Блог Анкара

In This Chapter

► What makes massage work

► Types of massage and how they help you

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M MVhat does massage really do for you anyway? Sure, it feels incredible to WW Receive one, and it looks nice to watch beautiful people massaging each other on how-to videos, but what’s going on beneath the surface? Is it worth it to actually fork over your hard-earned cash to have someone rub your skin for an hour? Should you spend your precious time and energy learning how to give a good massage yourself? Is massage really effective, or is it just an unnecessary, flashy indulgence, like fish eggs on toast?

Well, being a massage junkie myself, I find it difficult to imagine why anybody would Not Want to get a massage, anytime, anyplace, for any reason at all or no reason at all. For me, massage has just always seemed like such an obviously good thing to do, starting way back in 11th grade when Grace came over to visit at my parent’s house one afternoon, and nobody else was home. Being a typical seventeen-year-old, I was hoping that we were soon going to engage in some good old-fashioned hanky-panky, and when Grace told me to loosen my belt and lie down on the carpet, I began singing Handel’s Messiah Silently to myself.

Grace touched me then, on the small of my back, and I’ll never forget the sensation. "This is a massage technique that somebody taught me," she said. "How does it feel?"

"Ah, it feels, um, kind of, uh, unbelievable!" I said, and unbelievable was exactly the right word. Grace was doing something clearly non-sexual, and I could not believe that anything non-sexual could feel so good. I could not

Believe that there was a way to be so intimate with somebody and yet not get in trouble with her father, if he were to find out about it. In short, I could not believe that something that was neither illegal, immoral, nor fattening could be so sumptuously pleasurable.

I asked Grace to keep doing what she was doing, and as she did so, I began devising, right there with my face buried in my parent’s green shag carpeting, a future lifestyle that would include the absolutely highest number of massages possible.

This early experience pointed out a fundamental truth about massage therapy, but one that is often missed by those people who judge it before they even give it a try. That truth: There is a difference between sex and massage therapy. There, I said it, right here in Chapter 1, and I’m glad. Some people out there will forever be mixing the two up, which does a disservice to everybody else, especially those people who have shied away from massage over the years because of a perceived less-than-pristine image.

I discovered, in that youthful, eye-opening experience, that massage does indeed feel unbelievable, and that discovery was a great place to begin. Now, more than 20 years later, after studying massage and teaching massage and experiencing the myriad facets of massage both in the U. S. and in other countries, I’ve been introduced to other, deeper reasons for including it in my life, reasons with profound implications for improved health, well-being, and even longevity. These are the reasons I’d like to share with you in this chapter and throughout the book.

Basic Benefits of Massage

If I were to go into some of the stories about how massage has helped people change their lives, heal themselves, become rich and famous, and so on, you probably wouldn’t believe me right away, because, after all, we’re still in Chapter 1. So I’m going to start out slowly and offer you some of the simplest, everyday ways that massage can help you, some of which still may come as a surprise to you.

Here, then, not ranked in any particular order, are some basic benefits of massage that perhaps didn’t pop straight into your head the first time you thought about it. Massage…

J> Helps relieve muscular spasm and tension Raises immune efficiency

Improves circulation Promotes the healing of tissues Increases healthy functioning of the skin Engenders profound relaxation Offers emotional reassurance V Improves appearance

I’d like to take these points one at a time and let you get comfortable with them.

Helps relieve muscular spasm and tension

As you can see in Figure 1-1, there is a definite physical difference between muscles that are relaxed and happy and muscles that are tensed up due to stress, overuse, injury, and more.

But there’s more to it than that, believe it or not. Regardless of how wickedly clever my rope analogy is, the human body is much more complex. In fact, it’s so complex that nobody has completely figured it out yet, even though countless researchers have spent a lifetime trying to do so. A whole bunch of really interesting things about the body have been discovered, however, along with how it responds to various types of stimuli, including massage.

For example, one of the most direct effects of massage is to help loosen the tension we experience as knots, kinks, and spasms in our muscles. This is achieved in a number of ways:

The application of pressure creates awareness that there is indeed tension in a particular area, and the person receiving the massage can then begin to consciously release that tension.

V Through the application of friction to the area, a Thermodynamic Effect takes place, warming and softening the tight, hard tissue.

By stimulating Trigger points, The local nerves are soothed, allowing a release of contractions.

Raises immune efficiency

Did you know that there is a vast system of vessels running through your body, roughly parallel to your circulatory system, and that this system is filled with a fluid that is responsible for carrying away and eliminating many of the organisms, bacteria, viruses, and other microscopic bad guys that might otherwise attack you? Yes, it’s true. This is the Lymph system, Otherwise known as the Canadian Mounties of your body.

^tALfyj* Your lymph system has Nodes At various strategically located areas through-y^^^v out your body, and these nodes have the job of capturing the invaders and kN^r | processing them before eventual expulsion through your Excretory system. N^TJp? Now, you may be wondering, how the heck does this lymph fluid get pumped through your body anyway? Funny you should ask. I’ve devised a test to discern your knowledge on that very subject.

Holy anatomy quiz, Batman!

That’s right, but it’s just a one-question quiz, so don’t let your anxiety levels rise too high over it. Here we go:

Question: How does the body pump the critically important lymph fluid through its lymph vessels, keeping your inner ocean clean and healthy?

