Letters

Medicare Part D and Decompensation

To the Editor: We recently evaluated a woman in the emergency department who was disabled by recurrent major depression. One month before her visit, she became extremely distressed and hopeless when she received a brochure outlining the Medicare Part D program and became overwhelmed by the complexity of the possible prescription benefit plans. This hopelessness led her to abruptly discontinue her ten medications for depression and cardiac disease, and she attempted suicide by overdose one week later.

Caring for this patient prompted us to compare the Medicare Part D prescription plans ourselves. A Medicare Web site ( 1 ) listed the 18 companies that offer a total of 44 different plans in Massachusetts—a daunting list. We called the customer service number for each company to request a Web site that would provide a drug formulary. Two offices left us on hold indefinitely, two were not open, two provided us with incorrect Web site information, and two did not have formularies accessible online at that time. Of the ten companies' formularies that were online, only one explained the cost of prescription drugs for Medicaid recipients. We searched the formularies for the ten medications used by the patient, using generic and brand names as written in her medication list. Of the various plans, one offered all ten of her medications on its formulary; most offered from four to nine of them. In many cases, it was impossible to know the monthly cost of this list of drugs because of varying premiums, deductibles, copayments, and limits.

Among patients with mental illness, anticipation of changes in treatment providers or treatment plans can have a destabilizing effect. This case demonstrates the potential for psychiatrically and medically compromised patients to decompensate as they are faced with a complicated array of coverage options. Given 44 possible plans, each with relative advantages and disadvantages, covered and noncovered medications, and varying copayment options, it is understandable that individuals will experience stress over making such a decision. This stress is likely to be compounded when such a decision is made in the context of life-threatening illness, financial hardship, financial penalties for not choosing a plan in a timely fashion, and the possibility that a single plan will vary its formulary over time ( 2 ). In addition, considering the difficulty we faced as we researched the formularies over several hours, we wonder how physicians will obtain these lists when necessary.

Educating ourselves and our patients and maintaining their optimal treatment as they enroll in the Medicare Part D program will be an important and extremely challenging task.