UH researcher finds seniors reduce or discontinue use of essential medications when faced with a "donut hole" in drug coverage

Medical journal publishes findings this week; implications for new Mecicare plan cited

Seniors who use up their yearly drug benefits before the end of the year often resort to reducing their recommended dosages, or even stop taking their essential medications altogether — a situation that could endanger their health — according to a new study led by a University of Hawaiʻi investigator to be published in the Journal of the American Medical Association this week.


The research team studied seniors who were given a fixed amount of money from their health plans to cover medication costs for the year, commonly known as a benefit "cap." Nearly one in four of seniors who used up their benefit two and a half to six months before the end of the year said they either used less, stopped, or did not start at least one of their medications because of how much the medications cost. Essential drugs such as those for treating high cholesterol, hypertension, asthma, depression, and pain were among the top ten medications affected. Patients also stopped taking less essential drugs such as those for treating heartburn and allergies. Two-thirds of these seniors said that it was difficult to pay for their medications; a quarter of the seniors reported difficulty paying for rent and other bills because of how much their medications cost.


Researchers say this study points to what could happen to seniors under the newly adopted $410 billion national Medicare drug benefit program due to start in 2006. Medicare does not currently cover outpatient prescription medications for most people. Under the new plan, seniors will be asked to pay a monthly premium and a $250 deductible to receive the plan‘s drug benefits. Once the costs for medications reach a certain level ($2,250) seniors must pay all out-of-pocket costs until the cost exceeds $5,100 when catastrophic coverage begins to cover all expenses. Based on other studies, an estimated 40 percent of Medicare seniors — many of them likely to have chronic health problems — will fall into this "donut hole" gap between partial coverage and full coverage.


Lead researcher Dr. Chien-Wen Tseng, an assistant professor at the John A. Burns School of Medicine and investigator at the Pacific Health Research Institute, said "This study sends out an emergency signal to doctors that we need to be aware that seniors often only get a fixed amount of money from their health plans to cover their medications for the year. Do we really want to use it up on a heartburn or allergy medication? Physicians can also help by thinking twice when writing a prescription. We need to offer patients more choices if there‘s a less expensive drug that might also be just as good."

Physicians may also assume that if a senior has drug coverage, they can afford their medications. But that‘s not necessarily so, says Dr. Tseng. "Even if my patient‘s co-payment is $20 per month for a brand-name medication, that‘s $240 a year. Doctors often don‘t ask patients if they can afford their medications because we‘re not really trained to do that. But if we don‘t ask these questions, more of our seniors may be choosing between going to the pharmacy or the grocery market."

The study surveyed 1,308 seniors in 2002, half of whom exceeded their cap in 2001 and had a gap in coverage for two and a half to six months. The other half of participants had a higher benefit cap and coverage year-round. The researchers found that 24% of seniors who had a gap in coverage decreased their use of medications because of cost. Many participants also tried to lower their costs by calling pharmacies for cheaper prices (46%), asking doctors for samples (34%), or switching to less expensive medications (15%). A surprise finding was that even 16% of the seniors who had generous drug benefits and coverage year round said they decreased their medication because of cost, and one in three found paying for medications difficult.

Study co-author Carol M. Mangione, professor of general internal medicine and health services research at the David Geffen School of Medicine at UCLA agrees with Dr. Tseng. "Patients were making some pretty big trade-offs for spending money so they could cover their medication costs," she said. "The important thing about this study is that the kinds of medications these patients were using suggest they have chronic conditions for which proper medication is absolutely essential."

The study, "Cost-Lowering Strategies By Medicare Beneficiaries Who Exceed Drug Benefit Caps and Have a Gap in Drug Coverage," will be published in the August 25th, 2004 issue of the Journal of the American Medical Association. It was funded by the Robert Wood Johnson Foundation Clinical Scholars Program and the American Academy of Family Physicians. This study was conducted while Dr. Tseng was a Robert Wood Johnson Clinical Scholar at UCLA

Dr. Tseng is an assistant professor at the University of Hawaii John A. Burns School of Medicine Department of Family Medicine and Community Health and an Investigator at the Pacific Health Research Institute.

In addition to Drs. Tseng and Mangione, other researchers in the study included Robert H. Brook, professor of geriatrics and director of UCLA‘s Clinical Scholars Program; W. Neil Steers, visiting assistant resident of general internal medicine and health services research at UCLA; and Emmett Keeler, PhD, a senior mathematician of the Rand Corp.