Medicare: Closing the “Donut Hole”

The government has made a commitment to close the “donut hole” gap in Medicare coverage by 2020, but many current beneficiaries still find themselves falling into this pricey crevasse.

The donut hole is the disruption in prescription drug benefits that occurs when a Medicare Part D participant reaches their yearly maximum coverage amount (the total paid by both the beneficiary and their insurance provider), but before the “catastrophic” coverage part of their plan kicks in. And, despite its reference to an appetizing breakfast treat, there’s nothing sweet about this donut hole. The financial impact can be devastating for an older adult and their family. “A sizeable proportion of patients enter the gap and few reach catastrophic coverage,” write a group of researchers from the UCLA School of Public Health in an article published in the Journal of General Internal Medicine.

Who is most at risk for entering this costly gap?

Women, and older adults with dementia or diabetes, according to an analysis of more than 287,700 Medicare records, recently carried out by a team of UCLA scientists, led by Professor Susan Ettner. And once a person enters the gap, they aren’t likely to leave it again—less than seven percent of people who fell into the donut hole were able climb out within the same year. Those that did ended up incurring thousands of dollars in drug costs along the way.

Having dementia doubled a beneficiary’s risk of falling into the donut hole. Indeed, 66 percent of people who entered the coverage gap were taking at least one anti-dementia drug (e.g. donepezil, rivastigmine, memantine and galantamine) which, as a group, cost an average of $4.86 a day in 2006. Women were also more likely than men to encounter the donut hole. Researchers hypothesized that this might be because women are more likely than men to seek treatment for certain health conditions.

In a given year, based on the UCLA study results, a 75-year-old woman with dementia and depression would have a 48 percent chance of falling in the donut hole and only a 20 percent chance of climbing out by the end of the year. Diabetes, end-stage renal disease, coronary artery disease and COPD all also significantly upped an individual’s chances of experiencing a lapse in coverage.

Doctor-patient discussions still important, post-donut hole

The Patient Protection and Affordable Care Act of 2010 (“Obamacare”) contains provisions for closing the donut hole by gradually decreasing Medicare beneficiaries’ share of drug costs during the coverage lapse, until they reach the traditional 25 percent copay amount by the year 2020. In the meantime, honest discussions about prescription drugs between doctors, patients and their families can reduce the chances that an aging adult will fall into the donut hole, and decrease their out-of-pocket drug costs.

But even after the donut hole becomes a distant memory, these conversations remain vitally important, according to Ettner and her team. “Physicians who make a routine practice of prescribing lower-cost medications first and discontinuing those that do not appear to be effective may not only improve their patients’ adherence to more essential medications by keeping them out of the coverage gap, but also avoid exposing their patients to side effects associated with potentially unnecessary medications,” study authors note. Beyond Medicare Part D, there are other options for those who need help covering the cost of certain prescription medications. This Prescription Drug Assistance Program Locator can help you access additional financial assistance programs.


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