A. The heart pumps the lymph, just like it pumps the blood.

B. The centrifugal force from riding various carnival rides is the best way to get the lymph fluid moving.

C. Fear caused by sudden, unexpected physical proximity to vampires or werewolves causes the lymph vessels to contract, circulating the fluid.

D. Movement, muscular contraction, and massage therapy are the ways lymph fluid is most effectively moved through the body because the lymph system has no pump of its own, such as the heart.

Right! The answer is d. By helping your body circulate this lymph fluid, massage aids in the elimination of noxious invaders (toxins) From your body.

Our neglected muscles

Even though you have over 600 muscles that take up approximately 60 percent of your body weight, they sometimes get neglected, especially when it comes to your average physician.

For example, many times after serious trauma, such as a car accident, physicians perform appropriate procedures to save the life of the injured person and to repair any gross damage. Then physical therapists take over to help restore as much use and feeling to the affected areas as possible. What happens, though, when that person returns to his physician or physical therapist six months later complaining of

Chronic pain? If no further operations are warranted, and continued physical therapy doesn’t seem to help, there are only two choices as far as most physicians are concerned:

Prescribe drugs

V0 Counsel stoicism

Thafs right, the only two choices are to either mask the pain or learn to live with it. In the massage model, though, something restorative can be done with that 60 percent of your body known as Soft tissue to Bring about relief.

There are other factors at play, too, in massage’s effectiveness as an immune booster. As reported in LIFE Magazine (August 97), studies in orphanages have shown that infants and children deprived of touch experience stunted growth, both emotionally and physically. Further study showed that touch promotes the release of human growth hormone (HGH), which is essential to our development. If a child is not touched sufficiently, his or her development will be stunted, and susceptibility to disease will be increased, with potentially catastrophic results. Many of the untouched children in orphanages have died for lack of simple contact.

Improves circulation

This is the reason that the cigar-smoking octogenarians who frequented old-fashioned health spas used to give for receiving massage: "It’s good for the circulation!" they’d say. And they were right.

Students in massage school are taught to always massage in the direction of circulation, toward the heart, whenever they’re applying enough pressure to move the blood underneath the skin. The reason for this is that your veins have little one-way valves in them that keep blood from going back in the wrong direction. So obviously it’s not a good idea to push the blood back against these valves, potentially harming them. In fact, when these valves don’t work properly on their own, the blood seeps backward

And pools up, causing the appearance of varicose veins, which are a Contraindication For massage, but I’m skipping ahead to Chapter 10 already. Sorry about that.

You have the idea: Some massage movements physically push the blood around in its vessels and can therefore, when done properly, push it in the right direction, improving circulation.

Massage also draws more blood to the surface of the body and into areas of relatively poorer circulation, thus bringing with it much-needed oxygen and other nutrients for the tissues.

Promotes the heating of tissues

This benefit is primarily a result of the previous two. By helping to bring nutrient-rich blood into areas that are recovering from any type of problem, and by helping to cleanse these same areas of toxins (by stimulating the lymph system), massage promotes quicker healing.

Also, certain types of massage stretch and soften tissues in traumatized areas, helping them regain natural elasticity and strength faster.

But beware: You definitely don’t want to rush straight in and massage your cousin John’s swollen knee after his recent surgery unless you’ve been trained in bona-fide massage classes and know what you’re doing.

Increases healthy functioning of the skin

The skin is wheremassage has its most pronounced effects. In fact, I’ve devoted the whole of Chapter 3 to it. So let me just say here that massage includes several actions that leave the skin silky, vibrant, and fully functioning in both directions. By that I mean it promotes the shedding of dead cells while also encouraging the absorption of moisture, nutrients, vitamins, and other vital elements, especially when the massage is given with the aid of creams, oils, and lotions created for just that purpose.

In this sense, massage helps the skin "breathe." Just as our lungs breathe both in and out, inhaling and exhaling, healthy skin must breathe in both directions, too, and massage can help with that.

Offers emotional reassurance

In a famous experiment conducted by some truly sadistic researchers, some unfortunate little monkeys were brought up in cages with surrogate mothers. Each monkey had two mothers in the cage with him. One was a rag doll and the other was a hard wire shell. The uncomfortable wire mother had a nipple with real milk coming out, but the rag doll mother had no nipples and no milk. The researchers shocked the monkeys, then they sat back with smug-researcher-expressions on their faces to see what would happen. In every case, when they were desperate for comfort and safety, the monkeys scampered straight over to rag-doll-mommy, regardless of the fact that she had never provided any other kind of food or sustenance beyond the fact of being soft and cuddly.

This brings us to an important realization as far as humans are concerned, too: Almost every person alive, when shocked, would rather squeeze a rag doll than a hard wire shell with a nipple attached. This bit of information, I’ve found, makes a fascinating ice-breaker at cocktail parties.

Extrapolating from this data, the researchers were able to conclude, with a good degree of confidence, that tactile sensations are the most important factors involved with emotional comforting.

Massage, by offering a sustained, intentional, caring form of tactile stimulation, is one of the best ways to impart emotional reassurance, and emotional reassurance just may be the number one need of humans in the twenty-first century. We modern urban dwellers are all a bunch of shocked monkeys searching for Mom, basically. And massage is the ultimate rag doll.

Engenders profound relaxation

Dr. Robert Benson of Harvard wrote in The Relaxation Response That by repeating certain breathing and concentration exercises, people could greatly reduce their levels of stress. Massage, by its very nature, induces a similar response. It’s a mini-vacation that you can take right there inside your own body. No need to buy expensive plane tickets or submit yourself to the hassles of taxi rides and hotel rooms. Just close your eyes and let someone else send you to your own virtual Tahiti.

