Doughnut Hole Pushing Some Medicare Patients to Skip Meds-September 2008

Approximately 1 in 4 Medicare Part D enrollees paid enough for their prescriptions in 2007 to find themselves caught in the gap in coverage known as the “doughnut hole,” causing many of these patients to stop taking their medications, a new study reveals.

The study, conducted by researchers at Georgetown University, the National Opinion Research Center at the University of Chicago, and the Kaiser Family Foundation, also found that beneficiaries taking drugs for serious chronic conditions had a substantially higher risk of hitting the coverage gap: 64% of enrollees taking medications for Alzheimer’s disease reached it in 2007, for example, as did 51% of those taking oral antidiabetic medications and 45% of patients on antidepressants.

Researchers found evidence that patients change their use of prescription drugs when they fall into the doughnut hole and have to pay a prescription’s full cost. Across 8 classes of drugs used to treat a variety of relatively common conditions, researchers found that 15% of Part D enrollees who reached the gap stopped use of drug therapy for that condition; 5% switched to another medication in the class; and 1% reduced the number of drugs they were taking in that class.

Beneficiaries who reached the coverage gap faced almost a doubling of monthly out-of-pocket spending (from $104 prior to the coverage gap, to $196 in the doughnut hole), the analysis shows. In addition 84% of the Part D enrollees who reached the coverage gap did not incur enough additional drug spending in 2007 to qualify for catastrophic coverage—the point where Part D would pay 95% of drug costs.

“The Medicare drug benefit has produced tangible relief for millions of people, despite the unusual coverage gap that was created to make the benefit fit within budget constraints,” noted Drew Altman, Kaiser chief executive officer and president. “But if a new president and Congress consider changes to the drug benefit, it will be important to keep in mind that the coverage gap has consequences for some patients with serious health conditions.”