Adherence Goes Down in the 'Doughnut Hole'

Diabetes patients without coverage of the Medicare Part D “doughnut hole” spent more out of pocket on their medications and had worse medication adherence, compared with diabetes patients who had coverage.

Moreover, modified doughnut hole coverage of generic drugs conferred only “modest differences in out-of-pocket spending and no differences in adherence,” compared with diabetes patients without any coverage at all, according to a recent study.

The so-called doughnut hole refers to a coverage gap built into Medicare Part D (prescription drug coverage). Under Part D, beneficiaries pay only a copayment for their drugs until the total cost reaches a certain threshold. Once costs hit that level, they pay 100% of their drug costs until their out-of-pocket expenses reach a second, higher amount, and catastrophic coverage kicks in.

In 2006, the Medicare Advantage Prescription Drug (MAPD) plans on which the current study was based had a coverage gap that began at $2,250, and persisted until patients' out-of-pocket expenses hit the $3,600 mark; in 2010, the doughnut hole goes from $2,830 to $4,550.

The study, led by Vicki Fung, Ph.D., of the Kaiser Permanente Medical Care Program, in Oakland, Calif., compared diabetes patients in a staff-model, integrated health maintenance organization's (HMO) MAPD plan.

In the first group were 16,654 patients whose Part D plan provided no coverage in the doughnut hole; in the second group were 12,126 with employer-supplemented insurance offering some coverage in the gap.

All patients were at least 65 years old, had been covered under their plan at least from Jan. 1, 2005, through Dec. 31, 2006, and had one or more oral diabetes prescriptions dispensed in 2005. Patients with dual Medicare/Medicaid coverage were excluded, as were patients receiving a low-income Medicare subsidy.

A total of 17% of patients without gap coverage had out-of-pocket drug expenses of at least $2,250—putting them into the doughnut hole—as did 35% of those with some gap coverage. Patients without gap coverage had lower annual total drug costs, on average: $1,750 versus $1,802 for patients with employer-supplemented gap coverage, the researchers found. However, patients without gap coverage spent significantly more out of pocket than did their covered counterparts: an average of $806 annually versus $279, a 189% increase (Health Serv. Res. 2010 Jan. 7 [Epub doi:10.1111/j.1475-6773.2009.01071.x]).

Additionally, patients without gap coverage had a lower adherence rate: 62%, compared with 66% among patients who did have coverage. (Adherence was defined as having been dispensed enough drugs to cover greater than or equal to 80% of days prescribed.)

The researchers also conducted a parallel analysis of a separate, network-model HMO with the same study criteria as above, where 11,034 patients had a coverage gap and 3,950 had coverage of their gap with generic medications only.

In this plan, 34% of subjects with no gap coverage and 37% with gap coverage of generic drugs had out-of-pocket expenses equal to or more than $2,250.

Although adherence was statistically similar among these groups, out-of-pocket costs for patients without gap coverage was still, on average, 14% higher annually than for patients who received coverage of generic medications past the $2,250 threshold.

The Medicare prescription drug program is now entering its fifth year, and 89% of the 22.5 million enrollees in 2006 had no gap coverage, the authors noted.

“Our findings reinforce the need to examine carefully the clinical and economic effects of all Part D drug benefit and delivery structures,” they said.

Disclosures: The authors said that they had no corporate financial disclosures, and that although the MAPD plan administrators were able to review the paper, they had no control over design, conduct, or interpretation of the study.

Diabetes patients without coverage of the Medicare Part D “doughnut hole” spent more out of pocket on their medications and had worse medication adherence, compared with diabetes patients who had coverage.

Moreover, modified doughnut hole coverage of generic drugs conferred only “modest differences in out-of-pocket spending and no differences in adherence,” compared with diabetes patients without any coverage at all, according to a recent study.

The so-called doughnut hole refers to a coverage gap built into Medicare Part D (prescription drug coverage). Under Part D, beneficiaries pay only a copayment for their drugs until the total cost reaches a certain threshold. Once costs hit that level, they pay 100% of their drug costs until their out-of-pocket expenses reach a second, higher amount, and catastrophic coverage kicks in.

In 2006, the Medicare Advantage Prescription Drug (MAPD) plans on which the current study was based had a coverage gap that began at $2,250, and persisted until patients' out-of-pocket expenses hit the $3,600 mark; in 2010, the doughnut hole goes from $2,830 to $4,550.

The study, led by Vicki Fung, Ph.D., of the Kaiser Permanente Medical Care Program, in Oakland, Calif., compared diabetes patients in a staff-model, integrated health maintenance organization's (HMO) MAPD plan.

In the first group were 16,654 patients whose Part D plan provided no coverage in the doughnut hole; in the second group were 12,126 with employer-supplemented insurance offering some coverage in the gap.

All patients were at least 65 years old, had been covered under their plan at least from Jan. 1, 2005, through Dec. 31, 2006, and had one or more oral diabetes prescriptions dispensed in 2005. Patients with dual Medicare/Medicaid coverage were excluded, as were patients receiving a low-income Medicare subsidy.

