The so-called "doughnut hole" in Medicare Part D has proved to be a sinkhole for medication adherence, CVS Caremark Corp. and other researchers found.


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CVS Caremark: Adherence sinks in 'doughnut hole'

August 17th, 2011

WOONSOCKET, R.I. – The so-called "doughnut hole" in Medicare Part D has proved to be a sinkhole for medication adherence, CVS Caremark Corp. and other researchers found.

CVS Caremark said a new study published Tuesday in PLoS Medicine concludes that Medicare Part D beneficiaries who enter the doughnut hole — a gap in coverage where they must pay 100% of previously subsidized prescription costs — are twice as likely to discontinue their medications as they are to switch to more affordable or generic drugs.

The study conducted by researchers from Harvard University, Brigham and Women's Hospital and CVS Caremark examined prescription drug use among more than 660,000 Medicare beneficiaries enrolled in over 200 Medicare Part D and retiree drug plans in 2006 and 2007.

"The adverse clinical consequences of stopping or reducing adherence to essential medications can be both severe and costly. Our results indicate that beneficiaries faced with increased out-of-pocket cost burdens during the Part D coverage gap are twice as likely to discontinue their medications altogether, resulting in reduced medication adherence, rather than switch to more affordable or generic medications," the researchers stated.

Under the standard benefit, Medicare Part D participants get financial assistance to pay for medications until plan and out-of-pocket spending reaches an initial threshold of $2,830 (based on the 2010 benefit). At that point, the Medicare beneficiary is responsible for 100% of drug costs until they have spent more than $4,550, when the program's financial benefits restart.

Of the 663,850 beneficiaries that the researchers tracked in 2006 and 2007, roughly a third reached the doughnut hole seven months into the fiscal year. Other studies estimate that 11% to 14% of Part D participants who don't receive a low-income subsidy reach the coverage gap each year.

"No doubt, this is a difficult area for policymakers. Taking cost out of the health care system is something everyone is trying to achieve," Troy Brennan, executive vice president and chief medical officer at CVS Caremark, said in a statement.

"The Affordable Care Act incrementally eliminates the doughnut hole by 2020, but until that time program beneficiaries remain at risk of decreased drug utilization because of high out-of-pocket drug costs," noted Brennan, who heads the research initiative that conducted the study. "A strategy that promotes the use of low-cost medications and that keeps people adherent would result in better health outcomes and overall reduced health care costs. "

The lead author of the study, Jennifer Polinski of the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital and Harvard Medical School, explained that the Part D coverage gap has been somewhat of a double-edged sword.

"Proponents of the doughnut hole argue the coverage gap benefits the health care system by making participants more sensitive to medication costs. There is an expectation that people will seek less expensive drug options when they enter the doughnut hole and that action will result in cost savings both for them and for their health plans," Polinski stated. "However, our findings show that when beneficiaries have to bear the full financial burden of the cost of their medications, they are twice as likely to stop taking their medications altogether and become nonadherent than they are to switch to more affordable or generic drugs. The resulting decrease in medication adherence could ultimately result in higher medical costs as a result of adverse health events."

The Medicare Part D study stems from a three-year research collaboration between CVS Caremark, Harvard and Brigham and Women's Hospital to better understand why many consumers don't take their prescriptions as directed.

Last month, for example, the collaboration reported that greater use of generic drugs for chronic disease makes the cost of preventive health care much less than previously believed.  And in late May the researchers served up recommendations for how to promote medication adherence and improve the delivery of pharmacy care.

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