Geriatrics 6 Comments

Falling into Medicare Doughnut Hole Ups Nonadherence

Seniors caught in the Medicare Part D coverage gap known as the 'doughnut hole' are twice as likely to stop taking their medication, a new study found.


Between 11% and 14% of Medicare beneficiaries fall into the coverage gap each year and receive no financial assistance, wrote Jennifer Polinski, Sc.D, MPH, of Brigham and Women's Hospital Division of Pharmacoepidemiology, and colleagues in the Aug. 16 issue of PLoS Medicine.

The doughnut hole refers to a gap in Medicare Part D coverage that occurs when a beneficiary's total prescription costs are between $2,800 and $4,549 in a given year. During that gap, Medicare stops paying for drug costs, and the beneficiary must foot 100% of his or her prescription costs. Once drug spending tops $4,549 (or when the year starts over) Medicare begins paying for drug cost once again.

Moreover, the study found that making seniors pick up the pharmacy tab when their annual drug bill topped $2,800 didn't motivate them to switch from expensive brand names to generics -- the argument advanced when Congress created Medicare Part D.

"Our results demonstrate that while a blunt cost-sharing mechanism like the coverage gap does raise consumer sensitivity, it produces surprising consequences," the study authors said. "Instead of incentivizing beneficiaries to switch to lower-priced or generic drugs, entry into the coverage gap resulted in an abrupt discontinuation of or reduced adherence to drugs among elderly Medicare beneficiaries."

Very low-income beneficiaries receive government subsidies to help them pay for drugs in the doughnut hole, so they generally don't pay more than $15 for any single prescription while in the coverage gap.

The researchers followed more than 663,850 community-dwelling seniors enrolled in Medicare Part D or a retiree plan administered by CVS Caremark who spent enough on prescriptions in 2006 and 2007 to hit the doughnut hole.

The researchers found that one-third of Medicare enrollees reached the coverage gap threshold in about mid-August, leaving those with no financial assistance to pay for all of their drug costs either until they spent enough money on prescriptions ($2,250 in 2006 and $2,400 in 2007) or until the beginning of the following year when their benefits reset.

The nearly 2,000 Medicare beneficiaries who fell into the doughnut hole with no financial assistance were then compared with nearly 10,000 seniors who did have financial assistance from the government or because they had private coverage plans.

They found that seniors who were paying 100% of their costs in the coverage gap were twice as likely to discontinue taking a drug compared with those who had financial assistance (hazard ratio: 2.00 with a 95% confidence interval from 1.64 to 2.43).

Seniors in the doughnut hole with no financial assistance were 18% more likely than those with financial assistance to reduce their drug adherence.

They were also 2.6 times more likely to stop taking a brand-name heart drug, and nearly two times more likely to stop taking a generic cardiovascular drug, but they didn't switch to a cheaper generic to save money.

The researchers expected that seniors, when faced with mounting out-of-pocket costs, would switch to cheaper generics. In fact, that was one of the main arguments behind the coverage back when Medicare's drug benefit was created in 2006. If seniors saw how much drugs cost, they'd be more thrifty consumers and seek out cheaper drugs, some reasoned.

But the current study shows that hasn't been the case.

Rather than seeking cheaper alternatives to prolong entry into the doughnut hole, some seniors just stop taking their prescriptions once they reach the coverage gap or alter their dosing regimen to make their medication last longer.

The Affordable Care Act (ACA) will eliminate the doughnut hole by 2020 and until then, the law takes measures to help seniors defray the costs of the coverage gap.

For example, in 2010, many seniors received $250 checks in the mail, and this year 900,000 Medicare beneficiaries have already received a 50% discount on prescription drugs while in the doughnut hole.

But until the doughnut hole is truly closed in 2020 "beneficiaries may still be at risk of decreased drug utilization and adverse clinical consequences," the authors wrote.


One alternative strategy, the authors wrote, would be to encourage the use of generic drugs from the outset in order to forestall entry into the coverage gap.

The study was funded through grants from the National Institute on Aging, the National Institute of Mental Health, the National Heart, Lung, and Blood Institute, Robert Wood Johnson Foundation, and CVS Caremark.

The study authors reported a number of conflicts of interest, including that lead study author is a consultant for a company that contracts with the Centers for Medicare and Medicaid Services; another author is a consultant to United Healthcare, which sells Part D plans, and receives research funding from CVS Caremark, Aetna, and Express Scripts, which all have Part D business. Another author worked at CVS Caremark during the study, and CVS Caremark provided funding and data for the study.