Cancer Treatment, Other Health Costs Soar For Seniors
SAN JOSE, Calif. — As Marve Schneickert headed into a renewed bout with bladder cancer after a decade in remission, her doctor advised her to change health insurance plans — fast.
Schneickert was a member of Secure Horizons, one of the largest Medicare HMOs in the country. For years, she says, she was quite satisfied with her insurance, which provided additional benefits that Medicare does not pay for, such as prescription drugs.
But this January, Schneickert and thousands of other seniors were shocked to find Secure Horizons had drastically raised out-of-pocket costs for its sickest patients.
For Schneickert, that meant paying $275 a week for chemotherapy — a cost she says she can't afford.
Medicare HMO costs — for prescription drugs in particular — have been rising for seniors around the country, and other insurers have also increased some patient costs. But doctors and patients say they are stunned by Secure Horizons' cost increases, not only because of their size and scope, but because they affect life-saving medical treatments that patients cannot go without, including chemotherapy, radiation therapy and dialysis.
Secure Horizons, which is run by insurance giant PacifiCare Health Systems, says it has no choice if it is to continue insuring Medicare patients at all.
"There's no question we feel the pain some of our seniors have to face. Unfortunately, PacifiCare is being squeezed by paltry payments from the federal government," said spokesman Tyler Mason.
Secure Horizons' changes have drawn criticism because they affect its most vulnerable patients, but similar if less drastic cuts are becoming more common for Medicare HMOs. Indeed, advocates for seniors worry that they are a chilling indication of where Medicare HMOs may be heading in an era of rising costs.
A report released this month by the Commonwealth Fund, a health research foundation, bolstered their fears. The study said that 80 percent of seniors in Medicare HMOs will be forced to pay higher out-of-pocket hospitalization fees in 2002, compared to 33 percent in 2001.
Secure Horizons says it has no choice but to raise copayments if it is to stay in business. Once nominal copayments for chemotherapy now cost up to $550 per treatment for some drugs that are administered weekly.
"It's very unfair. I just have so much to live on," said Schneickert, who is 76 and lives in San Jose. "I probably would have been paying more than $1,000 more a month if I'd stayed with Secure Horizons."
Such costs have a surprise for seniors used to paying much less for their regular coverage. The monthly premiums for Secure Horizons, according to a federal price listing, run about $85, although prices can vary by region. The insurer says the recent cost increases make affordable premiums possible, but many seniors are still finding that equation hard to balance.
Schneickert was fortunate enough to find alternate insurance that pays almost all of the cost of her treatments. Some seniors, however, have been forced to change doctors in the middle of cancer care. Some with serious pre-existing conditions have struggled to find other coverage.
Some patients, in consultation with their doctors, have even delayed or altered certain therapies, fearfully balancing financial security against potentially compromised health. To make matters worse, new Medicare rules only allow seniors to change their insurance once during the year, forcing some to stay with Secure Horizons if they have already made their change.
"People in this situation are stuck in between," said Deirdre O'Reilly Marblestone, a San Mateo-based case manager for the Health Insurance Counseling Assistance Program. "It's really frightening. It's a choice between paying the rent, buying groceries, or getting your cancer medications."
Medicare is the U.S. government's health care safety net for seniors, but it typically does not cover all health care costs. To cover what Medicare does not, many seniors purchase supplemental insurance; some purchase Medicare managed care plans, such as Secure Horizons. Others obtain other fee-for-service insurance policies, known as Medigap policies, that offer different kinds of benefits and, often, more choice in doctors and hospitals.
Like its competitors in the Medicare managed care marketplace, Secure Horizons has been beset by spiraling drug costs at the same time the federal government has sharply cut the amount of money Medicare pays doctors and hospitals for services.
Although these Medicare HMOs signed up millions of seniors in the 1990s by offering free prescriptions, lower negotiated rates on medical treatments and other benefits, they have lately dropped out of the market in droves.
Roughly 2.2 million Medicare HMO members have lost their coverage in the past four years. Those that remain find dramatically scaled-back benefits, higher copayments, and increased premiums. Those changes are approved by the federal government, which monitors the benefits Medicare HMOs provide. Starting this year, for example, Secure Horizons covers only generic prescription drugs.
"It has been very difficult to ask our long-standing members to pay more," Mason said. "But it is necessary to offset lagging government reimbursement rates and increasing medical and pharmacy costs."
That explanation fails to comfort one San Jose woman whose husband has been forced to scale back the dosage of his weekly injections to make ends meet. The woman, who asked not to be identified, said her husband received the injections of a medication called Procrit for severe anemia. Their doctor advised lowering the weekly dosage slightly to qualify for a lower copayment, which saved the couple $100 weekly.
"We trust our doctor, and it's not a life-threatening thing at this point," the woman said. "But I resent that we have to balance his health with our budget."
Advocates for seniors say they are mystified by the federal government's approval of Secure Horizon's high copayments for chemotherapy and other treatments. The federal Center for Medicare Services must approve all such cost increases as part of the agency's annual review of Medicare HMO plans.
The agency approved Secure Horizons' new benefits package because it passed a sophisticated financial test that showed consumers would not be paying more overall with their Secure Horizons HMO plan than if they received Medicare alone, said Mary Anne Grandlich, the center's San Francisco branch manager. The federal government also allowed another Medicare HMO, Blue Cross "Senior Secure," to raise hospitalization copayments to $125 each day, up to an annual maximum of $2,000 — a substantial sum to many seniors.
"This was the first year we've had such large increases in copayments in California," Grandlich acknowledged. "We're hoping there will be some change in the way this process works next year."
Carol Jimenez, legal counsel for California Health Advocates, said she believes the federal agency "didn't look very closely at the packages."
"Clearly, the plans are discriminating heavily against people who have high medical needs and who are disabled, and they're not supposed to be doing that," Jimenez said.
Some medical professionals have even accused Secure Horizons of trying to rid itself of its sickest _ and most expensive _ patients. Secure Horizons' officials dispute that claim, saying they must increase some individual costs to continue to insure as many people as possible.
Physicians, distressed by the changes, are looking for ways to help Secure Horizons patients. Some Bay Area oncologists reported sending patients to local hospitals to have their weekly chemotherapy treatments, which typically last an hour and a half and are often performed in doctors' offices.
One Santa Cruz oncologist, Dr. Michael Alexander, has asked patients to come in more often for lower-dose injections, which is inconvenient and stressful for the very ill. "I think what they've done is unconscionable," he said.
"Everyone who is in this circumstance is in financial distress," said Connie Corrales, a Santa Clara County-based manager for HICAP. "My fear is, if Secure Horizons is doing it this year, will the other HMOs follow?"