HMOs drop patients

["Ken Hanly" <khanly@xxxxxxxxxxxxxxx>]

H.M.O.'s to Drop Many Elderly and Disabled People
http://www.nytimes.com/2000/12/31/national/31HMO.html

December 31, 2000

By JO THOMAS

SPRINGFIELD, Ohio   James Castle, a Medicare recipient and retired
factory worker with a bad heart, has been in three health
maintenance organizations in the past three years. His present one
is dropping him as of Jan. 1.

 The first, United Healthcare of Ohio, cut benefits, so he
switched. The second, Secure Horizons, left the state. His current
one, Aetna U.S. Healthcare, will drop all 52,330 Medicare H.M.O.
beneficiaries in Ohio on Jan. 1, having concluded that "inadequate
government reimbursements have made operating a number of our
Medicare H.M.O.'s no longer viable."

 Across the nation, 933,687 elderly and disabled people will be
dropped on the first day of 2001 by H.M.O.'s pulling out of the
Medicare program, the government says. These Medicare recipients
a sixth of those enrolled in H.M.O's   are likely to be poorer,
less educated and in worse health than others in the program,
according to a recent survey by an independent public policy
research group of those dropped last Jan. 1.

 "Terminations in 2000 affected a disproportionately vulnerable
subgroup of beneficiaries, many of whom were confused about their
options and worried about the future," concluded Marsha Gold and
Natalie Justh in the survey, which they conducted for Mathematica
Policy Research Inc. in Washington.

 "I think it's a dirty trick," Mr. Castle, 73, said as he thumbed
nervously through the thick stack of papers he had brought to the
Elderly United Downtown Center in Springfield in search of advice
from Lynn Heskett, the center's medical claims coordinator. As they
spoke, Ms. Heskett's phone rang incessantly with calls from other
elderly people in the same predicament.

 The most severe consequence for the elderly and disabled being
dropped by their H.M.O.'s, health experts say, is the loss of the
prescription drug benefits that covered 68 percent of those
enrolled in such plans.

 Although everyone dropped from a Medicare H.M.O. can return to the
basic fee-for-service Medicare, it does not pay for drugs. Neither
do the supplemental Medicare policies, the so-called Medigap plans,
in which enrollment is guaranteed to those who are dropped.

 The costs of these policies, which pay doctor and hospital charges
not paid by Medicare, vary among the private companies that offer
them. They also vary from state to state. In Ohio, they cost from
$40 to $143 a month. But the few Medigap policies that cover drugs
cost as much as $418 a month in Ohio, and acceptance is not
guaranteed.

 Edith Cain, who is 89 and a retired leather factory worker, takes
medication every day for vertigo and high blood pressure. She is
not sure how she will pay the additional cost of a Medigap policy,
let alone buy prescription drugs.

 Mrs. Cain, a widow with an income of $849 a month, was paying $10
a month for Aetna. Her new coverage will cost more than $100 a
month, without drugs. "It's terrible," she said. "It's
nerve-racking not to know what is going to happen to you."

 Nationally, 31 percent of those dropped by an H.M.O. have no other
health maintenance plan in their area to turn to, while the rest
have at least one, according to a separate analysis by Ms. Gold for
Mathematica and the Department of Health and Human Services.

 A few urban areas have been hit hard. The eastern part of
Indianapolis does not have an H.M.O. in which the elderly can
enroll, nor does Baltimore or the Washington metropolitan area. But
the situation is worst in rural areas, where 94 percent of those
being dropped as of Jan. 1 have no H.M.O. they can join.

 Here in Springfield, Julie Langdon, 61, says she has few options.
She is among the three million Americans on Medicare because they
are disabled. In Springfield, the only remaining H.M.O. that will
accept Medicare members, United Healthcare of Ohio, does not cover
prescription drugs. The only private company offering a Medigap
policy to disabled people under 65 in Ohio also does not provide
drug coverage.

 Ms. Langdon, who lives in a tiny house on the outskirts of town,
has had numerous blows to her health, including heart problems and
unsuccessful surgery for a goiter that left her with a damaged
vocal cord.