If you receive a massage and don’t relax, it’s the same thing as going to Tahiti and not enjoying the scenery, the warmth, the water, or the colorful little umbrellas in the cocktails. In other words, it’s up to you. Nobody can force you to relax while receiving a massage, just as no one can force you to enjoy the South Pacific, but you’d have to be kind of crazy not to.

Improves appearance

The combination of all the preceding benefits leaves just about anybody who receives them looking better than they did before they started, and in that way, massage can improve the appearance of even the most stubbornly unattractive person. You know the type: the man with the big crease down the middle of his forehead, or the woman with her mouth pulled taut like she just chewed an entire lemon. Most of what we deem unattractive is simply poor attitude, and the people with the strangest looking faces and bodies can still be very attractive, especially if they are…

Tension-free ^ Healthy

Flushed with the rosy glow of good circulation

Quickly recovering from any painful conditions

Covered with silky "breathing" skin i> Confident and emotionally assured W Profoundly relaxed

Who can resist a person like this?

The Massage Menu

There are literally hundreds of types of massage practiced around the world, many of them with wonderfully evocative names like Tui-na And Lomi lomi. This is not the section in which I’m going to explain each of those massage Modalities To you, however (a fairly extensive explanation of several major styles is the focus of one section in Chapter 5). Instead, what I’m doing here is explaining the generic types of massage, broken down into categories based on the observable effects they can have in your own life.

Think of this section like the menu in a restaurant. Each category (breakfast, lunch, dinner) consists of distinctly different dishes, and yet the foods used to prepare the dishes can be the same. So the same eggs used to make your omelet at breakfast can be used in your egg salad at lunch or your dessert after dinner. It’s the same with the following categories of massage. Any particular massage technique can be used to create various effects.

When you head into Chez Massage, you can order a-la-carte or request a prearranged sampling of offerings, like on a prix-fixe menu. The following do not present a completely exhaustive list, but they cover all the main entrees and several side dishes as well:

Relaxation massage

This category may be the most familiar to those of you who have not delved into the world of massage before. It’s the type of massage you see on TV. For example, in one of the older James Bond movies, Sean Connery poses as a massage therapist in a European spa and rubs some information out of one his enemies (a beautiful Russian enemy, of course). The impromptu maneuvers he made up at that point consisted of simple, straightforward rubbing and sliding. A trained massage therapist delivers quite a bit more effectiveness than Sean did, but in essence, the purpose of the relaxation massage is, duh, to relax. This is particularly helpful in these instances:

1)^ For stress relief, when the daily grind is just too much and the simple act of lying down and having someone pay solicitous attention to you for an hour is enough to make a big difference. For pampering, which is fine, as long as you don’t feel guilty about it.

Sports massage

Just ask the world-class athletes who travel with their own personal massage therapists. They’ll tell you what a difference a massage can make. Many Olympians and high-level players in all sports are true believers, but they are not the only ones who use massage as part of their training. Even amateur athletes and weekend warriors incorporate it whenever they can, specifically, pre-event, post-event, and for ongoing training.

Rehabilitative massage

This type of massage helps the body repair itself. Many people have found that it was the key factor in helping them heal quickly and get back to normal activity levels as soon as possible after injuries and after surgery.

Doctors are people, too

You may notice that on several occasions in this book, I allude to physicians as people who are not quite up to speed with reality when it comes to the very provable value of massage therapy. In fact, I’ve already said something to that effect in this chapter.

So I just want to make something clear before you get the wrong idea: i think doctors are great. I respect and admire doctors and consider several to be friends. Sure, there are some jerk doctors just like there are jerk massage therapists, but all-in-all, physicians are some of the most responsible, educated, humane, helpful humans on the planet, doing all kinds of good work.

When you hear me say anything less than complimentary about physicians or Allopathic medicine, It’s not the people themselves I’m referring to so much as the system we’ve created in which they work. Unfortunately, our present situation does not allow for doctors to spend the time with each individual patient that they’d probably like to. At the same time, many of them are realizing the value of massage and have even begun including it in their practices. In fact, a September 1998 survey of medical schools published in the Journal of the American Medical Association (JAMA) Revealed that 64 percent of medical schools offer courses in complementary medicine, including massage, which is the most popular alternative Modalitytauqht

Miriam Wetzel, Ph. D., director of curriculum development at Harvard Medical School, says that therapeutic massage is part of the school’s training. "I would like to see the medical community recognize that there is a difference between therapeutic massage and something that’s just relaxing," she says.

In France, where my co-author Michel Van Welden received his training, physicians look at massage in a wholly different light. "What we do is respected as part of the medical model all across Europe," says Michel. "Physicians there have no qualms about referring particular cases to massage therapists. In fact, the word we use in France for massage therapist is Kinesiother-apeut, Which really signifies a combination of massage therapist, physical therapist, and holistic practitioner who utilizes a number of healing tools, such as aromatherapy and herbology. There are 25,000 of them in France, which is an area the size of Texas. Most of them have their own clinics, and they are very highly regarded by physicians and patients alike."

Some of us in the alternative health world have given doctors a bum wrap for too long. I say let’s move forward toward an Integrative medicine That includes their expertise and ours together. This is already happening as witnessed by the quickly growing number of health clinics and hospitals with practitioners from many disciplines: M. D.s, acupuncturists, massage therapists, nutritionists, herbalists, and others.

