The Medicare donut hole: Now you're covered, now you're not

Mar 25, 2010

If you're older, a woman, and suffering from either dementia or diabetes, you are the most likely to be exposed to unsubsidized medication costs in the US. This is known as the coverage gap for enrollees of Medicare Part D - the US federal program which subsidizes the cost of prescription drugs for Medicare beneficiaries.

According to Dr. Susan Ettner from UCLA in the US, and her colleagues, these clinically vulnerable groups should be counseled on how to best manage costs through either drug substitution or discontinuation of specific, non-essential medications. This is important so that more essential medication is not discontinued with adverse effects on patients' health, for cost reasons only. Their findings have just appeared online in the , published by Springer.

In 2006, 3.4 million seniors signed up to a Part D plan which provides voluntary drug coverage to all . The plan was expected to improve adherence to drug regimens and health outcomes, via improved financial access to medications. However, the standard Part D benefit includes a coverage gap (or donut hole). After a Medicare beneficiary surpasses the prescription drug coverage limit, he or she becomes financially responsible for the entire cost of until the expense reaches another threshold - the catastrophic coverage threshold.

Dr. Ettner and team investigated which beneficiaries were more likely to fall into the gap, and in particular which medical conditions put them at high risk of gap entry as well as the medications contributing most to pre-gap spending. The researchers looked at records from over 287,000 Medicare beneficiaries across eight states.

They found that 16 percent of enrollees entered the gap, with nearly 3 percent entering the gap very early on, i.e. within the first 180 days. Of those who entered the gap, only 7 percent exited again. Women and patients with 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.

As an example, an average 67-year-old woman with diabetes and a typical set of comorbidities - hypertension, hyperlipidemia, coronary artery disease and depression - would have a 54 percent chance of falling into the Part D 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.

The authors conclude: "Our findings suggest that medication cost-counseling interventions focusing on these clinically vulnerable subpopulations may be warranted. Physician-patient discussions about the expense and undesirable side effects of particular medications are one approach to managing outpatient drug therapy and controlling costs."

Explore further: Loud talking and horseplay in car results in more serious incidents for teen drivers

More information: Ettner S, Mangione CM et al (2010). Entering and exiting the Medicare Part D coverage gap: role of comorbidities and demographics. Journal of General Internal Medicine. DOI:10.1007/s11606-010-1300-6

add to favorites email to friend print save as pdf

Related Stories

Seniors in Medicare's doughnut hole decrease use of meds

Feb 03, 2009

Beneficiaries enrolled in Medicare Part D who reached a gap in health care coverage known as the "doughnut hole" were much less likely to use prescription drugs than those with an employer-based plan, according to a University ...

Medicare drug plan changes affect seniors

Oct 04, 2006

U.S. officials say changes in the Medicare prescription drug plan for next year will include more choices and better coverage especially in the "doughnut hole."

Study addresses impact of Medicare Part D on medical spending

Jul 01, 2009

After enrolling in Medicare Part D, seniors who previously had limited or no drug coverage spent more on prescriptions and less on other medical care services such as hospitalizations and visits to the doctor's office, according ...

Recommended for you

Obama: 8 million signed up for health care (Update)

5 hours ago

President Barack Obama said Thursday 8 million Americans have signed up for health care through new insurance exchanges, besting expectations and offering new hope to Democrats who are defending the law ahead ...

User comments : 0

More news stories

Turning off depression in the brain

Scientists have traced vulnerability to depression-like behaviors in mice to out-of-balance electrical activity inside neurons of the brain's reward circuit and experimentally reversed it – but there's ...

Hackathon team's GoogolPlex gives Siri extra powers

(Phys.org) —Four freshmen at the University of Pennsylvania have taken Apple's personal assistant Siri to behave as a graduate-level executive assistant which, when asked, is capable of adjusting the temperature ...

Better thermal-imaging lens from waste sulfur

Sulfur left over from refining fossil fuels can be transformed into cheap, lightweight, plastic lenses for infrared devices, including night-vision goggles, a University of Arizona-led international team ...