Seniors reduce or discontinue medications when faced with gap in drug coverage, UCLA study shows

08/24/04

Seniors who use up their yearly drug benefits before the end of the year often resort to reducing their recommended dosages, or even stop taking their medications altogether--a situation that could endanger their health, according to a new study co-authored by a UCLA researcher.

In a study of 1308 seniors with a yearly cap on drug benefits, 24 percent of seniors who used up their benefit two-and-a-half to six months before the end of the year said they used less of, stopped, or did not start at least one of their medications because of the out-of-pocket costs. Among the 10 medications most affected were those drugs for treating high cholesterol, hypertension, asthma, depression, and pain. Two-thirds of seniors who faced this gap in drug coverage said that it was difficult to pay for their medications. Nearly one in four experienced difficulty paying their rent and bills because of these costs.

This study illustrates what could happen to seniors who fall into the "donut hole" in the new $410 billion national Medicare drug benefit. Seniors initially pay only 25 percent of medication costs, but there's a "donut hole" between $2,250 and $5,100 when they have no coverage. Other studies estimate that 42 percent of Medicare beneficiaries, many of them with chronic diseases, will be affected by this gap in coverage.

This study is also relevant to the 4.6 million seniors who are currently enrolled in Medicare managed care. These health plans often are able to offer drug benefits by placing an annual dollar "cap" on drug benefits. Members who spend past this cap, like seniors in the study, face a "donut hole" because they pay for medications out-of-pocket until new drug benefits kick in the following year.

"We found that patients were making some pretty big financial trade-offs between paying rent or buying food and purchasing medications so they could cover their drug costs," said Dr. Carol M. Mangione, senior study author and professor of general internal medicine and health services research at the David Geffen School of Medicine at UCLA "Low income seniors with serious chronic conditions such as diabetes and hypertension are likely to have the greatest problems covering their share of medication costs. Given the huge annual inflation in drug costs, health plans are already hard pressed to provide drug benefits for persons with Medicare. Doctors can help patients make the most of their benefits or keep them from exceeding the cap by identifying when less expensive but potentially effective medications such as generics are appropriate."

The study, "Cost-Lowering Strategies By Medicare Beneficiaries Who Exceed Drug Benefit Caps and Have a Gap in Drug Coverage," is published in the August 25 issue of the Journal of the American Medical Association.

The study surveyed 1308 seniors in 2002, half of whom exceeded their cap in 2001 and had a gap in coverage for two-and-a-half to six months. The other half of participants had a higher benefit cap and coverage year-round. The researchers found that 24% of seniors who had a gap in coverage decreased their use of medications, compared to 16% of seniors who had year-round coverage. Many of the study participants called pharmacies for lowered prices (46%), asked doctors for samples (34%) or switched to lower cost medications (15%). Researchers were surprised that so many seniors with coverage year-round were also decreasing their medication use because of cost. In fact, one in three seniors who had coverage year-round said paying for medications was difficult.

"This study sends out an emergency signal to doctors that we need to be aware that seniors often only get a fixed amount of money from their health plans to cover their medications for the year," said Dr. Chien-Wen Tseng, the study's principal investigator and assistant professor of family medicine and community health at the John A. Burns School of Medicine at the University of Hawaii "Do we really want to use it up on a heartburn or allergy medication? We can also help by thinking twice when writing a prescription. We need to offer patients more choices if there's a less expensive drug that might also be just as good."

This will require a new way of thinking by physicians,. Tseng said. "Instead of saying 'this drug is OK because your insurance will cover it', we need to think 'this drug may cost $60 per month. That's $720 per year. How much drug benefit does my patient have for the year?' If we don't ask these questions, a lot more of our patients will be choosing between going to the pharmacy or the grocery store."

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