Esthetic massage

We all want to look as good as we can, and massage can help. Through a combination of several of the benefits mentioned earlier in this chapter, massage softens your skin and gives you a healthy glow. It is also used to improve the

Appearance of certain skin irregularities such as cellulite, with varying degrees of efficacy. People include massage in their beauty regimen for its ability to promote a youthful appearance and as an auxiliary treatment to enhance the effects of other beautifying procedures, such as plastic surgery and facials.

Energy-balancing massage

If massage were a map of the world, energy-balancing would be China. Yes, that’s how big it is. Because energy is invisible, it’s easy to dismiss it as unimportant, as far as our bodies go. But for a moment, imagine your body without energy. That’s right: limp as a cooked noodle, flat as a pancake, blah as all get-out. Many of the massage styles I go over in Chapter 5 are based oh an understanding of the body’s energy systems, focusing on how to balance and enhance our inner invisible energy. These techniques can basically be categorized as either ancient systems, such as acupressure, or modern systems, such as cranio-sacral work.

Massage for increased awareness

Most of us inhabit our bodies without giving it much thought. We walk around in them and sit around in them and lie around in them, all on automatic pilot, relying upon the old patterns and habits we picked up in childhood. Sometimes, we’re negatively influenced by injuries and other traumas that turn these unconscious habits into potentially debilitating conditions. We feel "stuck" in certain postures and can’t get out. A massage can help you become aware of how you’re holding onto certain patterns of tension and thus let you break them, and it can help you gain self-confidence through releasing old, negative body images.

Spiritualty oriented massage

Depending on your frame of mind, any massage can be a spiritual experience, regardless of whether you receive it in an ancient Asian temple or the treatment room of your local health club. All you need are two people focused on awareness, breathing, releasing, and compassion. This spiritual aspect of massage can be used in the following ways:

Iv* For meditation, when the sensitive sharing that takes place between two people in a good massage leads you to quiet your mind and remember some of the more important things in life.

By ministers, nuns, and other clergy members who use this "laying on of hands" as a means to express compassion and in some cases to invoke healing.

By practitioners of Eastern traditions such as Taoism and Buddhism. Buddhist monks in Thailand, for example, often learn the art of massage and practice it in their temples.

Massage for emotional growth

Allowing yourself to be touched with caring, therapeutic intentions takes a high degree of maturity. Several types of massage have been developed to access inner psychological issues and bring them to light. This is especially true in specific cases of past emotional trauma involving abuse and negative body-image caused by being overweight or handicapped.

Massage for sensual pleasure

This type of massage can be performed by any two consenting adults who have a relationship of respect and trust between them. It’s especially useful for long-term couples seeking new and exciting activities to spice up their lives and for short-term couples looking for ways to slow themselves down and enjoy the moment rather than rush through to you-know-what.

Massage for non-humans

Believe it or not, there are special courses offered to teach people how to massage animals. As anyone who’s ever scratched behind the ear of an appreciative pet can tell you, they love it. Certain animals in particular have been the lucky recipients of massage:

Horses, especially race and show horses that are each worth more than the gross national product of the average third-world country

Dogs and cats and other "people with fur" that we live with on an intimate basis

Chapter 2

In This Chapter

^ Deciphering the jargon of Medicare drug costs ^ Getting a grip on how costs are connected

^ Recognizing how a drug plan’s benefits may fluctuate in a given year ^ Knowing how costs may be adjusted from year to year

M T’s all about money, right? You’re thinking about Part D because you’re

Looking for some relief from the outrageous cost of prescription medicine. Okay, a lot of drugs aren’t especially expensive, and some of them allow you to avoid the even steeper costs of surgery and hospital stays. But plenty of meds out there can still take a big bite out of the average retiree’s Social Security check, and some cost more than the typical mortgage payment for a house. (Think I’m kidding? The priciest cancer drugs range from $4,000 to more than $10,000 a month.) So you’re wondering how much money you’ll save in Part D — and, at the same time, how much it’ll cost you.

Medicare says that "on average" people with Part D coverage save about half the cost of their medications. But that calculation runs the gamut from people who don’t save anything to those who save thousands of dollars a year. Again, your individual savings depend on the drugs you use, how many you take, and — to a degree that may surprise you — the Medicare drug plan you choose. That said, you can’t judge a plan on cost alone. Whether a plan covers all of your drugs, or makes you go through hoops to get some of them, is equally important when you’re choosing the plan that’s best for you (see Chapter 4 for details).

In this chapter, I explain the out-of-pocket expenses you’re likely to have in Part D and how those costs add up if you’re in the Regular Part of the program. But if your income is low, see Chapter 5. It explains the much greater financial assistance available to people who qualify for the Extra Help part of the program, and therefore pay much less.

Decoding the Jargon of Medicare Drug Payments

As you’re well aware, health insurance has its own special language — a whole lexicon of jargon relating to coverage, payments, restrictions, and the like. In the following sections, I explain the meanings of words and phrases used in Part D to describe your out-of-pocket expenses.

Making a commitment: Monthly premium

Here’s an easy one: Your Monthly premium Is the amount a plan charges each month to provide drug coverage, in addition to the monthly Part B premium (see Chapter 1 for more info on Part B). Medicare prescription drug plans (PDPs) that cover Only Drugs always charge premiums, which vary a great deal among plans. Medicare Advantage prescription drug plans (MAPDs) that cover both healthcare and drugs usually charge a single monthly premium for the whole package, though some have no premiums at all. If you’re married, you and your spouse must each pay a premium to be in Part D, even if you both join the same plan. In other words, there’s no price break for married couples.

