Seniors with these medical
conditions at high risk of falling into Medicare 'donut hole'
Researchers recommend counseling to
manage drug regimens to avoid high drug cost
2, 2015 - Among seniors, women and patients with diabetes and dementia
are the most likely to fall into the Medicare Part D prescription drug
plan "donut hole" - the gap occurring after beneficiaries reach their
annual coverage limit and before catastrophic coverage kicks.
Because this gap leaves them
exposed to unsubsidized medication costs, these clinically vulnerable
groups should be counseled on how to best manage costs through either
drug substitution or discontinuation of specific non-essential
medications, according to Susan Ettner, lead author of the new research
published online in the Journal of General Internal Medicine.
"This is important so that more
essential medication is not discontinued, with adverse effects on
patients' health due to cost reasons only," said Ettner, professor of
medicine in the division of general internal medicine and health
services research at the David Geffen School of Medicine at UCLA.
"These patients need to continue
adhering to their medication regimen."
As an example, an average
67-year-old woman with diabetes and a typical set of "co-morbidities" -
hypertension, hyperlipidemia, coronary artery disease and depression -
would have a 54-percent chance of falling into the coverage gap and
being exposed to the full cost of her medication. If she fell into the
gap, she would have an 11-percent chance of exiting again, but in the
meantime, she would have incurred more than $3,600 in total
out-of-pocket drug expenses.
"Our findings suggest that
medication cost-counseling interventions focusing on these clinically
vulnerable subpopulations may be warranted," the authors conclude.
"Physician-patient discussions about the expense and undesirable side
effects of particular medications are one approach to managing
outpatient drug therapy and controlling costs."
In 2006, 3.4 million seniors
purchased a Part D plan, which provides prescription drug coverage to
all Medicare beneficiaries. The plan was expected to improve adherence
to drug regimens and health outcomes through improved financial access
to medications. However, the standard Part D benefit includes a coverage
gap, the so-called donut hole.
After a Medicare beneficiary
surpasses the prescription drug coverage limit for the year, he or she
becomes financially responsible for the entire cost of prescription
drugs until the expense reaches another threshold - the catastrophic
Looking at records from more than
287,000 Medicare recipients in eight U.S. states, primarily in the West,
Ettner and her team investigated which beneficiaries were most likely to
fall into the gap, as well as which medical conditions could put them
there. They also examined which medications contributed most to pre-gap
They found that 16 percent of
enrollees entered the gap, with nearly 3 percent entering the gap very
early, within the first 180 days of the year. Of those who entered the
gap, only 7 percent exited again. Women and patients with dementia and
diabetes were the most likely to enter the gap.
Other conditions also predisposed
beneficiaries to gap entry, including end-stage renal disease, coronary
artery disease, chronic obstructive pulmonary disease, mental health
conditions and congestive heart failure.
Study co-authors are Neil Steers,
O. Kenrik Duru, Norman Turk, Elaine Quiter and Carol M. Mangione, all of
UCLA, and Julie Schmittdiel of the Kaiser Permanente Medical Care
The research was supported by
funding from the Centers for Disease Control and Prevention, the UCLA
Resource Center for Minority Aging Research, a Building
Interdisciplinary Careers in Women's Health K12 Career Development Award
from the Office of Research on Women's Health, and a Harold Amos Medical
Faculty Development Award from the Robert Wood Johnson Foundation.
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