Part D 'Doughnut Hole' Raises Costs, Lowers Adherence

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

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). 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 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 out-of-pocket expenses hit $3,600; 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 MAPD plan. In the first group were 16,654 patients whose Part D plan provided no coverage in the doughnut hole; in the second were 12,126 with employer-supplemented insurance offering some coverage in the gap.

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

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 than did their covered counterparts: an average of $806 annually versus $279, a 189% increase (Health Serv. Res. 2010 Jan. 7 [doi:10.1111/j.1475-6773.2009.01071.x

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

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

The authors declared no conflicts, and said MAPD plan administrators reviewed the paper but 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 adherence compared with diabetes patients who had coverage.

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). 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 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 out-of-pocket expenses hit $3,600; 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 MAPD plan. In the first group were 16,654 patients whose Part D plan provided no coverage in the doughnut hole; in the second were 12,126 with employer-supplemented insurance offering some coverage in the gap.

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

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 than did their covered counterparts: an average of $806 annually versus $279, a 189% increase (Health Serv. Res. 2010 Jan. 7 [doi:10.1111/j.1475-6773.2009.01071.x

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

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

The authors declared no conflicts, and said MAPD plan administrators reviewed the paper but 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 adherence compared with diabetes patients who had coverage.

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). 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 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 out-of-pocket expenses hit $3,600; 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 MAPD plan. In the first group were 16,654 patients whose Part D plan provided no coverage in the doughnut hole; in the second were 12,126 with employer-supplemented insurance offering some coverage in the gap.

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

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 than did their covered counterparts: an average of $806 annually versus $279, a 189% increase (Health Serv. Res. 2010 Jan. 7 [doi:10.1111/j.1475-6773.2009.01071.x

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

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

The authors declared no conflicts, and said MAPD plan administrators reviewed the paper but had no control over design, conduct, or interpretation of the study.