Forking over the first financial slice: Annual deductible

The amount you may have to spend out of pocket on drugs each year Before Your coverage starts is the Annual deductible. The maximum amount is set by law and increases each year ($275 in 2008, $295 in 2009). However, many plans charge lower deductibles or none at all. Most people in plans with deductibles spend this amount at the beginning of the calendar year. But if you join Part D later in the year, there’s no reduction — you still have to spend the required deductible amount before your coverage begins.

Sharing the pain: Co-payments and coinsurance

Co-payments and coinsurance are what you pay for your share of each covered prescription. Your share may be in the form of a Co-pay, Which is a flat dollar amount — say $20. Or it may be coinsurance, which is a percentage of the drug’s total cost — say 25 percent. Some plans use only co-pays and some only coinsurance; others use both, according to the type of drug.

Leveling on costs: Tiers of charges

You may find that your plan charges you different co-payments (or coinsurance) for different drugs. That’s because the plan arranges its covered drugs into three or four levels, or Tiers, According to price:

V Tier One: This tier has the lowest co-pay because it covers the least expensive drugs, usually the generic kind. (Generics Are low-cost copies of brand-name drugs that have been on the market long enough to have lost their exclusive marketing rights.) A few plans don’t charge any co-pays for Tier 1 generics.

V Tier Two: This tier has a medium-priced co-pay because it covers the plan’s Preferred Brand-name drugs. The plan prefers you to use these drugs because it pays less for them after having negotiated good discounts with the drug manufacturers.

V Tier Three: This tier has a higher-priced co-pay because it covers Non-preferred Brand-name drugs. The plan prefers you not to use these drugs because they’re expensive, or perhaps because the plan hasn’t managed to negotiate adequate discounts for them.

V Tier Four: This tier has the highest co-pay because it comprises very expensive or specialty drugs, such as anti-rejection drugs used after organ transplant surgery and drugs used to treat certain cancers. In most cases, plans charge coinsurance — a percentage of the total cost — for drugs in this tier. This percentage is usually 25 percent but can be 33 percent or higher.

These tiers are typical of many Part D plans. However, some plans arrange them differently — for example, putting preferred generics in one tier and nonpreferred generics in another. So a plan may have more than four tiers. Then again, some plans (those that charge the same cost percentage for all drugs) have only one tier.

Getting out your wallet: Full price

You pay full price for your drugs during the deductible (if your plan has one), in the coverage gap (if you fall into it; see Chapter 15), or if you’re taking a drug that your plan doesn’t cover. Full price Actually means the price your plan pays for each drug. If the plan has negotiated a decent discount, its price may be quite a bit less than you’d pay retail at the pharmacy. If the full price of your drug is lower than the co-pay for its associated tier, you pay full price, because that’s the lesser cost.

Counting the cost: True out-of-pocket costs

True out-of-pocket costs Is an odd bit of jargon — which bureaucrats shorten to the acronym TrOOP — that relates to the coverage gap (also known as the doughnut hole). If you fall into the gap, you can only get out of it when you’ve spent a certain amount out of your own pocket for drugs since the beginning of the year. This TrOOP amount ($4,050 in 2008, $4,350 in 2009; it increases every year) includes

V Your deductible (if any) before drug coverage starts

V Your co-pays in the initial coverage period

V Anything you’ve spent on prescriptions while in the gap, according to certain rules

Are there any "false" out-of-pocket costs? Yes, actually — premiums and some other payments that don’t count toward the TrOOP limit. (Wouldn’t you think bureaucrats would call these FrOOPs? But they don’t!) Details on what counts and what doesn’t are in Chapter 15.

Grasping How Costs Fit Together and Add Up

So when it comes to choosing the least expensive Medicare drug plan, you just pick the one with the lowest premium, right? Nope! This approach is a trap many people fall into, and it’s why most plans have tried to keep their premiums relatively low ever since the Part D program began. Low premiums are designed to lure you in the door. But if you’re smart, you want to know more about what’s inside before you cross the welcome mat. No, nothing bad is lurking behind that beckoning door. It’s just that — With one exception — The premium contributes much less to your overall out-of-pocket expenses than two other items that contribute far more: the medications you take and the way your plan is designed.

So what’s the exception to avoiding the plan with the lowest premium? If you take no drugs right now, or only the occasional one, then absolutely opt for the plan in your area that has the lowest premium. Overall, you’re still paying more in premiums than you get back in benefits. But what you’re buying at this point isn’t drugs but Insurance. You’re playing safe because you don’t know what the future holds — it may bring some unforeseen illness that requires expensive medications. Choosing a plan with the lowest premium gives you the comfort of having insurance at the least cost (see Chapter 7).

This section focuses on the calculations everyone else — those who already take a number of drugs or a few costly ones — needs to make.

The importance of the drugs you take

If you absorb just one bit of knowledge from this book, I want it to be the realization that The drugs you take are the most important part of choosing a Medicare drug plan. Your medications, their dosages, and how frequently you take them are the keys to how much you may spend out of pocket in any plan. Why? Two reasons:

V Huge differences exist among the co-pays for meds in different tiers, even among drugs used to treat the same medical condition. For example, the co-pay for a nonpreferred drug in Tier 3 can be twice as much as a similar preferred drug in Tier 2; a generic version in Tier 1 can cost a fraction of either. So if you’re paying a hefty co-pay (say $60) for a Tier 3 drug, and you realize an alternative Tier 2 drug costs $30 or that a Tier

1 generic is available for $5, what are you going to do? Ask your doctor whether a lower-priced drug may work just as well for you. Well, why not? It’s your money!

