Dazed and Confused

One great thing about computers is they enable us to answer many questions at once. In a blink, a computer can sift through enormous quantities of information, apply numerous variables, calculate and tabulate, and retrieve answers to questions so complex they could take humans hours to process. Medicare-approved drug discount cards, which went into effect June 1 and last until the Medicare drug benefit begins in 2006, seem to have been designed specifically with this capability in mind.

The concept behind the cards is simple. Like other discount cards already offered by some pharmacies, they give seniors reduced prices on certain prescription drugs-plus a $600 yearly drug benefit for those with low incomes. In practice, though, the program has become very complex. Instead of offering one card, as the Veterans Affairs Department does, for example, the Center for Medicare and Medicaid Services (CMS) approved 73 private-sector card sponsors-with the idea that competition would drive down prices. The cards, which cost up to $30 per year, cover different drugs at different prices and can be used at different pharmacies. Seniors can choose only one card, and they cannot make a change until November, though sponsors may adjust prices and add or drop drugs every week.

"The questions keep mounting," said Sen. Tom Daschle, D-S.D., at a Senate Finance Committee hearing in early June: "Should I sign up for the card? If so, which card should I choose? Will my pharmacy take it? Does it offer discounts? If those discounts change, what happens to my benefits? What will my drug needs be if the circumstances change? Is it worth the enrollment fee, and on and on."

To answer these questions, CMS developed a tool for its Web site, www.medicare.gov, that allows seniors to plug in variables-current drug coverage, income, location, how far they're willing to travel to a pharmacy, and the drugs and dosages they take-and retrieve a breakdown of all the cards available. "One of the things that I think is very significant about the drug card is that it's almost essential that you use the Web," said Trish Nemore, an attorney with the Center for Medicare Advocacy, a nonpartisan organization based in Connecticut, in a Webcast on the Kaiser Network, a nonpartisan health policy Web site. "It's very difficult to make a comparative decision without using the Web."

During May, the price-comparison Web tool registered 14 million hits-a clear sign that seniors are interested in saving money. But visits to the Web site didn't add up to high enrollment in the program. By early June, only about 600,000 seniors had voluntarily signed up; 2.4 million more had been automatically enrolled by their health maintenance organizations.

One problem is that seniors, and especially those with low incomes, are not an especially Internet-savvy bunch. Only 22 percent of Americans 65 and older use the Internet, according to the Pew Internet & American Life Project, a nonprofit study of technology use funded by The Pew Charitable Trusts. Without the ability to easily navigate the Medicare Web site, many seniors feel overwhelmed by the array of choices. "You talk to any hundred seniors and at least 99 of them will say this is bewildering," says Ron Pollack, executive director of Families USA, a nonpartisan health care advocacy organization.

And while computers can provide a lot of information, they frequently can't answer all the questions users want to ask. Medicare's Web tool, for example, does not tell seniors the retail prices of the drugs they buy; it just says how much they'll pay under various discount plans. This makes it hard for seniors to tell how much money they'll save, and whether they'll recover the enrollment fee.

Users of the site also report glitches-the tool produces prices that are far too high or low. And even when the Web tool works properly, it often presents a confusing array of choices that users must study to determine which best fit their needs. "They're doing a very good job of making a relatively simple program very confusing," says Judith Stein, executive director of the Center for Medicare Advocacy.

Without the technology behind Medicare's Web tool, there would be no way to compare the cards' prices and coverage. CMS has developed other ways for seniors to get information about the cards, but all roads lead back to the Web tool.

The agency published a 36-page guide to choosing a card, but it does not detail all of the options-that would take far too many pages and would become quickly outdated. Instead, it refers seniors to the Web site and to Medicare's toll-free hot line. Like the Web site, the hot line has been bombarded with inquiries. The phones there rang nearly 4 million times during May-roughly two-thirds of the total calls for all of 2003. But when a senior calls the hot line, a Medicare representative plugs his or her needs and preferences into the Web tool, explains the results, prints them and mails them to the senior.

State Health Insurance Assistance Programs are chipping in, too, by providing one-on-one counseling. And in late May, HHS gave $4.6 million to a coalition of community-based organizations to help educate seniors about the program.

At workshops throughout West Virginia, seniors spend at least an hour learning about the cards and using the Medicare Web tool with a volunteer counselor, says Linda Calvert, director of the West Virginia assistance program. "We give them the opportunity to use the computer if they want to," Calvert says. "But usually they want the volunteer to do it." Calvert says some seniors come to the workshops for help choosing a card even after obtaining their results from the Web tool.

But complex as it may seem, picking a discount card is child's play compared to navigating the Medicare drug benefit coming in 2006, health care advocates warn. "It gives us a sense of the problems ahead," Stein says.