Medicare beneficiaries report decreased use of essential medications during gaps in coverage


Medicare beneficiaries who exceed their annual drug benefit cap report having to reduce their use of essential medications and experience difficulty paying for prescription medications, according to a study in the August 25 issue of JAMA, the Journal of the American Medical Association.

The majority of Medicare drug benefits in managed care (Medicare+Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year, according to background information in the article. With the risk for coverage gaps in the newly adopted national Medicare drug benefit, understanding how caps and coverage gaps affect medication use is critical to designing adequate drug benefits for Medicare beneficiaries. The exact impact of caps and the coverage gap on medication use is uncertain.

Chien-Wen Tseng, M.D., M.P.H., of the University of Hawaii Department of Family Practice and Community Health and the Pacific Health Research Institute, Honolulu, and colleagues from the UCLA Robert Wood Johnson Clinical Scholars Program conducted a cross-sectional survey of Medicare+Choice beneficiaries with capped drug benefits to determine the cost-cutting strategies, the type of medications involved, and financial burden of drug costs for patients who exceeded caps and had a gap in coverage compared with those patients who did not exceed their caps.

The survey (completed in 2002) included Medicare+Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs. Study participants (n=665) exceeded a $750 or $1,200 yearly cap in 2001 and had coverage gaps of 75-180 days. Control participants (n=643) had $2,000 caps which they did not exceed. Study and control participants were matched by average total drug expenditures per month.

The researchers found that a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18 percent vs. 10 percent, respectively), but similar proportions reported stopping medications completely (8 percent for both) and of not starting prescribed medications (6 percent vs. 5 percent). Overall, 24 percent of patients exceeding caps decreased their use of at least one medication because of cost, compared to 16 percent of patients who did not exceed the cap.

"Patients exceeding caps more often called pharmacies to find the best price (46 percent vs. 29 percent), switched medications (15 percent vs. 9 percent), used samples (34 percent vs. 27 percent), and had difficulty paying for prescriptions (62 percent vs. 37 percent)," the authors write. "Twelve of the 20 therapeutic classes most often affected by decreases in use of medication were for chronic health problems such as hypertension, hyperlipidemia, and emphysema or asthma."

"This study emphasizes the tradeoffs involved in setting cap generosity for Medicare beneficiaries," the researchers write. "Lower caps may allow drug benefits to be offered to a greater number of beneficiaries by decreasing the cost of providing such a benefit, but exceeding the cap can increase the risk for decreasing essential medication use due to cost and increase financial burden. Even with a generous cap, some beneficiaries will exceed their drug benefits and those who are ill or have many chronic health problems are most likely to have high prescription expenditures and to be at risk for exceeding the cap. Therefore clinicians, insurers, and the public will need to consider how to best balance the cost and benefits of their medications to maximize the benefit from such plans." (JAMA. 2004; 292:952-960. Available post-embargo at

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