By Bill Zeeble, KERA 90.1 reporter.
Dallas, TX – Bill Zeeble, KERA 90.1 reporter: 20 years ago, Karen Guerrero, who's 58, was diagnosed with a degenerative eye disease that now qualifies her as disabled. So she knows about medical problems. But last August she got harsher news. Guerrero was diagnosed with small cell cancer in her liver and right lung.
Karen Guerrero, Secure Horizons cancer patient: My prognosis to start out with was 9 months to a year, maybe a little more.
Zeeble: Last month, things got even worse. The price of Guerrero's potentially life-saving chemotherapy jumped from a 6-dollar co-pay for office visits, to $150 co-pay per drug. The cost of her monthly visits used to total $36. Not now.
Guerrero: My treatment was one of the highest my doctor was giving. So it would be 3 thousand one hundred and some dollars.
Tammy Chambers, director of Contracting, Texas Cancer Care: There's no way patients could pay that.
Zeeble: Tammy Chambers is director of contracting at Fort Worth's Texas Cancer Care, which works with Secure Horizons. Chambers couldn't believe the price hike, but tracked it down and verified it. The president of Texas Cancer Care, Doctor William Jordan, says the cost increase may end up scaring some patients to death.
Doctor William Jordan, president of Texas Cancer Care: The two or three who've elected not to continue have been so overwhelmed by this, they've said to heck with it, I'm not going to take any more treatment, I'll just go home and die.
Zeeble: A defiant Karen Guerrero says she thought about that, but rejected it. On a fixed income, she skipped one treatment for a week, after her doctor said the pause would not be fatal. Then she scrambled for other coverage ? not easy, with her condition. She'd already opted out of Medicare, because for just a few dollars more each month, her choice of Secure Horizons promised to pick up most of the 20% in medical expenses Medicare doesn't cover. That's why programs like it are called Medicare Plus Choice. But now feeling abandoned by Secure Horizons, Guerrero managed to get on the more expensive Medicare, resume her chemotherapy, and pursue some way to pay her doctors. She's convinced Secure Horizons raised its prices to force sick, costly patients like her out of the HMO.
Guerrero: They might as well have lined us up and shot us down the way they've done us. You don't do people like that. If you know anything about cancer...we know we're going to die...if you have a certain kind (of cancer). It's not right. It's not right for them to do us this way. 'Cause every minute, every hour, every day we have is precious to us. You can't set a money amount on it. I just don't believe that!
Zeeble: Guerrero's doctors gave her some better news a few days ago. Against the odds, her cancer may now be in remission. As for Secure Horizons, Vice President Michael Kinney denies the company wanted to force Guerrero and other cancer patients off the plan, even though, in Guerrero?s case, that's exactly what happened. He says the decision was based on economics.
Michael Kinney, Vice President, Secure Horizons Senior Solutions: Our benefit on a line by line basis, cannot be less than Medicare. What we're trying to do is provide value above and beyond Medicare with the resources we're given.
Zeeble: When Kinney says resources, he really means money. He says reimbursements from the Medicare system to plans like Secure Horizons, have been half the needed amount in recent years. Ever since the Balanced Budget Act 1997, or BBA, Medicare reimbursements have risen 2 to 3% a year. Meanwhile, Kinney says actual medical costs have gone up 6 to 10% a year.
Kinney: As you can see, every year there's a gap of 6,7,8%, costs have to come from somewhere. They can either come from providers, or from members. You can either exit a county which everyone has done except us, you can add premium onto your benefit packages, or [and] you can increase cost sharing?
Zeeble: ...or he continued, the plan can raise base fees, as others have done, or raise co-pays.
Kinney: That's what we did.
Zeeble: Kinney adds the $150 per drug co-pay for chemotherapy may sound extreme compared to last year's 6 dollars a visit, but it follows years of other cuts combined with additional price hikes for other services.
Kinney: The benefits seniors were used to seeing prior to BBA, ancillary benefits like eye vision and hearing aid coverage, those sorts of things were the first to go. Pharmaceuticals were cut significantly in resulting years, and now you're starting to see some more extreme cuts. And the extreme cuts are a result of the extreme nature of the problem.
Jordan: You know the old saying, 'when elephants fight, the grass hurts.'
Zeeble: Again, Texas Cancer Care's William Jordan.
Jordan: What you have here is a symptom. It's a very pronounced symptom of a very dysfunctional relationship.
Zeeble: Jordan acknowledges Secure Horizon's cost boost isn't just a symptom of problems between physicians and insurers, both scrambling for a smaller pool of money. It's a symptom of problems between those two and the government.
Jordan: Medicare is underfunded, there's no question about that. But it's nothing new. So why this was an epiphany for Secure Horizons all of a sudden we don't know. But it clearly has to do with the funding of the Medicare program.
Zeeble: Which is why the president's latest budget calls for a 6 and a half percent reimbursement increase for programs like Secure Horizons. Brandeis University's Stuart Altman, professor of national health, and an appointee to President Clinton's National BiPartisan Commission on the Future of Medicare, says there's no question Secure Horizons is telling the truth. He says the plan's been hammered.
Stuart Altman, Brandeis health professor, Clinton appointee, National BiPartisan Commission on the Future of Medicare: Three years ago, after the BBA was passed in 1997, the managed care plans went to people in Washington and said you've created an unacceptable alternative and how ironic. You wanted to improve the number of people going into Medicare-plus-choice programs, yet the policies you've set in motion are going to destroy the program. People in Washington poo-poohed them. "Oh, they're making so much money, they'll just forget about it." Of course, that isn't what's happened. We've had a substantial erosion of Medicare plus choice plans through out the country.
Zeeble: While Altman and others have called for serious changes and new thought regarding Medicare, the high chemotherapy cost for Secure Horizons patients in North Texas persists. 38-thousand plan members are signed up in North Texas. So Congress has gotten directly involved.
Ms. Bret Karr, chief of staff for representative Kay Granger: I think it's a learning process for everyone. We will improve the care we've promised the seniors and that they deserve.
Zeeble: Brett Karr is chief of staff for Kay Granger, who represents Fort Worth in Congress.
Karr: I spoke with Secure Horizons and they assured me a solution, or possibly a band- aid solution, but a way to address the co-pay issue would be out very soon. I tried to press further on what is 'very soon' and didn't get the answer, but understand they have a system to work in and we?re eagerly awaiting their proposal.
Zeeble: Some possible ideas might include a return to last year's pay structure, with a more gradual implementation of new price hikes. There could be transition fees, or different co-pays, or services. In the long run, many, including Jennifer Boulanger, say Medicare reimbursements should at least go up. She's the Acting Deputy Director of Health Plans, at the Centers for Medicare and Medicaid Services in Baltimore.
Jennifer Boulanger, acting deputy director of health plans, Centers for Medicare and Medicaid services: I'm hopeful. But predicting what Congress will do is a difficult thing.
Zeeble: On Wednesday, Ways and Means Chairman Bill Thomas made the case for increased reimbursements for plans like Secure Horizons and other Medicare Plus Choice programs. But at the same hearing, others said instead of dumping more money into the system, maybe it's time Congress admits the program is a failure. For KERA 90.1, I'm Bill Zeeble.