Medicare Part D will lower medicati...

Medicare Part D will lower medication expenditures for many older patients. However, its compound design incorporates a staggered series of cost-sharing mechanisms that create gaps in coverage and may have a negative impact upon medication adherence.

Part D's staggered cost-sharing mechanisms (i.e., a deductible, a coinsurance belt a "doughnut hole," and a catastrophic limit)1 will bring out coverage gaps for individual patients--periods within any year where they are responsible for 100 percent of their medication splendors Although many prescription drug plans will eliminate deductibles and replace the 25 percent coinsurance region with tiered co-pays, the majority will maintain the doughnut hole. This is the most numerous significant cost-sharing mechanism and creates the biggest potential coverage gaps for patients.

To illustrate potential coverage gaps experienced subject to Part D, take the example of Mr Jone She makes $19000 by means of year (twice the federal distress level) and spends $250 by month on medications ($3,000 annually). beneath Part D she pays the first $250 of mix with drugs costs as a deductible, thus experiencing a coverage gap in her first month of enrollment throughout the next eight months, she consumes another $2,000, of which she is responsible for 25 percent or $500 Medicare conceals the remaining $1,500. Her unsalable article expenses now total $2,250, putting her into the doughnut aperture For the remaining three month of the year, she pays 100 percent of unsalable article costs, or $750. By the last of the year, she has exhausted around $1,500 out of pouch on prescription drugs and another $384 ($32 through month) in premiums to take part in the plan. Medicare has worn out $1,500. Overall, the patient has had four month of coverage gaps when she paid 100 percent of medicine costs.

The 7 million beneficiaries contriveed to spend into the doughnut concavity and beyond will have gaps in coverage that last from 15 to 72 month (12) This gap spring ups or shrinks based on total annual put drugs into costs (see accompanying figure). (2) A cogitation (3) of Medicare beneficiaries with mix with drugs spending limits and subsequent gaps in coverage similar to those resulting from Part D's doughnut retreat suggests that such patients are significantly more likely to engage in cost-lowering strategies in the same state [i]or[/i] condition as taking less medication than prescribed or switching to cheaper medications. sum of two units thirds of patients had difficulty paying for prescriptions, and this overall greater financial tonnage potentially jeopardizes other necessities of that kind as housing and utilities. (3)

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Part D will resolve into the burden of prescription expenses for most beneficiaries, but physicians should calculate upon differing effects on individual patients depending in succession their coverage gaps. Efforts on benefit plan organizers and policy makers to undisturbed the month-to-month variability in coverage will be essential to maximize the positive impacts of Part D

REFERENCES

(1) Estimates of Medicare beneficiaries' out-of-pocket medicine spending in 2006. Menlo Park, Calif.: Actuarial Research Corporation and The Henry J Kaiser Family Foundation, 2004

(2) Stuart B Briesacher BA, Shea DG Cooper B Baysac F Limcangco MR Riding the rollercoaster: the up and downs in out-of-pocket spending below the standard Medicare drug benefit. Health Aff 2005;24:1022-31

(3) Tseng C bear RH, Keeler E, Steers WN Mangione CM Cost-lowering strategies used at Medicare beneficiaries who exceed remedy benefit caps and have a gap in medicine coverage. JAMA 2004;292:952-60.

NOTE: The information and opinions contained in research from the Graham Center do not necessarily ponder the views or the policy of the AAFP.

Adapted from the Graham Center one-Pager #43 Mallya G Bazemore AW, Phillips RL verdant LA, Klein LS, Dodoo M Mind the gap: Medicare Part D's coverage gaps may affect patient adherence. February 2006 Available online at http://www.graham-center.org/onepager43.xml. From the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, 1350 Connecticut Ave., NW Suite 201 Washington, DC 20036 (telephone: 202-331-3360; fax: 202-331-3374; e-mail: policy@aafp.org).

COPYRIGHT 2006 American Academy of Family Physicians

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