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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

Feb. 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."


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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 coverage threshold.

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 spending.

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 Program.

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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