V The co-pays that Different Plans charge for the Same Drug also vary a lot. Plan X’s co-pay (or coinsurance) for a particular brand-name drug may be quite a bit higher or lower than Plan Y’s. Each plan negotiates the price of each drug with the company that makes it. If Plan X wins a relatively low price for a drug, it will charge you less for that drug (through a lower co-pay) than a plan that doesn’t get such a good deal. And if your costs are high enough to take you into the doughnut hole, where you pay full price (see Chapter 15), you’re still paying less under Plan

X due to the steeper discount it has negotiated. This cost advantage is another good reason for comparing plans carefully before choosing one.

But wait a minute, you may say: What if one of my drugs is least expensive under Plan X, but another drug I take has the lowest price in Plan Y, and maybe a third is cheapest under Plan Z? You need to find out which single plan will cost you the least out of pocket for your whole batch of drugs throughout the entire year — including co-pays, premiums, deductibles, and possible costs in the doughnut hole. Don’t worry! Figuring out your potential cost savings isn’t as difficult as you may think. Flip to Chapter 10 for step-by-step guidance on how to do so in a reasonably fast and efficient way.

Here’s another wrinkle regarding prescription drugs that baffles people. The law says Part D enrollees pay about 25 percent of the cost of their drugs during the initial coverage period. Yet I often hear from folks who say things like: "My plan charges me $28 for one of my drugs, but it only costs $35 full price at my local pharmacy — so I’m paying 80 percent, not 25." In response, Medicare officials say a Part D drug plan can vary its charges and benefits any way it wants, but its total package must be at least Actuarially equivalent To the standard benefit created by Congress.

Translated into English, Actuarially equivalent Means that the whole amount a plan shells out for all of its enrollees — collectively, not individually — must be about 75 percent of the enrollees’ total drug costs, with the remaining 25 percent paid by the enrollees themselves. If you’re in the type of plan that exactly mirrors the standard benefit, then you Will Pay a strict 25 percent of each prescription’s cost. But if you’re in a plan that has tiered co-pays or maybe offers extra benefits, such as a waived deductible or some coverage in the doughnut hole, you may pay more than 25 percent of the price for some drugs — or, in some cases, less. What you pay depends on the plan’s design.

The importance of the plan you choose

Each plan has its own mix of costs and benefits. And although this fact may make the plans seem harder to compare, their different designs allow you flexibility in finding one that best meets your needs. Here are some of the different designs Part D plans typically offer:

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V A plan that mirrors the basic design for minimum Part D coverage outlined by Congress features a full deductible, 25 percent coinsurance for each prescription during the initial coverage period, a doughnut hole, and standard catastrophic coverage.

V A plan that charges no deductible (or a reduced one) and has tiered co-pays for prescriptions during the initial coverage period (probably with coinsurance for drugs in the highest tier), a doughnut hole, and standard catastrophic coverage.

V A plan that looks like either of the preceding designs, but charges nothing for drugs in Tier 1.

V A plan that looks like either of the first two designs, but also covers generic drugs in the doughnut hole.

V A plan that looks like either of the first two designs, but also covers generic and some brand-name drugs in the doughnut hole.

About the only aspect that stays the same in every plan is catastrophic coverage. The federal government heavily subsidizes this level of coverage, and its low co-pays are fixed each year by law. Otherwise, you can find many variations from plan to plan. Plenty have tiered co-pays and charge a full deductible. Some have three or five tiers of charges rather than four, some don’t use tiers at all, and a few charge nothing for generic drugs. To make matters even more confusing, plans can be here one year and gone the next. In 2006, one plan charged a straight 30 percent of the cost of all of its covered drugs throughout the year with no doughnut hole — but this plan vanished in 2007. Expect to see other creative plan designs come and go in the future.

Putting together drug costs and plan designs: Three common examples

So in one hand you have all these different costs, and in the other you have all these different plan designs. And you know what? None of it really matters! In this book, I give you a strategy for navigating the prescription drug plan maze that focuses on only the medications You Take, as well as a few other personal preferences you may have. This strategy can help you whittle your choices down to just a few plans — the ones that will cost you the least out of pocket but cover all (or most) of your drugs. (Hooray!) You may then want to consider these options according to certain conveniences, like being able to buy your drugs at a favorite local pharmacy, receive them by mail order, or purchase them anywhere in the country. In other words, the process of choosing begins with You, Not the plans.

I explain this strategy in detail in Chapter 10. In the meantime, it may help to know how the different costs and plan designs can work for different people. I provide some examples in the following sections — the people may not be real, but the math sure is!

Hearty Harry: Feeling healthy and happy

Hearty Harry is still in good shape. But years of energetic activity — hoop jumps, rock climbing, and daredevil skiing (not to mention chasing after his grandkids) — have proved tough on his joints, so he’s had knee and hip replacements. The only med he needs is something to keep his blood pressure in check. Choosing a Part D plan felt a bit like searching for all the hiders in a 20-person game of hide-and-seek, but he finally settled on a plan with a low premium ($15 a month), a full deductible ($275), and 25 percent coinsurance. Hearty Harry has to pay the plan’s full price for his blood pressure pills ($32 a month) until he meets the deductible, and because his drugs don’t cost much, he doesn’t meet it until halfway through September. At that point, he starts getting coverage, and his drug payments drop to $8 a month (25 percent of $32) for the rest of the year. Here’s what he pays out of pocket:

V January through August: $15.00 a month for premiums + $32.00 a month full price for drugs = $47.00 per month.

