Medicare Drug Plan 'Doughnut Hole' Could Impact Seniors' Health

Lack of coverage can spur cutbacks in necessary prescriptions, study finds

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TUESDAY, Feb. 3 (HealthDay News) -- American seniors who reach the no-coverage "doughnut hole" in the Medicare Part D drug plan are less likely to use prescription drugs than those with an employer-based plan, a new study finds.

The finding raises concerns about health consequences and increased costs from hospitalizations and doctor visits resulting from this lack of drug coverage, say researchers at the University of Pittsburgh Graduate School of Public Health.

A change in policy that would mandate the coverage of generic drugs in the doughnut hole through a modest increase in initial prescription co-payments could help protect seniors, the team suggested.

The doughnut hole in Medicare Part D begins when a person's annual individual drug expenditures reach a certain amount, pegged at $2,250 in 2006. Coverage begins again when those expenses reach the "catastrophic" phase of coverage, which was $5,100 in 2006.

The University of Pittsburgh team compared two groups of seniors with Medicare drug coverage provided by a large Pennsylvania insurer in 2006. One group was covered through Medicare Advantage prescription drug plans (MA-PD) with either no doughnut hole coverage or generic coverage only. The other group was covered through more generous employer-sponsored plans with full coverage in the doughnut hole.

One in four (25 percent) of those enrolled in MA-PD reached the doughnut hole, the researchers reported, but only 5 percent of that group reached the catastrophic phase of coverage.

Those who lacked coverage in the doughnut hole reduced their monthly prescriptions by 14 percent once they entered the doughnut hole, compared to only 3 percent of those with generic coverage in the doughnut hole. The researchers saw no reduction in prescriptions for those with employer-based plans.

Those with diabetes were more likely to reach the doughnut hole, and reach it sooner, than those with hypertension. Seniors with more than one chronic illness were also much more likely than others to reach the doughnut hole -- 34 percent of those with both hypertension and diabetes reached it, as did 61 percent of those with hypertension, high cholesterol, congestive heart failure and diabetes.

The study was published online Tuesday in the journal Health Affairs.

"Our findings raise concerns about whether people with chronic illnesses who lack doughnut hole coverage are able to effectively manage their conditions. Without needed prescriptions, we could potentially see an increase in hospital and physician costs," lead author Yuting Zhang, an assistant professor of health economics, said in a university news release.

More information

The U.S. Centers for Medicare and Medicaid Services offers tips for reducing costs during the coverage gap.

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