Study: Medicare ‘doughnut hole’ hurts Rx compliance

FRANKLIN LAKES, N.J. —In a development that could put many seniors at risk and drive up long-term Medicare costs, many seniors with high cholesterol appear to be dropping their drug therapy rather than paying out-of-pocket for their medications once they reach the Medicare Part D drug coverage gap.

That’s the finding of a new study from the big pharmacy benefit management firm Medco Health Solutions. Medco, which unveiled the results of its research in September, found that Medicare beneficiaries who were prescribed cholesterol-lowering statins are nearly twice as likely to abandon their medications when they reach the coverage gap, or doughnut hole, and become responsible for paying the entire cost of their medications than they are in the initial phase of the benefit when the cost of the medication is covered. The result “may put them at higher risk for heart attack and stroke,” the PBM warned.

The study, conducted last year, showed the price-sensitivity of older Americans when confronted with the drop in coverage; the rate of patients who suspended generic statin treatment was 20 percent lower than those on a brand-name medication. It also showed that many seniors still opt for the higher-cost branded drug over the generic when somebody else—in this case the Medicare Part D program—is footing the bill. Once they hit the doughnut hole, a majority of beneficiaries want to switch to lower-cost generics.

“This research confirms the concerns related to patient health in the coverage gap and also validates the positive impact generics have on helping patients remain compliant with their medications,” said Dr. Woody Eisenberg, chief medical officer of Medco Retiree Solutions.

According to the Medco research, 22 percent of Medicare Part D recipients reached the gap by July 2007. By December of last year, the company reported, “exactly half were either in the gap or had such high costs that they had proceeded to the catastrophic coverage phase of the benefit.”

Researchers also found that “reaching the coverage gap dramatically stimulates the use of generics among all Medicare recipients.”

During 2007, the doughnut hole took effect when beneficiaries’ total drug costs reached $2,400. Beneficiaries were then responsible for paying 100 percent of their drug costs until total costs reached $5,451, when catastrophic coverage begins to cover 95 percent of a beneficiary’s drug costs.

In a response to the coverage-gap problem, Medco said it has introduced a communications program that alerts its prescription drug plan members and specific health plan beneficiaries through mailings and outbound phone calls of their proximity to the gap long before they reach it. In addition, reported the company, “Medco offers members prescription forms they can bring to their physician or contacts the doctor on the member’s behalf to discuss generics that can lower the member’s costs.”