A total of 17% of patients without gap coverage had out-of-pocket drug expenses of at least $2,250—putting them into the doughnut hole—as did 35% of those with some gap coverage. Patients without gap coverage had lower annual total drug costs, on average: $1,750 versus $1,802 for patients with employer-supplemented gap coverage, the researchers found. However, patients without gap coverage spent significantly more out of pocket than did their covered counterparts: an average of $806 annually versus $279, a 189% increase (Health Serv. Res. 2010 Jan. 7 [Epub doi:10.1111/j.1475-6773.2009.01071.x]).

Additionally, patients without gap coverage had a lower adherence rate: 62%, compared with 66% among patients who did have coverage. (Adherence was defined as having been dispensed enough drugs to cover greater than or equal to 80% of days prescribed.)

The researchers also conducted a parallel analysis of a separate, network-model HMO with the same study criteria as above, where 11,034 patients had a coverage gap and 3,950 had coverage of their gap with generic medications only.

In this plan, 34% of subjects with no gap coverage and 37% with gap coverage of generic drugs had out-of-pocket expenses equal to or more than $2,250.

Although adherence was statistically similar among these groups, out-of-pocket costs for patients without gap coverage was still, on average, 14% higher annually than for patients who received coverage of generic medications past the $2,250 threshold.

The Medicare prescription drug program is now entering its fifth year, and 89% of the 22.5 million enrollees in 2006 had no gap coverage, the authors noted.

“Our findings reinforce the need to examine carefully the clinical and economic effects of all Part D drug benefit and delivery structures,” they said.

Disclosures: The authors said that they had no corporate financial disclosures, and that although the MAPD plan administrators were able to review the paper, they had no control over design, conduct, or interpretation of the study.

Diabetes patients without coverage of the Medicare Part D “doughnut hole” spent more out of pocket on their medications and had worse medication adherence, compared with diabetes patients who had coverage.

Moreover, modified doughnut hole coverage of generic drugs conferred only “modest differences in out-of-pocket spending and no differences in adherence,” compared with diabetes patients without any coverage at all, according to a recent study.

The so-called doughnut hole refers to a coverage gap built into Medicare Part D (prescription drug coverage). Under Part D, beneficiaries pay only a copayment for their drugs until the total cost reaches a certain threshold. Once costs hit that level, they pay 100% of their drug costs until their out-of-pocket expenses reach a second, higher amount, and catastrophic coverage kicks in.

In 2006, the Medicare Advantage Prescription Drug (MAPD) plans on which the current study was based had a coverage gap that began at $2,250, and persisted until patients' out-of-pocket expenses hit the $3,600 mark; in 2010, the doughnut hole goes from $2,830 to $4,550.

The study, led by Vicki Fung, Ph.D., of the Kaiser Permanente Medical Care Program, in Oakland, Calif., compared diabetes patients in a staff-model, integrated health maintenance organization's (HMO) MAPD plan.

In the first group were 16,654 patients whose Part D plan provided no coverage in the doughnut hole; in the second group were 12,126 with employer-supplemented insurance offering some coverage in the gap.

All patients were at least 65 years old, had been covered under their plan at least from Jan. 1, 2005, through Dec. 31, 2006, and had one or more oral diabetes prescriptions dispensed in 2005. Patients with dual Medicare/Medicaid coverage were excluded, as were patients receiving a low-income Medicare subsidy.

A total of 17% of patients without gap coverage had out-of-pocket drug expenses of at least $2,250—putting them into the doughnut hole—as did 35% of those with some gap coverage. Patients without gap coverage had lower annual total drug costs, on average: $1,750 versus $1,802 for patients with employer-supplemented gap coverage, the researchers found. However, patients without gap coverage spent significantly more out of pocket than did their covered counterparts: an average of $806 annually versus $279, a 189% increase (Health Serv. Res. 2010 Jan. 7 [Epub doi:10.1111/j.1475-6773.2009.01071.x]).

Additionally, patients without gap coverage had a lower adherence rate: 62%, compared with 66% among patients who did have coverage. (Adherence was defined as having been dispensed enough drugs to cover greater than or equal to 80% of days prescribed.)

The researchers also conducted a parallel analysis of a separate, network-model HMO with the same study criteria as above, where 11,034 patients had a coverage gap and 3,950 had coverage of their gap with generic medications only.

In this plan, 34% of subjects with no gap coverage and 37% with gap coverage of generic drugs had out-of-pocket expenses equal to or more than $2,250.

Although adherence was statistically similar among these groups, out-of-pocket costs for patients without gap coverage was still, on average, 14% higher annually than for patients who received coverage of generic medications past the $2,250 threshold.

The Medicare prescription drug program is now entering its fifth year, and 89% of the 22.5 million enrollees in 2006 had no gap coverage, the authors noted.

“Our findings reinforce the need to examine carefully the clinical and economic effects of all Part D drug benefit and delivery structures,” they said.

Disclosures: The authors said that they had no corporate financial disclosures, and that although the MAPD plan administrators were able to review the paper, they had no control over design, conduct, or interpretation of the study.