Last week, the Centers for Medicare & Medicaid Services (CMS), the agency that administers the Medicare Part D prescription drug program, released statistics on the number of complaints about Part D received by 1-800-MEDICARE, by CMS regional offices, and by Medicare Integrity Contractors.  CMS reports that they received 2.3 complaints per 1,000 beneficiaries during June 2006.  Most complaints were about problems with enrollment and disenrollment.  Data were also collected for three other complaint categories: benefits/access, pricing and co-insurance, and other.  The Center for Medicare Advocacy (the Center) questions whether these numbers accurately reflect the scale and scope of the problems beneficiaries are experiencing with Part D.  As reported in the Center’s Report, “Medicare Part D Progress Report: Six Months Later Headaches Persist” (http://www.medicareadvocacy.org/PartD_6MonthReport072006.pdf), the Center’s experience with beneficiaries enrolling in plans, accessing plan benefits, and being charged improper cost-sharing amounts indicates a significantly higher rate of complaints.

Low numbers on problems with enrollment

CMS reports receiving 2.3 complaints per 1,000 beneficiaries during June 2006, or 2.6 per 1,000 enrollees for stand-alone prescription drug plans (PDPs) and 1.4 per 1,000 enrollees for Medicare Advantage plans (MA-PDs).  The most significant problems involved enrollment and disenrollment.  Complaints for PDPs represented 65% of the total complaints.  It is important to note, however, that open enrollment was closed May 15, 2006 for PDPs.  It was during this month that CMS reported some of the most significant increases in enrollment.  Reporting numbers only from June, the month after enrollment ended, does not give a complete picture of what beneficiaries may have experienced when they enrolled or tried to switch plans before the deadline for PDP enrollment.  Enrollment in MA-PDs was open until June 30, 2006.  We would expect, therefore, that enrollment complaints for MA-PDs might be higher during and after June, since enrollment was still open until June 30.  Indeed, the data from CMS seem to support this notion: 78% of the complaints that were received about MA-PD plans were about enrollment.  This is one possible interpretation of the June numbers, but it is impossible to definitively explain this variation without data from previous months, and for MA-PDs, from at least the month following close of enrollment.

At the same time, persons dually eligible for Medicare and Medicaid (duals) in particular are experiencing major difficulties: enrollment in multiple plans at once and being switched into different plans without consent.  With such confusion, many duals do not fully understand what has happened or simply acquiesce to new plan assignments in order to avoid problems. In both cases, duals would likely not have reported problems to Medicare or its contractors that would actually be logged as a complaint.  It is also possible that many of these problems occurred in the months prior to June and are not reflected in CMS’s statistics.

Excluding complaints filed with plans

CMS’s numbers also seem artificially low because they do not count the myriad places beneficiaries, family members, pharmacists, and others who assist beneficiaries may have filed a complaint.  The largest source of complaint data aside from CMS would likely come from advocates and the Part D plans.  Furthermore, CMS has indicated that they view the 1-800-MEDICARE number to be a fall back to beneficiaries contacting their plans.  Thus, if a beneficiary were to call, but had not yet contacted their plan, the complaint would not be logged.  Additionally, CMS notes that its data may not include complaints reported by pharmacies, an important source of information.  Indeed, millions of beneficiaries have relied on their pharmacists for help when encountering problems with their Part D plans; pharmacists often make calls to doctors’ offices, plans, 1-800-MEDICARE, and advocacy groups on behalf of beneficiaries.

In addition to the complaints filed with 1-800-MEDICARE, CMS regional offices, and Medicare Integrity Contractors, CMS should, at a minimum, include complaints filed with plans and Social Security Administration (SSA) offices.  It should further be noted that beneficiaries have also voiced complaints to numerous advocacy organizations, State Health Insurance Assistance Programs (SHIPs), and Congressional offices.  Including these complaints in the total numbers would give a more accurate picture of the problems that need to be addressed, and would likely reflect a different scale and scope of the problems beneficiaries are facing.

Who decides what constitutes a complaint?

It is not clear exactly how 1-800-MEDICARE flags a call as a complaint, or what criteria are used to classify a particular call as a complaint.  None of the data released by CMS contains details about its Medicare Complaint Tracking Module (CTM).  In fact, a simple Google search for “Medicare Complaint Tracking Module” produces only two results – both footnotes from CMS’s publication of the complaint statistics.  In a recent Medicare Ombudsman call, the Center was told that there were no public documents about this process, and no plans to make public any such documents.

The Center’s own experience calling 1-800-MEDICARE on behalf of beneficiaries raises concerns about how complaints are tracked.  Customer Service Representatives (CSR) have informed the Center that there are no reference numbers when official complaints are filed.  Complaints are identified by the beneficiary’s Medicare number, the CSR representative who took the complaint, and the date and time of the complaint.  While the CTM system is supposed to correct some of these inefficiencies, it is still unclear how a call is determined to be a complaint.

Complaints about access to benefits

As the Center for Medicare Advocacy notes in its report on the first six months of Part D, beneficiaries are largely unaware of the processes available to them to appeal inappropriate coverage decisions.  A beneficiary who is asked to get prior authorization for a drug that should be protected because of its class may not know that unfair restrictions are being placed on the drug or what to do to appeal such a restriction.  Often beneficiaries are in the dark about how quickly a plan is required to respond to appeals requests, and therefore do not know that they should file a complaint when those time limits are exceeded.  Although notices regarding appeals are required to be posted at pharmacies, they are often posted in awkward places, are hard to read, or are not posted at all.  The Center’s experience in aiding beneficiaries with complaints also indicates that beneficiaries are largely uneducated about their appeals rights; this seems to be reflected in the numbers CMS released, where only .2 complaints for every 1000 beneficiaries were received by PDPs for benefits/access problems and .1 per 1000 for MA-PDs.

Unless and until a true and verifiable complaint tracking system, publicly available for analysis, is in place, CMS should refrain from making claims about how well their system is working.  The Center for Medicare Advocacy and other advocacy groups have fielded thousands of calls, emails, and written correspondences that belie the numbers CMS is touting.  This program is not the simple success they claim.  The real solution is not a fragmented array of plans and agencies who fail to communicate with each other, but rather a uniform benefit within the traditional Medicare program.

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