Seniors at risk from drug plan gap
A UH researcher finds that 28% cut back on medications when coverage changed
Seniors could cut back on or stop medications after a Medicare health plan stops covering brand-name drugs, falling into a gap nicknamed the doughnut hole, a Hawaii researcher reports.
That may happen even if some plans provide generic drug coverage during the gap, said Dr. Chien-wen Tseng, professor in the University of Hawaii Department of Family Medicine and Community Health and Pacific Health Research Institute researcher.
In a study as a UCLA Robert Wood Johnson clinical scholar, Tseng discovered the trend before the federal drug program began.
The study, published in the Sept. 14 issue of the American Journal of Managed Care, found 27 percent of seniors switched their medications because of cost, she said. They generally went to generics or cheaper brand-name drugs, she said.
Working with UCLA and RAND investigators, Tseng studied 611 seniors in managed care plans in 2001 and 2002. The plan provided brand-name coverage in 2001, but as costs rose it offered only generic coverage in 2002, she said.
"We also found 28 percent told us they decreased use of medications, stopped, stretched or didn't fill new medications," she said. The decreased use affected drugs for treating high cholesterol, pain, asthma, depression and other serious medical conditions, she added.
The findings are important because four out of 10 Medicare beneficiaries have Part D drug plans that cut off benefits, and find themselves in a gap in coverage now being called a doughnut hole, Tseng said.
When a senior's drug costs reach $2,250 under the Medicare program, coverage stops. The senior then must pay all costs for medicine out of pocket until reaching $5,100, or when coverage begins again at the start of the next calendar year.
Many seniors may run out of drug benefits before the end of the year because they don't know how close they are to the doughnut hole, she said.
"People going to the pharmacy, when the total drug benefit hits $2,250, all of a sudden are asked to pay the entire cost of the bill."
Some Medicare drug plans cover generic-only drugs during the gap period to help seniors, Tseng said.
"Insurers, physicians and Medicare must realize that these 'generic only' drug benefits are not complete solutions to the coverage gap," she said.
"A lot of people hit the doughnut hole pretty fast," said Mary Rydell, federal Health Care Financing Administration regional administrator in Hawaii. "Especially renal patients."
She said Hawaii Medicare beneficiaries enrolled in Part D drug plans include 11,270 in stand-alone plans and 52,961 in Medicare Advantage health plans. Another 24,554 Medicare/Medicaid recipients were automatically enrolled.
Only the Hawaii Medical Service Association offers both generic and brand-name drug coverage with a "high option" plan during the gap period, she said.
Tseng said about 65 percent of seniors in her study were having trouble paying for medicine in 2002. If they preferred brand name pills or their medicine was only available in a brand name, they had to pay full cost instead of only a co-payment, she said.
With high prescription costs, seniors said they couldn't participate in enjoyable activities and it was difficult for them to pay rent and other bills and get medical care, she said. Some said they had to borrow money or get help paying for medications.
"The need to make prescription medications affordable for patients is a critical health issue for Hawaii, as well as nationally," Tseng said, noting nearly 204,000 residents -- 20 percent of the population -- are believed to be without drug benefits.