Medicare meltdown Many elderly aren't getting vital medicines because of glitches in the new drug program.

Posted: January 12, 2006

Nearly two weeks after it began, the new Medicare prescription drug program remains plagued by problems, and calls for help are growing, advocates report.

Many of the most vulnerable elderly and disabled patients have been unable to get medicine since the program's start on Jan. 1, according to interviews with patients, medical professionals and public-interest lawyers.

In one case, a man whose leg was recently amputated cannot get Medicare to cover the antibiotics he needs to stop a life-threatening infection, according to lawyers for Community Legal Services. In another case, a woman with lung cancer was turned away from her first chemotherapy treatment because of a Medicare mix-up.

FOR THE RECORD - CLEARING THE RECORD, PUBLISHED JANUARY 13, 2006, FOLLOWS: The range of patients cared for by the Visiting Nurse Association of Greater Philadelphia was incomplete in a story on Medicare in yesterday's Inquirer. The Philadelphia VNA is a nonprofit provider of home-health and hospice services to homebound patients of all income levels throughout Southeastern Pennsylvania.

"There are breakdowns at every point, and there is no one there to fix them," said Michael Campbell, executive director of the Pennsylvania Health Law Project.

Calls for help to Pennsylvania's health insurance hotline have reached record levels, and several pharmacists said they had never seen greater chaos.

"This is not getting better. It's getting worse, and it's an outrage," said Sam Brog, executive director of the Philadelphia Association of Retail Druggists. "They should end the program and start over."

Lorraine Ryan, a Medicare spokeswoman in the Philadelphia office, said the agency is "concerned about people encountering difficulties getting medication."

She said the agency had identified a computer glitch that caused several hundred thousand of the poorest recipients nationwide to be overcharged and thus they had to go without their drugs. The agency is working on the problem, she said.

She called the overall number of complaints "small" compared with the millions who have already been helped. But, she said, "it is unacceptable that anyone is not getting medication or benefits."

Medicare drug coverage, the biggest expansion of the program in its 40-year history, began Jan. 1. The federal government expects the new benefit to cut average drug costs by 50 percent for all 42 million Medicare beneficiaries.

But only about one million people had voluntarily signed up by late December.

By yesterday, six states, including New Jersey, had acted to pay for temporary supplies of medicine for Medicare patients.

In New Jersey, officials suspected months ago that some problems would occur. So they set up a safety-net plan to pay for medications if eligible people became stuck in the new system.

But the volume of the complaints has surprised them. "We saw by Friday that this was mushrooming into a bigger problem than we had imagined," said Suzanne Esterman, a spokeswoman for the New Jersey Department of Human Services. "We saw we had to step in and make sure no one would go without drugs."

New Jersey has spent more than $6.4 million to fill about 69,000 prescriptions since the federal program began, Esterman said.

Sen. Frank R. Lautenberg (D., N.J.) said through a spokesman that he plans to introduce an emergency measure to force the federal government to reimburse states that have paid for drugs.

In Pennsylvania, officials have so far declined to pay for medications. They said federal officials told them that they would not get reimbursed and that some of the state's poor and elderly are still covered under PACE, the state's drug program for the elderly.

Gov. Rendell's spokeswoman, Kate Philips, said Rendell was watching the situation. "We are not going to allow people to go without vital prescription drugs, and we're committed to making the federal benefit work," she said.

In Philadelphia, some patients said their emergency supplies were growing short.

Thomas Tucker, 59, of the East Falls neighborhood has tuberculosis and spends his days tethered to an oxygen machine. A Medicare recipient because of his disability, he needs drugs to help his inflamed, scarred lungs absorb more oxygen.

"I get light-headed, my breathing gets shallow, and it feels like I'm getting cut off," he said.

He and a cadre of nurses, social workers and lawyers have tried to get his three medications since he was released from the hospital 12 days ago - to no avail.

"If a team of people who understand the system as well as we do can't help him, who can?" asked Mary Beth Hardiman, a nurse with the Visiting Nurse Association of Greater Philadelphia, a nonprofit that provides home health care to poor patients.

To be sure, many Medicare recipients will benefit greatly from the new program.

Although there are no hard numbers, health experts on the front line said the number of patients seeking help has continued to rise.

"Our call volume this week is the highest it's ever been," said Jack Vogelsong, who runs Pennsylvania's insurance information program in the Department of Aging. "People are not getting what they were promised."

Even health professionals and lawyers who pride themselves on knowing the inner workings of Byzantine government programs said they were frustrated by the complexity and scope of the problems.

Campbell, of the Pennsylvania Health Law Project, said his agency has been trying to help patients but can't get through to the right officials to find answers. The agency has been receiving about 120 calls a day this week. "We're a group of lawyers who have jumped in because it's a real crisis," he said.

In many cases, pharmacists have become the only salvation for patients desperately in need of medicine. But they, too, have been stymied by long waits and unanswered phone calls.

"I've been a practicing pharmacist for 21 years, and this has been the worst two weeks of my life," said Dave Ostrow, the owner of Cambria Pharmacies Inc. at Fifth Street and Allegheny Avenue in North Philadelphia.

His frustration is shared by Bob Schreiber, a pharmacist for 35 years and owner of Burns Pharmacy in Morrisville, Bucks County. "If you get through to CMS [the federal Centers for Medicare and Medicaid Services], they can't tell you anything, because they are untrained and don't know how the program works," Schreiber said.

What pharmacists, telephone operators and providers don't face is the fear that Tucker stares down each day as his supply of drugs dwindle.

Tucker heard about the new drug program but thought his old Medicaid plan would continue.

After he was released from the hospital for severe breathing problems on New Year's Eve, he called his pharmacy to get his medications, but was told that his coverage no longer worked and the pharmacy had no record of his new plan.

He then called his new insurer, who told him he was not eligible until Feb. 1. Since then, a team of people has been trying to sort out the delay.

His doctor gave him a small supply of medication to tide him over, but that is running low.

"What should I do then?" he asked. "I have all these people helping me. What about someone who is going it alone?"

Some of those people are calling Pam Walz, director of the Elderly Law Project of Community Legal Services in Philadelphia.

"This is a disaster unfolding quietly out of public view in the homes of the poor and disabled," she said.

Contact staff writer John Sullivan at 215-854-2827 or johnsullivan@phillynews.com.

More Information

Contact these agencies and organizations for Medicare advice:

Medicare: 1-800-MEDICARE (1-800-633-4227) or www.medicare.gov.

Pennsylvania Health Law Project: 1-800-274-3258 or 1-866-236-6310 (TTY) or www.phlp.org.

Center for Advocacy for the Rights and Interests of the Elderly: 215-545-5728 or www.carie.org.

Community Legal Services Elderly Law Project (for low-income Philadelphia residents): 215-227-2400.

APPRISE, a health-insurance counseling program for Pennsylvanians: 1-800-783-7067.

New Jersey State Health Insurance Assistance Program: 1-800-792-8820 http://nj.gov/health/senior/ship.shtml. Or in Burlington County: 609-894-9311, Ext. 7498. Camden County: 1-877-222-3737. Gloucester County: 1-856-468-1742.

SOURCES: Health experts; Medicare counselors; Medicare

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