V September: $15.00 for premium + $21.66 for drugs = $36.66 for this month. (Meeting the deductible on September 20, Hearty Harry’s coinsurance kicks in, reducing his drug payments to about $2.66 for the remaining ten days of the month.)

V October through December: $15.00 a month for premiums + $8.00 a month coinsurance for drugs = $23.00 per month.

V Grand total: Over the course of the entire year, he pays just under $482, which includes his monthly premiums ($15.00 x 12 = $180), annual deductible ($275), and coinsurance for the rest of the year ($8.00 x 3 =

$24.00 + $2.66 = $26.66).

Hearty Harry likes this deal almost as much as he likes seeing his favorite basketball team lose, because over the year he pays out about $97 more for his coverage than his single drug actually costs ($32 x 12 = $384). However, after a lifetime of close calls on cliff faces and ski slopes, he figures his risk-taking days are over, so he settles for paying the extra to have insurance, just in case.

Normal Norma: Taking some medications regularly

Normal Norma isn’t the dynamo she used to be, but she remains in reasonably good health as long as she takes regular meds to control diabetes and a thyroid condition. She takes five drugs (four brand-names and one generic), which would cost her well over $4,000 a year retail without insurance. As a diligent consumer, she compared Part D plans carefully and found the least expensive one that covered all of her drugs. This plan has a premium of $23.50 a month and no deductible, so her coverage starts at the beginning of the year. For eight months she’s in the initial coverage period, with medium co-pays. But at the beginning of September, she hits the doughnut hole (the time when she pays full price for medications in the gap before coverage kicks back in), and her drug expenses jump to almost three times as much each month for the rest of the year. Here’s what Normal Norma pays out of pocket:

V January through August: $23.50 a month for premiums + $92.96 a month for drugs = $116.46 per month.

V September: $23.50 for premium + $309.37 for drugs = $332.87 for the month. (The total cost of her drugs that both she and her plan pay reaches the $2,510 limit of initial coverage very early in September, pitching her into the doughnut hole.)

V October through December: $23.50 a month for premiums + $312.81 a month for drugs (full price in the doughnut hole) = $336.31 per month.

V Grand total: Throughout the whole year, she pays just over $2,273, which includes her monthly premiums ($23.50 x 12 = $282). At the discounted prices this plan pays for her drugs ($3,756 for all of them), she saves $1,483.

Remaining cost-conscious, Normal Norma did some extra research in an effort to bring her costs down further. Unfortunately, no lower-cost versions of her four brand-name drugs exist yet, so that idea didn’t work. But she found that if she buys her drugs in 90-day supplies from the plan’s mail-order service, she can stave off the doughnut hole for another couple of weeks and pay less — $1,823 over the whole year — saving herself a total of $1,933.

Sickly Sam: Shelling out for expensive specialty drugs

Sickly Sam is hanging in there. He’s doing okay after a recent heart transplant, but he needs a cocktail of medicines to prevent rejection and deal with side effects. He chose a Part D plan that covers all of his drugs, features a $26.40

Monthly premium, and has no deductible. At this plan’s full price, his meds cost a whopping $1,340.77 a month, a tough sum to pay when he goes into the doughnut hole. But he gets through the gap quickly and by mid-May he’s into the catastrophic phase of coverage, with low costs to the end of the year. Here’s what he pays out of pocket:

V January and February: $26.40 a month for premiums + $371.27 a month for drugs (in the initial coverage period) = $397.67 per month.

V March and April: $26.40 a month for premiums + $1,340.77 a month for drugs (in the doughnut hole) = $1,367.17 per month.

V May: $26.40 for premium + $676.90 for drugs = $703.30 in May. (Halfway through the month, his drug expenses from the beginning of the year reach $4,050, the limit of the doughnut hole, and he begins catastrophic coverage.)

V June through December: $26.40 a month for premiums + $72.64 a month for drugs (catastrophic coverage) = $99.04 per month.

V Grand total: Over the course of the year, Sickly Sam pays just over $4,926 out of pocket, including the monthly premiums ($26.40 x 12 = $316.80). The full price of his drugs under this plan amounts to $16,089 over the course of the year, so he saves $11,163.

Although he has a hard time paying the bills during his two and a half months in the doughnut hole, Sickly Sam feels his low payments for the last seven months of the year are like seven months of opening birthday presents, eating cake, and playing games Without Having to turn any older.

Knowing the Costs That Plans Can (And Can’t) Change during a Calendar Year

Since Part D went into effect in 2006, a common complaint among consumers is that they’re normally allowed to change plans only once a year, whereas those plans can change their charges any time during the year. This statement is only partly true; some regulations protect enrollees against the whims of any plan that wants to make changes. This section lists the rules on what plans can and can’t do during the year, from January 1 through December 31.

The costs your plan can’t change

Plans Can’t Change these costs during the year:

V The amount of the monthly premium.

V The amount of the annual deductible (if any).

V The overall design of the plan (for example, whether it covers any drugs in the coverage gap).