 When a reporter visited recently, she said she had had throat
surgery the day before, and she was cutting her pain pills in half
to make them last. An unfilled prescription was on her kitchen
table.

 "That's a prescription I have to get filled," she said, "but I'm
afraid to. I think it will be too expensive."

 In fact, having the prescription filled would cost her a maximum
copayment of $20, as a member of the Aetna H.M.O. She pays the
health group a premium of $91 a month. When she is dropped by Aetna
as of Jan. 1, she will have no drug coverage.

 Two years ago, 70 percent of the H.M.O.'s offering a Medicare plan
charged no monthly premium for their basic contract, according to a
Mathematica analysis of health data for the Commonwealth Fund. This
year, only 42 percent charge nothing.

 Here in Springfield, the Aetna Golden Medicare H.M.O. plan charged
no monthly premium when it opened in August 1998, just after
another H.M.O. announced plans to leave the state.

 Bruce Turner, general manager for Aetna U.S. Healthcare in
Southern Ohio, said the other plan's departure caused Aetna's
membership here to soar even after the health care plan began
charging Medicare recipients monthly premiums of $91 or $107. The
plan included prescription drugs.

 Mr. Turner said the sudden increase in premiums was necessary
because a large hospital chain had said it would drop the Aetna
Medicare H.M.O. statewide because its reimbursements were too low.

 The hospitals, which included one in Springfield, rescinded their
withdrawal notice when Aetna agreed to pay more, Mr. Turner said,
but worries about being able to keep health care providers
contributed to Aetna's decision to drop its Medicare H.M.O.'s here.

 When he got the news, Mr. Castle said, he decided not to join
another H.M.O. He bought a Medigap policy for $143 a month.
Although his policy does not pay for drugs, Mr. Castle is among the
fortunate. His medications are covered by insurance from a former
employer.

 As he was speaking with Ms. Heskett in the medical claims office,
she took a call from a cancer patient who will lose her
prescription drug benefit when Aetna drops her. She had been unable
to buy a Medigap plan that included drug coverage.

 "They tell her they can't give her drug coverage because she takes
too many drugs," Ms. Heskett said. She could only urge the woman to
keep looking for a company that would sell her a policy.

 Some members of Elderly United have tried going to Canada to cut
their drug costs. In November, 12 of them traveled by bus to
Windsor, Ontario, with Pharm Trip, a Columbus company that charges
$95 to take patients from the United States to Canada to buy
three-month supplies of pharmaceuticals at savings of up to 73
percent over mail-order prices in the United States.

 Gretchen Margraf, program director for the state-run Ohio Senior
Health Insurance Information Program, said her office was averaging
800 to 1,000 calls a week from elderly and disabled residents being
dropped from H.M.O.'s who were asking what they should do. In all,
65,617 elderly people are affected in Ohio.

 The H.M.O withdrawals from Medicare will affect 64,329 people in
New York, 51,185 in Connecticut, 12,411 in New Jersey, 87,727 in
Florida, 53,464 in California, 21,781 in Massachusetts, 89,641 in
Pennsylvania, 53,038 in Maryland, 32,177 in Washington and 180,749
in Texas.

 Susan Pisano, vice president of the American Association of Health
Plans, an industry group in Washington, contends that the Medicare
managed care program, known as Medicare+Choice, has been
"underfunded and overregulated."
The New York Times on the Web

 "Payments have gone up 2 percent a year, while expenses have gone
up 10 percent a year," Ms. Pisano said. "Plans have been forced out
of markets."

 She contends that the plans need $15 billion in the next five
years for Medicare enrollees. That does not include billions of
dollars that H.M.O.'s would get for providing drug benefits under
President Clinton's plan and most Congressional proposals.

 Under a bill approved by Congress just before it adjourned,
H.M.O.'s will receive $10 billion more for Medicare over five years
than under the current law.

 The Health Care Financing Administration, which runs Medicare,
said 65 H.M.O.'s had chosen not to renew their Medicare contracts
next year, while 53 health plans would withdraw from selected
counties.




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