Minding Medicare’s Drug Gap

When Congress created the Medicare prescription drug program, it adopted an unusual idea to hold down costs: the so-called doughnut hole.

The program pays most of a participant’s drug bills until expenses reach $2,250 in a year. Then it stops paying until costs exceed $5,100. That leaves a hole of $2,850 that seniors with serious prescription needs are expected to manage on their own.

Now, six months into the drug program -- the first new major healthcare benefit for the elderly in decades -- 3.4 million seniors are approaching the doughnut hole.

Most of them are middle-class seniors with multiple chronic illnesses. (The poor are exempt from the gap.) Some have already experienced an abrupt surge in prescription costs.

Melvin Kinnison, 65, of Huntington Beach was shocked to discover that the out-of-pocket cost to refill his prescription for antiseizure medication was jumping to $178 from $10. He left the pharmacy empty-handed.

“It hit me like a slap in the face,” said Kinnison, a former Los Angeles County sheriff’s deputy.

Kinnison is trying to figure out how to handle a monthly tab for heart, diabetes and acid reflux medications that has climbed to $1,000 from $80. “I thought Medicare is supposed to be helpful,” he said. “It sure isn’t.”

Sensing a political opportunity, some Democrats are campaigning on a promise to shrink or close the doughnut hole. As November’s congressional elections draw nearer, more seniors will confront the gap.

But the significance of the issue extends beyond the immediate problem. At stake is a basic approach of the Bush administration and many conservatives and business leaders for dealing with the cost crisis in healthcare. They say consumers must be made to take more responsibility for their medical affairs. Costs are growing so fast, they say, the government and private employers cannot shoulder the burden alone.

They say seniors can avoid problems like Kinnison’s if they purchase a plan that covers the doughnut hole. The Medicare drug benefit is delivered through private insurance plans, which individuals choose. The plans that cover the doughnut hole -- most plans don’t -- charge higher premiums. Of the estimated 23 million seniors enrolled in the Medicare benefit, about 2.4 million paid extra for some level of gap coverage.

Medicare Administrator Mark B. McClellan also points out: “Even among the people in plans with a doughnut hole, there are steps consumers can take” to make sure they never reach the hole, such as using lower-cost generic drugs and monitoring costs.

“What millions of these beneficiaries had before was no coverage at all for their prescription expenses,” McClellan said.

He urged concerned seniors to call (800) MEDICARE to find out about generics. Medicare officials also advise seniors to carefully read their drug plans’ monthly statements, which contain information on how close they are to the gap.

In the long run, some experts suggest, some seniors may wish to switch from traditional Medicare to managed care plans, which are more likely to provide coverage in the doughnut hole. Seniors can also anticipate the gap and save ahead for it.

Those strategies may help many seniors, but not everyone, critics of the doughnut hole say.

The higher premiums for blanket coverage may be beyond the reach of some. Generics are not available for all drugs. And a senior’s health needs can change, making it difficult or impossible to plan ahead.

Moreover, such careful management is itself an obstacle for some seniors, whose medical and other problems complicate the situation.

Some doctors worry that vulnerable patients may fall victim to the gap, unable to pay the suddenly higher costs of their medicines.

“There is a huge amount of evidence from research and clinical experience that seniors skip medicines when the price is too high,” said Dr. Joshua Sharfstein, Baltimore’s public health commissioner.

“If we find that people are skipping their medications, that is a subject of concern.”

Some seniors say their solution to the gap will be to import medications from Canada, which is illegal. But if they saved money, they’d take longer to reach the other side of the gap, when “catastrophic” drug coverage kicks in at the $5,100 mark.

Industry experts say a hole in the middle of an insurance benefit is highly unusual. Most medical insurance plans have a yearly deductible. And some prescription drug plans limit how much they will pay each year.

