Cost-Lowering Strategies Used by Medicare Beneficiaries Who Exceed Drug Benefit Caps and Have a Gap in Drug Coverage

University of Hawaii Department of Family Practice and Community Health, Honolulu, and UCLA Department of Medicine, Los Angeles, Calif.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 09/2004; 292(8):952-60. DOI: 10.1001/jama.292.8.952
Source: PubMed


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. In the new national Medicare drug benefit, beneficiaries with high medication expenditures will also face a period without drug coverage when their total drug costs exceed annual caps but are not high enough to qualify for catastrophic coverage.
To describe strategies adopted by beneficiaries exceeding annual drug benefit caps to lower prescription costs, the type of medications involved, and their financial burden.
A survey (completed in 2002) of Medicare + Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs (65% response rate). The different caps offered in different counties were used as a natural experiment. Study participants (n = 665) exceeded a 750 dollars or 1200 dollars yearly cap in 2001 and had coverage gaps of 75 to 180 days. Control participants (n = 643) had 2000 dollars caps, which they did not exceed. Study and control participants were matched by average total drug expenditures per month.
Proportion of beneficiaries reporting specific strategies to decrease medication costs, medications affected, and difficulty paying for prescriptions.
In multivariate analyses adjusting for demographic and health characteristics, a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18% vs 10%, respectively; P<.001), but similar proportions reported stopping medications completely (8% for both, P =.86) and of not starting prescribed medications (6% vs 5%, P =.39). Patients exceeding caps more often called pharmacies to find the best price (46% vs 29%, P<.001), switched medications (15% vs 9%, P =.002), used samples (34% vs 27%, P =.006), and had difficulty paying for prescriptions (62% vs 37%, P<.001). Twelve 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.
Medicare beneficiaries often decreased use of essential medications and experienced difficulty paying for prescriptions during gaps in coverage. Health professionals need to explore how they can lessen the impact of caps on patients' health and financial burden.

