Medicare Drug Plan Hits Snags in State

California health officials reported Friday that database errors and overloaded telephone help lines were spreading confusion and frustration among seniors seeking vital medicines under the new Medicare prescription program.

Though some warned of a looming crisis, Medicare officials and insurance companies called for patience and promised swift relief.

California pharmacists, on the frontline of the new program, complained that improvements were coming too slowly.

“There’s a large amount of problems out there,” Stan Rosenstein, the state’s deputy director of medical services, said in an interview. “We are significantly worried. When it gets to a situation where people aren’t getting their medications, that is very concerning to the state.”

Most of those affected are low-income seniors and disabled people.

Lakewood resident Andrew Gnagy said it took him about 15 hours on hold on the telephone over three days to get prescription refills arranged for his 84-year-old mother. Sue Gnagy has heart problems, diabetes and a thyroid condition. The pharmacy said it would cost $974.26 to buy the drugs directly -- about $40 more than his mother’s monthly Social Security check.

Until Jan. 1, she had been getting her prescriptions at very little cost through Medi-Cal, California’s version of the federal-state Medicaid health program.

Under the system that took effect Sunday, about 1 million Medi-Cal beneficiaries had their drug coverage switched automatically to a private insurance plan subsidized by Medicare.

“Many people in my mom’s situation, without their medicines, would die,” Gnagy said. “People who have no one to advocate for them and don’t have the stamina to stay on the phone 12 or 15 hours will just go without their medicines.”

Though acknowledging problems, federal officials defended the new program and said hundreds of thousands of seniors had been getting their prescriptions without incident, many at lower cost.

The drug benefit is considered one of the Bush administration’s main domestic policy achievements. It offers outpatient prescription coverage to 43 million elderly and disabled beneficiaries through government-subsidized private plans, at an estimated cost of $700 billion over 10 years.

California is critical to the program’s success, because the state has a nation-leading 4 million people on Medicare, including the 1 million previously served by Medi-Cal.

“All we are asking for is a little patience -- hours, not weeks -- until we can get a handle on individual cases,” Medicare senior policy advisor Larry Kocot told reporters on Thursday. “We are chasing down everything that we hear. We are addressing [problems] and addressing them to our satisfaction.”

Kocot said Medicare had fixed technical problems that had initially hobbled a database for pharmacists. The agency also urged companies offering drug plans to beef up staffing at swamped telephone call centers.

Advocates for the poor have reacted with dismay to the problems, saying their warnings that a sudden transition would cause such problems went unheeded.

“This is a public health disaster,” said Jeanne Finberg, a lawyer in the Oakland office of the National Senior Citizens Law Center. “There are people going to pharmacies and being told they can’t get medications that are supposed to be covered. There are people who can’t get confirmation that they are in a plan.”

Across the country, about 6 million low-income elderly and disabled people were automatically switched into Medicare drug plans on Jan. 1.

At least one state, Vermont, found the problems for low-income beneficiaries so overwhelming that it decided to use state funds to pay their prescription bills until Feb. 10.

“It just wasn’t working,” Joshua Slen, Vermont’s Medicaid director, said Friday.

Vermont estimates it will cost $7 million to provide the transitional coverage for its 30,000 Medicaid beneficiaries, and Republican Gov. Jim Douglas is demanding that Washington “fully reimburse” the state.

For California, with more than 30 times as many Medi-Cal beneficiaries being transferred, the cost to duplicate Vermont’s approach would be prohibitive.

However, other New England states are considering similar emergency relief, Slen said.

Echoing Medicare officials, the health insurance industry also is urging patience.

“Challenges are being faced where they arise,” said Mohit M. Ghose, a spokesman for America’s Health Insurance Plans, the main industry trade group. “Given the amount of resources that are now being dedicated to improving systems, including call-center capability for pharmacies, any snapshot you take today could change.”

In California, pharmacists say they are not seeing the improvements fast enough.

“It’s incredibly frustrating, because it appears that [Medicare] and the [drug] plans are expecting us to be the point people for all of the problems,” said John Cronin, senior vice president of the California Pharmacists Assn. “If the patients can’t get their medicines, they are going to have to come in again and again until this is resolved.”

Cronin, who owns Community Pharmacy of Escondido, said he dreaded to think what would happen when pharmacies started to deal with problems considered more difficult to resolve, such as when a plan denies coverage for a particular drug.

“The problems that we are having now concern eligibility and billing,” he said. “This is very basic stuff, the kind of thing that should have been taken care of long before this plan rolled out.”

The issues are technical, but according to pharmacists and state officials, the problems revolve around accuracy and access.

Many beneficiaries still do not have membership cards from their drug plans, and a Medicare database where pharmacists can verify enrollment is riddled with errors concerning eligibility and co-payments. California’s Rosenstein said one of the state’s large pharmacies reported an error rate of about 40%.

Such errors mean that computerized billing requests from pharmacies to the plans are automatically rejected. But when a pharmacist calls to try to resolve the problem, help is frequently unavailable because phone lines are tied up with other callers.

“Unfortunately, those lines are the only lines that can give the provider the information they need,” said Rosenstein.

Gnagy, the Lakewood resident who cares for his elderly mother, said his mother did have her membership card for her new insurer, called the Blue Cross Medicare Rx Value Plan. But when Gnagy went to Sam’s Club pharmacy in Long Beach on Monday, the pharmacist was unable to get the computerized bill through to the insurer.

Pharmacy staffers called the insurer to no avail.

“They called me Tuesday and said, ‘We can’t get these people to answer the phone -- you might have better luck,’ ” Gnagy said.

“I put in a total of 15 1/2 hours of dialing and being put on hold,” he added. “My longest session was 6 1/2 hours -- I have a hands-free phone.”

By Wednesday, Gnagy said, he started to panic, because some of his mother’s 12 medications were running out. Her social worker gave him some numbers to call. One of them turned out to be a local agency that protects the elderly from abuse. He said agency officials misinterpreted his frustration as an indication that his mother was in danger, and soon an enforcement officer was at the door.

“I felt extremely violated,” he said. “They came in and physically checked my mom for bruises.”

On Thursday morning, said Gnagy, he was finally able to reach the drug plan and obtain a telephone number the pharmacy could call. On Friday, the pharmacy called to say his mother’s prescriptions were ready.

Things will get better, said a spokeswoman for the parent company of the Blue Cross plan, WellPoint. “We apologize for any delays,” said Kellie Bernell. “We are doing everything to open lines and increase service to our beneficiaries.”