Clinical Geriatrics

Much of the discussion regarding the healthcare reform bill just signed into law centers around insurance access—providing coverage for the uninsured and helping those not able to find insurance. But what about those who already have “good” insurance? What happens to today’s Medicare patient?

While much of the reform will not impact older adults already covered by Medicare, such as those reforms focused on holding private health insurers more responsible, there are areas where older adults will definitely feel the impact. The consequences for older persons covered by today’s Medicare are likely to be a little bit of good, bad, and potentially ugly. These include:

The Good:
o Lowered out-of-pocket expenditures for prescription drugs
o Decreased expenditures for certain types of preventive care

The Bad:
o Decreased managed care benefits
o Higher Medicare premiums for wealthier individuals

The Potentially Ugly:
o Decreased access to primary care providers (PCPs)

The Good: Paying Less
With the signing of the Patient Protection and Affordable Care Act (H.R. 3590)¹ on March 23, 2010, comprehensive health system change began. Perhaps the most positive step put forth by the legislation is for the approximately one in four Medicare Part D beneficiaries affected by the coverage gap or “donut hole.” Most Medicare Part D prescription drug plans have a coverage gap during which beneficiaries must pay the entire cost of their prescription drugs. The gap begins once a senior has spent $2830 on prescription drugs in 2010 and lasts until catastrophic coverage kicks in when a patient has spent $4550 out-of-pocket on medications. The new legislation provides a $250 rebate to Medicare beneficiaries who reach the Part D coverage gap in 2010.

The donut hole will be gradually filled in before completely closing in 2020. Beginning in 2011, pharmaceutical manufacturers will be required to provide a 50% discount on brand-name prescriptions in the Medicare Part D coverage gap, and in 2013, federal subsidies for generic prescriptions will also be phased in. The out-of-pocket amount that qualifies an enrollee for catastrophic coverage in Medicare Part D will also be reduced beginning in 2014 and going through 2019 until the donut hole is completely eliminated in 2020.

While this filling of the Medicare Part D coverage gap will likely assist in Medicare beneficiaries’ ability to be more adherent, there will be some older adults currently covered with employee retiree benefits for prescription coverage who may see a decrease in their coverage. The employee retiree prescription coverage is likely to become less available as a result of the elimination of company tax advantages in providing retiree Part D–like coverage. Up until now, these companies have received a tax subsidy for providing their retiree prescription drug coverage similar to that available under Medicare Part D.

Beyond the changes to prescription drug coverage, Medicare beneficiaries will see that their cost-sharing for preventive services such as cancer screenings will be eliminated on January 1, 2011. In addition, to encourage even greater screening, federal payments to physicians for preventive services will be increased. Coverage of an annual wellness visit that includes a comprehensive health risk assessment and a personalized prevention plan will also be added to the services covered by Medicare. These changes on both the Medicare beneficiary and the physician sides should come together to increase the number of older adults undergoing screening.

The Bad: For Some, Paying More and Getting Less
While it appears that the Medicare Part D benefits will improve, the opposite is true for the Medicare Part C program. Medicare Part C is Medicare’s managed care program, or Medicare Advantage (MA).