Coverage gap leads many to forgo medicine, study says

WASHINGTON - Many people in Medicare with diabetes, high blood pressure, and other chronic conditions stop taking their medicine when faced with picking up the entire cost of their prescriptions, researchers say.

About 3.4 million older and disabled people hit a gap, known as the doughnut hole, in their Medicare drug coverage in 2007. When that happened, they had to pay the entire costs of their medicine until they spent $3,850 out of pocket. Then, insurance coverage would kick in again.

About 15 percent of those hitting the coverage gap stopped their treatment regimen. That rate varied depending upon illness. For example, about 10 percent of diabetes patients stopped buying the medicine, as did 16 percent of patients with high blood pressure and 18 percent of patients with osteoporosis.

The drug benefit, which began in 2006, has come in under budget. Most participants report they are satisfied with the program. But many lawmakers and health analysts say improvements could be made.

"If a new president and Congress consider changes to the drug benefit, it will be important to keep in mind that the coverage gap has consequences for some patients with serious health conditions," said Drew Altman, chief executive officer and president of the Kaiser Family Foundation, which conducted the study with researchers at Georgetown University and the University of Chicago.

The Republican-led Congress in 2003 crafted the doughnut hole to make the drug benefit more affordable for the government.

The researchers based their findings on pharmacy claims data provided by IMS Health, a company specializing in collecting healthcare data. They excluded people who get extra help in paying for their drug coverage because of their income; they do not pay the full cost of medicine even when in the doughnut hole.

When looking at spending by people who did not receive the extra help, researchers could determine when they hit the coverage gap, which began at $2,400 in total drug spending.

The researchers focused their analysis on eight categories of drugs. Those least likely to stop taking their medicine were Alzheimer's patients, at 8 percent. Those most likely, at 20 percent, were patients with heartburn, ulcers, and acid reflux disease.

Jeff Nelligan, a spokesman for the Centers for Medicare and Medicaid Services, said the coverage gap kicks in after participants have saved about $1,600 on their drug costs, on average. He also noted that many plans offer some coverage when beneficiaries hit the doughnut hole.