Drug Benefit Enrollment Varies by County

It’s low in Mono, high in Solano, and about average in Orange — six months into the enrollment period for the new Medicare prescription drug plan, seniors and people with disabilities who are eligible for Medicare are signing up with varying enthusiasm across California counties. While some regions have seen impressive results, others — mostly rural counties — have had less success enrolling eligible residents in the new drug program.

In April, CMS announced its preliminary enrollment figures for Part D, the new prescription drug benefit passed with the Medicare Modernization Act in 2003. Overall, California beneficiaries are well covered compared to the rest of the nation, ranking second just below Hawaii with 78% of eligible beneficiaries enrolled in some kind of creditable prescription drug plan.

However, a closer look at the data reveals that some counties have markedly outperformed others: 90-91% of eligible residents in Solano and Sacramento counties enrolled in Part D while only 56% of those in Alpine and 59% of those in Sierra counties signed up.

Medicare Microclimates

So why the wide variance? The CMS analysis doesn’t answer that question, but Jack Cheevers, communications director for CMS Region IX, believes the situation, which also is apparent in other states, can be attributed to two factors: the higher number of dual eligibles and the higher penetration of HMOs in urban areas.

“Dual eligibles in urban counties were automatically enrolled, which helped to lift enrollment figures there,” he said.

Tricia Neuman, Medicare Policy Project director for the Kaiser Family Foundation, agrees with that analysis. She says urban county enrollment also was buoyed by the existing concentration of managed care organizations in metropolitan areas where it’s easier for HMOs to form provider networks.

“Not all counties are starting from the same place, which helps to explain why there’s state to state and county to county variation,” she noted. “Some counties and states got a running start because they had high Medicare Advantage enrollment going into this.”

The absence of HMOs and integrated care networks also might contribute to the lack of outreach resources in such areas, leaving rural beneficiaries further isolated from the web of connections that otherwise would keep them informed.

Providers, research analysts and senior assistance groups in the field have their own theories.

Bonnie Burns — director of education for California Health Advocates, the umbrella group for local counseling agencies that educate Medicare beneficiaries — believes that county-to-county differences probably are attributable to the unique characteristics of each region’s population. Los Angeles County, for example, has lower enrollment than other counties because of the complex ethnic mix of its eligible residents, she said.

According to Lauri Medeiros, director of the California State Rural Health Association, enrollment in remote, rural areas has been hindered by lower numbers of people with access to the Internet and the limited resources of rural pharmacies.

“There is a greater proportion of older residents in rural areas, but broadband isn’t even available in 33% of these areas, so Web surfing and Internet outreach really aren’t an option,” she said. “People tend to go through the traditional routes to get information, but there are also fewer health provider organizations and pharmacies in rural areas.”

The Lifeline: Struggling Small Pharmacies

Small, independent pharmacies — already struggling for survival in many cases — have the fewest resources to invest in outreach and education for rural beneficiaries.

In Fresno, some independent pharmacists have complained that they’re taking a hit from the Medicare drug benefit’s lower reimbursement rates at a time when they’re barely able to make ends meet. Delayed payments associated with glitches in Part D’s rollout only make matters worse for small, community-based proprietors – an ongoing problem that CMS has pledged to fix.

In some instances, communities are too small to support even one small community pharmacy, creating pockets where beneficiaries have no access to professionals versed in Part D.

“Seniors in rural areas don’t have the benefit of that routine communication with a pharmacist or pharmacy, and that would be another path where people would find out that they need to sign up,” Clare Smith, executive director of California Health Advocates, said.

Cautious Consumers

In the wake of the initial confusion surrounding Part D, other beneficiaries are waiting to see how the plan shakes out.

“A lot of people began hearing horror stories in January [about the program] and wanted to hold off until the problems got worked out,” Lori Howton — outreach specialist for the Area 4 Agency on Aging, which counsels rural seniors in Nevada, Placer, Sierra and Yolo counties — said . “People waited until their hand was forced and now everyone’s calling to enroll.”

These risk-averse people might be right to worry, argues Bonnie Burns. With ongoing consolidation in the health care insurance market, fewer and fewer plans may be available in the future, which could limit consumer choice or cause premiums eventually to creep upward. And with fewer competitors to worry about, plans may also begin to limit their formularies, cutting out high cost cancer drugs or other expensive name-brand medications.

Deadline Extension?

According to Smith, the fact that some California residents haven’t taken advantage of the Medicare drug benefit is no fault of their own but rather a failure of CMS’s outreach efforts. Extenuating circumstances, not personal choice, probably led to a tepid response in certain regions and for that reason, the enrollment deadline should be extended so that beneficiaries who missed the boat during the initial sign-up period aren’t faced with onerous fines — currently, a 1% increase in premiums for every month delayed beyond May 15.

“[CMS] hasn’t reached everyone, and we will have a lot of people facing a penalty because they haven’t been informed. The problem with this benefit is that it’s just too complicated and it has moved too quickly,” Smith said.

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