Newswise — A UCLA and RAND study found that almost one fourth of Medicare patients with a typical prescription drug benefit of $750 in managed care plans exceed their annual dollar limit on prescription drugs -- leaving them without drug benefits for a portion of the year.
The study, published in the July 9 issue of the Journal of the American Medical Association (JAMA), also reported that once the drug benefits ran out, out-of-pocket costs could triple if patients chose to stay on the same medications.
The study revealed that 15 out of the top 20 medications with the highest total prescription expenditures are for chronic conditions such as diabetes, cardiovascular disease, high cholesterol, osteoporosis, dementia, osteoporosis, stroke prevention and asthma/emphysema. Researchers point out that even a short interruption of these medications due to lack of drug coverage may lead to adverse health events.
In addition, one third of these top 20 medications had generic equivalents in the same treatment class, which are generally much cheaper and may help extend patients' drug benefits.
Over six million or 15 percent of Medicare beneficiaries are enrolled in Medicare managed care plans, which often feature an annual "cap" on prescription drug benefits.
Senior author Dr. Carol Mangione, professor of medicine, David Geffen School of Medicine at UCLA, notes that at the time this research was conducted, traditional fee-for-service Medicare did not include an outpatient drug benefit. "Currently, there is legislation pending in Congress that would provide a drug benefit to all enrollees. However, until precise information becomes available about the structure of the benefit (deductibles, premiums, co-pays, caps, and drug pricing), it is impossible to predict its impact on Medicare beneficiaries."
"Health care professionals, government officials and the public need to work closely together to develop drug benefits for the elderly that protect their health, but also promote cost-effective and appropriate use of medications," said Dr. Chien-Wen Tseng, the first study author, who is currently an assistant professor of family medicine at the University of Hawaii.
UCLA and RAND researchers reviewed pharmacy claims from 2001 from a large Medicare managed care plan with an annual drug benefit. The plan represented over 400,000 patients who filled at least one prescription in 2001. The generosity of the cap offered to patients varied according to region and market factors.
Researchers found that 22 percent of patients exceeded a $750 annual drug benefit cap; 14 percent of patients exceeded a $1,000 cap and 4 percent exceeded a $2,000 cap. Tseng noted that on average, patients exceeded their drug benefits about three months before the end of the year.
Once a cap is met, patients paid the entire cost of the prescriptions for the remainder of the year. Researchers calculated that after exceeding the annual drug cap, costs for patients could triple in order for them to remain on the same medications. For all patients, monthly drug costs averaged $79-$100 -- but after exceeding the drug benefit cap, out-of-pocket costs rose to $179-$305.
Both Mangione and Tseng note that "Even a short interruption in these medications can make an important difference in managing a chronic condition." For this reason, all of the authors agree that we need a better understanding of what people do when they exceed their drug benefit. In addition, achieving the maximum health benefit from a limited drug benefit needs to be a priority for both doctors and patients.
The authors of the study are Dr. Chien-Wen Tseng who was a UCLA Robert Wood Johnson Clinical Scholar when this research was conducted and is currently an assistant professor of family medicine at the University of Hawaii; Dr. Robert H. Brook, professor of medicine, David Geffen School of Medicine at UCLA; professor of Health Services, UCLA School of Public Health; director, UCLA Robert Wood Johnson Clinical Scholars Program; and director of RAND Health; Emmett Keeler, Ph.D, adjunct professor of Health Services, UCLA School of Public Health and senior mathematician, RAND Health; and Dr. Carol Mangione, professor of medicine, David Geffen School of Medicine at UCLA.
The study was funded by the Robert Wood Johnson Foundation Clinical Scholars Program, the American Academy of Family Physicians, the UCLA Center for Health Improvement in Minority Elders/Resource Centers for Minority Aging Research, National Institutes of Health.
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