I walked into the dialysis unit to make my weekly rounds. One of the great things about working in the dialysis unit is that, unlike virtually any other medical setting, you get to see your patients as a group, watch them interact with each other, and be greeted with waves and hellos as you walk around. It’s a little bit like a party, except that every patient is attached to a dialysis machine.
An affable Asian man in one of the chairs gestured me over. What he lacked for in English vocabulary, he made up for in body language. "Doctor," he said, shaking his head in amazement and waving a prescription in the air, "Doctor, you think I won lottery?!" I looked at the bill. The pill I had prescribed to him was going to cost…"Eight hundred dollar, doctor!! Last month, only ten dollar!! What happen?"
What happened was my patient had fallen into the Medicare Part D "doughnut hole."
That meant that, until he reached the "catastrophic care" threshold,
he would be paying the full cost of his medications, up to just over
$3,600 in costs before the limits kicked in.
That meant $800 for a bottle of pills.
He was laughing in amazement. "Eight hundred dollar! Good joke, doctor!"
This was not going to be an easy conversation.
It’s much easier to tell someone that his medicine costs are going to
be $3,600 for the year than to try to convince him to pay $800 for
pills that cost $10 the month before. With my patient, I found the
latter to be impossible. There was no way he was going to be able to
swallow the idea that this little bottle required an $800 payment, even
if he had the money saved somewhere.
I made some adjustments that helped him make it through the rest of
the year without spending $3,600. I gave him a cheaper (but possibly
less desirable) alternative to the $800 medicine and asked for some
free samples from the company. I gave him generic medicine to use for
his high blood pressure. Now, perhaps I should have done those things
to start with, well before the limits kicked in. These and other ways
to bridge the gap are suggested by the federal government.
But the thing is, often we don’t have that luxury. New medications
are expensive and sometimes necessary. The costs, over months of
therapy, are high. (And to be fair, Medicare Part D does provide
substantial coverage to some people who in the past might have been in
a "hole" all year long.)
It’s April now, and things are back to normal on the dialysis unit.
But each as each month ticks by, I’ll be getting closer to the day when
someone comes in and waves another $800 prescription at me. And we’ll
be back in the hole together.
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