Medicare Beneficiaries Decreased Use of Essential Medications During Coverage Gaps

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Medicare Beneficiaries Decreased Use of Essential Medications During

Coverage Gaps

Newswise ‹ 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 Wood

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

plan¹s 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.

³Patients 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),² the authors write.

³Twelve 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.²

³This study emphasizes the tradeoffs involved in setting cap generosity for

Medicare beneficiaries,² the researchers write. ³Lower 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.²

(JAMA. 2004; 292:952-960. Available post-embargo at http://JAMA.com)

Editor¹s Note: The research for this study was performed at the Wood

Clinical Scholars Program and the Division of General Internal

Medicine and Health Services Research, Department of Medicine, Geffen

School of Medicine at UCLA. The research was supported by grants from the

Wood Foundation Clinical Scholars Program and American

Academy of Family Physicians. Senior author Carol M. Mangione, M.D.,

M.S.P.H., is partially supported by the NIA grant UCLA Resource Center for

Minority Aging Research.