) Oregon
    Health Science University Evidence-Based
    Practice Center. Now includes 15 states and two
    non-profit organizations.
  • Medication Errors Panel Report (CA State Cap.)

Medication Errors 2020 (ABC)
  • 20/20 program on Pharmacy Errors
  • Results of the 20/20 program http//blogs.abcnews
  • Pharmacies dont track errors
  • Pharmacists are too busy (fill 350 prescriptions
    per shift)
  • Pharmacy techs sometimes unqualified
  • You unwittingly sign away your right to talk to

Medication Errors Panel (CA)
  • The Medication Errors Panel, in response to
    California Senate Concurrent Resolution 49
    (2005) http//
    t.pdf (Jackie Speier)
  • Costs associated with drug-related deaths and
    injuries in the US exceeds 177 billion per year.
  • Institute of Medicine at least 1.5 million
    Americans sickened, injured or killed each year
    by medication errors
  • CA problem costs 17.7 billion dollars and
    causes harm to 150,000 Californians.

Rx Marketing to Doctors
  • Industry spends 12 B/year on drug marketing to
    MDs, or 13,000/doctor
  • There is 1 sales rep for every 5 MDs
  • Gifts, lunches, trips, educational grants,
    entertainment, free samples
  • Even small gifts create obligation and influence
    prescribing decisions
  • Free samples create loyalty to brand and
    unwillingness to use generics (30-80 lower cost)
  • Doctors are paid to promote expensive new drugs
    and off- label uses

The FDA and the Pharmaceutical Industry
  • US drug prices are the highest in the world and
    getting worse. We paid 81 more for brand drugs
    (average) than Switzerland, Britain, Germany,
    Canada, Sweden, France, and Italy.
  • FDA ties to Pharma (Tauzin)

Whos really in charge here?
  • Out of control industry marketing marketing is
    30 of cost of drugs 10-15 spent on RD over
    4.5 B spent in 2006 ads promote drugs for new
    diseases, 50 most heavily marketed drugs
    accounted for 50 of increased sales)
  • Industry influence in government (Medicare Part
  • Quality of care compromised
  • Pharmaceutical costs out of control
  • Consumers cans afford their drugs

  • Negotiations
  • Opening up US prescription drug pricing to world
    competition and free trade (Prescription Drug
    Importation debate)
  • 2007 Pharmaceutical Market Access and Safety Act,
    HR 380 ( Emanuel and Emerson) and Senate S-242
    (Dorgan and Snow 30 co-sponsors)

2007 Pharmaceutical Market Access and Drug Safety
  • S 242 and HR 380
  • Allows individuals, wholesalers and pharmacists
    to import from FDA-approved facilities in 30
  • Raises drug safety with provisions against
  • Has provisions to stop drug companies from
    cutting off supply to countries

Federal Congress people
Representative Find your Congressperson http//ww
  • Senators
  • http//
  • Boxer, Barbara- (D - CA) 112 Hart Senate Office
    Building, Washington 20510
  • (202) 224-3553
  • Web form
  • Feinstein, Dianne- (D - CA) 331 Hart Senate
    Office Building, Washington DC 20510
  • (202) 224-3841
  • Web Form

Where to Go For Help/Info
  • Health Insurance Counseling and Advocacy Program
    (HICAP) Call 1-800-434-0222 to reach your local
    HICAP or go to
  • National Committee to Preserve Social Security
    and Medicare http// (a
    national, nonprofit organization)
  • Social Security 1-800-772-1213 or go to
  • Center for Medicare and Medicaid Services (CMS)
    Call 1-800-MEDICARE or go to
  • Low income subsidy go to
    help or call 1-800-772-1213

Together, we can fix this!