Download full-text


Available from: Emmett B Keeler, Dec 18, 2013
31 Reads
  • Source
    • "Patients taking costly medications for chronic conditions such as osteoporosis may reach this spending limit sooner, and as a consequence, they may resort to cost-coping behaviors to manage their healthcare spending during the resulting gaps in coverage [14-17]. Some studies of Medicare Part D patients have identified cost-coping strategies such as using medications less frequently than prescribed, discontinuing medications, not filling prescriptions, and switching to less expensive agents [18-20]. Other studies suggest that cost-related responses are more common among patients who have better knowledge of their benefits and who report fewer financial burdens [21,22]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Improper medication adherence is associated with increased morbidity, healthcare costs, and fracture risk among patients with osteoporosis. The objective of this study was to evaluate the healthcare utilization patterns of Medicare Part D beneficiaries newly initiating teriparatide, and to assess the association of medication adherence and persistence with bone fracture. Methods This retrospective cohort study assessed medical and pharmacy claims of 761 Medicare members initiating teriparatide in 2008 and 2009. Baseline characteristics, healthcare use, and healthcare costs 12 and 24 months after teriparatide initiation, were summarized. Adherence, measured by Proportion of Days Covered (PDC), was categorized as high (PDC ≥ 80%), moderate (50% ≥ PDC < 80%), and low (PDC < 50%). Non-persistence was measured as refill gaps in subsequent claims longer than 60 days plus the days of supply from the previous claim. Multivariate logistic regression evaluated the association of adherence and persistence with fracture rates at 12 months. Results Within 12 months of teriparatide initiation, 21% of the cohort was highly-adherent. Low-adherent or non-persistent patients visited the ER more frequently than did their highly-adherent or persistent counterparts (χ2 = 5.01, p < 0.05 and χ2 = 5.84, p < 0.05), and had significantly lower mean pharmacy costs ($4,361 versus $13,472 and $4,757 versus $13,187, p < 0.0001). Furthermore, non-persistent patients had significantly lower total healthcare costs. The healthcare costs of highly-adherent patients were largely pharmacy-related. Similar patterns were observed in the 222 patients who had fractures at 12 months, among whom 89% of fracture-related costs were pharmacy-related. The regression models demonstrated no significant association of adherence or persistence with 12-month fractures. Six months before initiating teriparatide, 50.7% of the cohort had experienced at least 1 fracture episode. At 12 months, these patients were nearly 3 times more likely to have a fracture (OR = 2.9, 95% C.I. 2.1-4.1 p < 0.0001). Conclusions Adherence to teriparatide therapy was suboptimal. Increased pharmacy costs seemed to drive greater costs among highly-adherent patients, whereas lower adherence correlated to greater ER utilization but not to greater costs. Having a fracture in the 6 months before teriparatide initiation increased fracture risk at follow-up.
    BMC Musculoskeletal Disorders 01/2013; 14(1):4. DOI:10.1186/1471-2474-14-4 · 1.72 Impact Factor
  • Source
    • "A change to one factor will often impart changes to others. One factor that does not always negatively impact drug wastage but which is important with respect to patient health is the unintended forcing of non-compliant behavior by prescribing higher-than-needed doses of medications a patient cannot afford; in some of these cases, low-dose prescribing can promote compliance by making the prescription more affordable (e.g., Tseng et al., 2004). Increased compliance is also known to lead to reduced overall health care costs (Roebuck et al., 2011). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The prescribed use of pharmaceuticals can result in unintended, unwelcomed, and potentially adverse consequences for the environment and for those not initially targeted for treatment. Medication usage frequently results in the collateral introduction to the environment (via excretion and bathing) of active pharmaceutical ingredients (APIs), bioactive metabolites, and reversible conjugates. Imprudent prescribing and non-compliant patient behavior drive the accumulation of unused medications, which pose major public health risks from diversion as well as risks for the environment from unsound disposal, such as flushing to sewers. The prescriber has the unique wherewithal to reduce each of these risks by modifying various aspects of the practice of prescribing. By incorporating consideration of the potential for adverse environmental impacts into the practice of prescribing, patient care also could possibly be improved and public health better protected.
    Science of The Total Environment 11/2012; 443C:324-337. DOI:10.1016/j.scitotenv.2012.10.092 · 4.10 Impact Factor
  • Source
    • "Gaps in coverage may increase out-of-pocket spending for beneficiaries because they pay the full price of drugs filled during these periods; beneficiaries also may decrease drug use or treatment adherence, leading to decreases in total drug costs. Studies prior to Part D have found both effects, i.e., total drug spending and adherence decrease for both discretionary and necessary drugs, while out-of-pocket expenditures increase (Hsu et al. 2006; Tseng et al. 2004). In at least some cases, lack of coverage leads to higher rates of downstream clinical events including hospitalizations (Hsu et al. 2006). "
    [Show abstract] [Hide abstract]
    ABSTRACT: To compare drug costs and adherence among Medicare beneficiaries with the standard Part D coverage gap versus supplemental gap coverage in 2006. Pharmacy data from Medicare Advantage Prescription Drug (MAPD) plans. Parallel analyses comparing beneficiaries aged 65+ with diabetes in an integrated MAPD with a gap versus no gap (n=28,780); and in a network-model MAPD with a gap versus generic-only coverage during the gap (n=14,984). Drug spending was 3 percent (95 percent confidence interval [CI]: 1-4 percent) and 4 percent (CI: 1-6 percent) lower among beneficiaries with a gap versus full or generic-only gap coverage, respectively. Out-of-pocket expenditures were 189 percent higher (CI: 185-193 percent) and adherence to three chronic drug classes was lower among those with a gap versus no gap (e.g., odds ratio=0.83, CI: 0.79-0.88, for oral diabetes drugs). Annual out-of-pocket spending was 14 percent higher (CI: 10-17 percent) for beneficiaries with a gap versus generic-only gap coverage, but levels of adherence were similar. Among Medicare beneficiaries with diabetes, having the Part D coverage gap resulted in lower total drug costs, but higher out-of-pocket spending and worse adherence compared with having no gap. Having generic-only coverage during the gap appeared to confer limited benefits compared with having no gap coverage.
    Health Services Research 04/2010; 45(2):355-75. DOI:10.1111/j.1475-6773.2009.01071.x · 2.78 Impact Factor
Show more