Under the Medicare drug benefit designed by Congress, beneficiaries pay the first $250 in drug costs for the year. The plan then pays 75% of the next $2,000. After that comes the $2,850 doughnut hole, for which seniors are solely responsible. Then, when a beneficiary’s drug bills for the year exceed $5,100 ($250 plus $2,000 plus $2,850), Medicare pays 95%.

“I think this is unique,” said Dan Mendelson, president of Avalere Health, a healthcare research and consulting firm.

The company’s research shows that 15% of stand-alone drug plans for seniors with traditional Medicare offer coverage in the gap. Among managed care plans, 24% offer coverage in the gap.

Economist Jack Rodgers of PricewaterhouseCoopers likened the Medicare benefit to two plans rolled into one: The first offers limited coverage of medication, with a cap at $2,250; the second provides a more generous benefit for higher bills. In between is the doughnut hole.

“A lot depends on whether you look at the doughnut or you look at the hole,” said Rodgers, adding that he believed the availability of enhanced plans, albeit for higher premiums, would soften the impact of the gap.

Recent estimates by PricewaterhouseCoopers indicate that 3.4 million beneficiaries will have to pay full freight in the gap.

An additional 2.4 million have signed up for enhanced plans that provide doughnut hole coverage, mostly for generic drugs.

And 10 million are low-income beneficiaries, whose coverage in the gap is subsidized by the government.

The remaining seniors will not spend enough to reach the gap.

Those who have no coverage in the doughnut hole will have to ride what some experts call a benefits roller coaster.

“For the first five, six, seven months of the year, everything is hunky-dory,” said Ronald Ozminkowski, a senior researcher with the information firm Thomson Medstat. “Then come July and August, they’re on their own and they will have to start paying everything out of their own pockets. That will last most of the rest of the year, until the federal government says, ‘OK, enough is enough.’ ”

And the cycle starts again the following year.

By analyzing national data on prescription spending, analysts are trying to calculate when patients with different kinds of ailments will hit the gap.

“Patients with illnesses like rheumatoid arthritis and multiple sclerosis, who use very expensive drugs, will accelerate through the gap in two to three months,” said Mendelson, of Avalere Health. “Those with more common disorders such as high cholesterol and diabetes will take longer to hit the doughnut hole, generally in the fall.”

Democrats say the coverage gap can be closed if Congress grants Medicare authority to directly negotiate lower prices with drug manufacturers. Eliminating the gap with tax dollars would be expensive, perhaps costing more than $10 billion a year now, and bigger sums in the future.

But Leonard Cleveland, 68, a retired machinist who lives in El Monte, said a $2,850 gap was too much for people with fixed incomes. “If they just shortened the gap, people could make it through, [with a] credit card or whatever,” Cleveland said.

His wife, Helen, who is partially blind and on medication for depression, back pain, allergies and migraines, has fallen into the gap.

“I didn’t think it would total up that fast,” said Cleveland, who cares for his wife and a 42-year-old daughter who is disabled.

Dr. John Hsu, a research physician with Kaiser Permanente in Oakland, said drugs shown to be highly effective for common problems such as high blood pressure and diabetes should be provided to beneficiaries at no cost, even in the coverage gap.

“A lot of forms of cost-sharing are like blunt instruments,” Hsu said. “With any medication that we have good, reliable data on, we need to think hard about encouraging its use and not putting any barriers in front of patients.”

And, because failure to take prescribed medicines could mean that untreated illnesses become more serious, it might even save Medicare money.

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(BEGIN TEXT OF INFOBOX)

“Doughnut hole”

Some seniors enrolled in Medicare’s drug benefit plan fall into a gap after their costs reach $2,250, which leaves them responsible for paying the next $2,850.

Who is covered

Low income (no gap): 44%

Costs are less than $2,250 (no gap): 31%

Face coverage gap: 15%

Paid for extra coverage: 11%

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Numbers do not add up to 100% due to rounding.

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Source: PricewaterhouseCoopers analysis for Healthcare Leadership Council