Staying alive

[NRSKarenRN, BSN, RN]

wednesday, january 16, 2002 go to: s m t w t f s

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for elderly, a struggle with rising health costs

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lottery games more popular, but elderly get less help

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by ovetta wiggins

inquirer harrisburg bureau

the kenny home in horsham, montgomery county, is colder and darker than it was a year ago.

magdalene kenny, 73, is turning down the heat and lights to help make up for the $124 increase she and her husband face in monthly premiums for their medicare hmo policy this year. the kennys' premiums went from $159 to $283.

james irwin, 88, of lafayette hill, montgomery county, does not know what to do when his drug samples run out. with an income of about $900 a month, reductions in gas and electric bills will not go very far in paying for the two $250 bottles of medicine his doctor prescribed last month to treat his heart disease.

seniors such as the kennys and the irwins in pennsylvania, new jersey and across the country are finding themselves in a growing health-care financial crunch, hammered by rising insurance premiums and skyrocketing costs of prescriptions.

to make matters worse, the pennsylvania lottery fund, which pays for programs for the elderly, is going broke.

"these are problems that are cutting across social barriers," said nora dowd, president of the pennsylvania chapter of the aarp. "it doesn't matter where you live, whether it's urban, suburban or rural, seniors everywhere are feeling the pinch."

lottery proceeds pay for the largest state-run prescription-drug program for the elderly in the nation, and they also fund activities at senior centers, home-health aides, in-home meals and transportation.

the impact of the looming shortfall already is being felt.

beginning this month, the state department of aging is requiring seniors who earn $895 a month or more to help pay for some state-funded home-care assistance.

"part of the reason for this is because the lottery is running out of money," said holly lange, senior vice president of the philadelphia corporation for aging, which provides senior services in philadelphia.

if nothing is done to limit costs of prescription drugs or raise revenue for the lottery fund, all senior programs, including the popular prescription-drug program, will be in jeopardy, state department of aging secretary richard browdie said. the lottery fund is projected to be broke by september 2003.

in fiscal 2003-2004, the lottery fund could be as much as $188 million in the red.

"the pressure on the legislature to do something is tremendous," browdie said. "if the legislature doesn't give us cost-containment measures, we can't provide the programs."

the philadelphia corporation for aging, which gets most of its funding from the lottery, has gotten by the last few years with annual increases of 2 and 3 percent, lange said.

"with those types of increases, we are barely able to maintain the services that we have," she said. "we're at a level where we really can't serve any more people."

the philadelphia agency does more fund-raising these days and relies on money that comes from the federal government and other state agencies, including the state department of public welfare.

sen. tim murphy (r., allegheny), chairman of the senate aging committee, said negotiations are under way to deal with the looming shortfall.

in some respects, murphy said, the lottery fund situation is similar to the one facing thousands of seniors as they try to figure out how to pay their bills.

"we're spending the savings account to make ends meet," murphy said. "if you use your savings to make your car payments, you know it's only a matter of time before you can't make the payments anymore."

at stake is the pharmaceutical assistance contract for the elderly (pace) and pacenet, the discount prescription-drug programs that help 225,900 low-income seniors pay for their medicine. pace is for seniors with an annual income of less than $14,000 a year or couples with income less than $17,200. for pacenet, income limits are $17,000 per person, and $20,200 for a couple.

since traditional medicare does not cover prescription drugs, pace is one way some seniors in pennsylvania have been able to afford their medications. many seniors, such as irwin, either ineligible for or unaware of pace and pacenet, opted to sign up for a medicare managed-care plan that offered prescription-drug coverage.

they were attracted by insurance companies' promises of discounted drugs and low premiums. and they signed up in droves. by last year, 24 percent of pennsylvania's medicare beneficiaries were enrolled in medicare hmo plans.

traditional medicare is the federal government-funded plan that covers 80 percent of doctor bills and much of a hospital stay. it does not cover prescription drugs.

under a medicare hmo, the government pays a fixed amount of money to a private company to provide a participant's needs. seniors pay a monthly premium for the plan, which replaces regular medicare, and in return they receive, in some cases, up to $1,200 a year in prescription-drug benefits.

for a while, the plans seemed to be a dream come true.

now, though, insurance companies across the country contend that federal reimbursement rates are not covering the growing costs of health care. so they have increased premiums or limited coverage. in some cases, they have dropped their plans from selected counties entirely.

almost 110,000 elderly people in pennsylvania and new jersey lost medicare hmo coverage from their insurers last month - about 20 percent of the 536,469 in the nation who lost their insurance.

citing the mounting costs, aetna u.s. healthcare discontinued its policies at the end of last year in montgomery, bucks, burlington, gloucester and camden counties.

seniors who lost their medicare hmo coverage can switch to another plan if they can find one. or they can join the traditional medicare program. those who get into new plans are likely to pay higher premiums, and those who choose traditional medicare may need to pay more for prescription drugs and other benefits.

jimmie hubert of norristown, montgomery county, was notified that his wife, marie, a diabetic who suffered a massive stroke in 1996, was being dropped by aetna this month.

now he is trying to find coverage that will not cost hundreds or thousands of dollars if marie needs hospitalization.

if hubert decides to go with traditional medicare, it would cost him an $812 hospital deductible and 20 percent of doctor bills and other expenses.

even with pace, which covers most of his wife's prescriptions, hubert is spending about $200 a month on medicine. hubert's medications are not covered under pace because his income - $1,100 a month - is too high, and some of his wife's brand-name drugs are not covered.

"it's hard on me because i have other bills - the mortgage, electric, gas, car insurance, life insurance," said hubert, 68.

magdalene kenny in horsham has a medicare hmo policy with independence blue cross, known as keystone 65. her monthly premium nearly doubled this year, going from $59 to $94.

she still has not paid the bill, she said. instead, she is searching for an hmo that will offer her a lower rate.

staying with keystone would mean spending almost a quarter of her $430 social security check on her premium.

"how do i pay $100 out of that?" she said with a nervous chuckle. "that's why we keep the heat turned down and the lights turned off."

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ovetta wiggins' e-mail address is [email protected].

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the worst part is that the sr citizens all thought that the mc hmo programs would always cover the cost of drugs. medicare benefits have basically remained the same since 1965 when started. when these plans introduced ~4-5 years ago, no one realized that the mc hmo's sign up for 1-2year coverage of mc benefits and that they can change plan benefits yearly. in philly area there was no co-pay for meds for first 3 years, 2 years ago $5-10 co-pay. now this year only keystone care has rx coverage available for additional $75.00 month extra on top of mc payment---- for only $500 med coverage over 6 months!

over past year ~40- 50% of our homcare patients didn't get 1 or more meds ordered by doctors as unable to pay cost. seeing an increase in medicaid plans not having prescribed meds on formulary with patients not aware they need to just call dr to get formulary covered med ordered.

past three months seeing slight increase in rehospitalization rates due to no meds/refills not obtained as unable afford: philly hospitals required to give 1 week supply at discharge and client then sent to federal or city health clinic to get meds.