V The tier structure of co-pays. So if a plan has three tiers of co-pays rising from $5 to $28 to $60 through the different levels, and charges 25 percent coinsurance in the fourth tier, the charges in each tier must stay the same throughout the year.

V Any costs set by law. These costs include the maximum amount of the deductible, the minimum dollar limit of initial coverage, the maximum out-of-pocket limit that ends the coverage gap, co-pays at the catastrophic level of coverage, and all co-pays for people who receive Extra Help. (See Chapter 5 for more on this program.)

The costs your plan can change

Plans Can Change these costs during the year:

V The Full price Cost of drugs: A plan can change these prices on a weekly basis (see the earlier section "Decoding the Jargon of Medicare Drug Payments" to understand what this term means). These price fluctuations usually vary by only a few dollars or cents, but they can still add up. Such changes — up or down — may affect what you pay during the deductible period (if your plan has one) and in the doughnut hole (if you fall into it). These changes Don’t Affect you in the initial coverage period if your plan charges tiered co-pays for your drugs. But if you pay coinsurance in this coverage period, any changes Will Affect you because you’re paying a percentage of the full price.

V The co-pay for different drugs: A plan can move any drug into a higher or lower price tier, which consequently raises or reduces your co-pay. However, plans can’t make this change during the annual enrollment period (November 15 to December 31) or during the first 60 days of a new year.

Being aware of your rights

You have some rights and protections in relation to the costs of your drugs that are worth knowing about:

V If one of your drugs is moved up to a higher tier of charges, You can’t be asked to pay a higher co-pay for it during the year. Say one of your medicines is in Tier 2 and your co-pay is $24. You’ll continue to pay that amount for the rest of the year, even if your plan moves the drug into Tier 3 where the co-pay is normally $56. However, if your drug is moved to a lower tier — yes, it can occasionally happen! — your co-pay drops to the lower level.

V If your doctor thinks a particular drug is the only one that will work for you but your plan places the drug in its tier of nonpreferred drugs and doesn’t offer a generic or a similar drug in its preferred tiers, you can request your plan to charge you a lower co-pay. (You’ll need your doctor’s help in making this request; see Chapter 4.) You Can’t Ask your plan to do this if the drug you need is in the highest specialty tier of charges or if the requested change would put your co-pay in the lowest (usually generic) tier.

V If any of your plan’s changes will affect a drug you’re taking, your plan must notify you in writing at least 60 days in advance, unless the drug has been withdrawn from the market for safety reasons.

What should you do if your plan violates any of these rights? Contact the plan, point to the regulations in question, and ask for the mistake to be rectified by filing a Coverage determination, Which means asking the plan to look into the facts of your case. If that doesn’t work, you can appeal the plan’s decision. See Chapter 19 for details.

Understanding How Costs May Change from Year to Year

Drug plans have only so much wiggle room to hit you with higher costs DurinG the year. But they do have the right to change everything from one year to the next. No, this privilege doesn’t necessarily mean raising all charges. But with the price of prescription drugs on the rise in general, Part D costs tend to creep up, not down.

Cost increases for enrollees in Part D aren’t solely related to drug plans raising their premiums and co-pays. Medicare, the federal program, also controls several costs and dollar caps that affect all enrollees, regardless of the private plan they’re in. These costs change by law each year and generally go up, because they’re tied to the rising cost of drugs in the whole Part D program.

Medicare typically changes these costs and benefits from year to year:

V The maximum amount of the annual deductible

V The limit to the initial coverage period

V The limit on out-of-pocket expenses that gets you out of the doughnut hole (if they ever get that high) and into catastrophic coverage

V Co-pays at the catastrophic coverage level

V Co-pays for people receiving Extra Help (see Chapter 5)

Drug plans can change the following costs and benefits from one year to the next:

V Monthly premiums

V Annual deductible (no higher than the maximum amount set by law)

V Co-pays for each tier of charges in the initial coverage period

V Percentage of coinsurance in the initial coverage period

V Full-price charges in the deductible or doughnut hole

V Covered drugs

V Overall plan design

Following are some recent trends in annual cost changes:

V Medicare-controlled costs have gone up steadily. For example, the maximum deductible rose from $250 in 2006 to $295 in 2009. The out-of-pocket limit that triggers the end of the doughnut hole rose from $3,600 in 2006 to $4,350 in 2009, which means it costs more to get to the catastrophic coverage level. On the other hand, the annually raised limit on total drug costs in the initial coverage period — which went up from $2,000 in 2006 to $2,700 in 2009 — means you get a bit more coverage before hitting the doughnut hole than you did in previous years.

V Drug plan costs are more variable. Consumers certainly see the effects if their premiums or co-pays suddenly take a jump on January 1. But often changes are much more subtle — for example, more drugs moved to a higher cost tier. From 2007 to 2008, a few plans lowered their premiums and/or co-pays, but most plans raised both, especially through increased charges for brand-name drugs. And in the most dramatic change of 2008, coverage for brand-name drugs in the doughnut hole — which in the previous two years had saved a lot of money for enrollees with high costs — all but vanished.

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Your Part D plan must mail you a notice each fall (usually in October) to inform you of any changes it will make in costs and benefits for the following year. This mailing is called the Annual Notice of Change, And it’s important that you read it, as explained in Chapter 17. If you haven’t received this notice by early November, call the Medicare help line at 800-633-4227 (877-486-2048 for TDD users) and complain.

Chapter 4