TUESDAY, Aug. 24, 2004 (HealthDayNews) -- Seniors in insurance plans with caps on drug coverage often cut back on essential medications when they reach that cap, a new study says.
The finding could highlight a potential problem with the new Medicare drug coverage plan, which contains a provision that partly restricts reimbursement for drugs.
The study of 1,308 participants in the California-based program found that 24 percent of those who used up their drug benefits before the year ended either stopped taking a medication, used less of it than recommended or did not start taking a medication.
Among the 10 medications most affected by the self-imposed cutbacks were those for chronic conditions, including high cholesterol, high blood pressure, asthma, depression and pain, the study found.
The findings appear in the Aug. 25 issue of the Journal of the American Medical Association.
Drug therapy is often a life-and-death issue for older people, said Dr. Chien-Wen Tseng, who led the study while she was at the University of California, Los Angeles David Geffen School of Medicine.
"In our study, we studied the people who are most vulnerable," she said. "Sixty-eight percent had high cholesterol, 46 percent had heart disease, 70 percent had high blood pressure and a quarter had diabetes."
The study also illustrates what could happen to older people who fall into what is being called a "donut hole" in the new Medicare drug benefit, scheduled to start in 2006, said Tseng.
The benefit plan calls for Medicare participants to pay 25 percent of the first $2,250 annual cost of drugs. But coverage then stops until an individual's costs reach $5,100, when it kicks in again.
"Other studies have shown that a significant number of people fall into that donut hole," said Tseng, who now is assistant professor of family medicine at the University of Hawaii and a senior investigator at the Pacific Health Research Institute. Many will not be able to pay the $2,850 required for coverage to resume, she said.
Half of the seniors in Tseng's study went past the drug cap in 2001 and were on their own for anywhere from two-and-a-half months to six months. Of these, 24 percent reduced their use of medications, compared to 16 percent of seniors whose costs stayed beneath the cap, the study found.
Many of the seniors tried maneuvers to reduce costs, with 46 percent asking pharmacies for lower prices, 34 percent asking doctors for free samples and 15 percent switching to lower-cost medications, according to the study.
One important implication of the study is that doctors have to consider cost when they prescribe drugs, Tseng said. There are many lower-cost generic drugs for conditions such as high blood pressure, she said, and "the physician has to consider whether it is best to go directly to the most cost-effective drugs."
Many people in Medicare struggle with the same health problems as those found in Tseng's study, said Kenneth E. Thorpe, professor of health policy at Emory University, who has studied the effect of cost on drug use. At least one third of Medicare participants have chronic conditions that require drug therapy, he said. Other studies have found that cost is a major factor in them getting that therapy.
"When you increase what people have to pay out of pocket, the likelihood that they will renew a prescription or fill a new one goes down," he said.
The donut hole in the Medicare plan is "a counterproductive benefit design," Thorpe said. "If you have chronically ill patients, you want them to take the necessary drugs."
The Medicare drug benefit plan has been controversial from the start. It was passed by the closest of margins in the House of Representatives, but only when the Bush administration said it would cost no more than $400 billion. That estimate has since been revised upward to $530 billion.
Some conservative Republicans have denounced the plan as a big-spending government giveaway. Democrats have attacked it as insufficient to meet the needs of many older people.
The controversy is bound to grow as the starting date of the plan draws closer, Thorpe said. "It will be very much an issue starting the first of next year," he said.
More information
Much of what you need to know about Medicare and the drug plan is available from the federal government.
