THE “DONUT HOLE” AND OTHER COMPLEXITIES OF MEDICARE PART D

Overall, the results of the latest Kaiser Family Foundation survey tracking beneficiary satisfaction with the Medicare drug benefit look encouraging. More than 80% of older adults enrolled in a Medicare prescription drug plan were satisfied with their coverage, according to the survey, which included 1585 older adults, 623 of whom were enrolled in a plan. That’s good news.

Nearly 20% of beneficiaries, however, reported having had a “major problem” with their plan. These included problems that required them to cover unexpected costs or leave the pharmacy without a prescription. That is cause for concern. So, too, is the fact that older adults in worse health, and those taking six or more medications, were more likely to report such problems than those in better health and those taking fewer drugs. Older, frailer adults and those in greatest need of the benefit, it seems, are finding the drug benefit harder to negotiate.

Leaving the pharmacy without needed medications can obviously be a life-threatening problem. So, too, can encountering unexpected drugs costs. Faced with such costs, older adults with fixed incomes may decide to cut back on their medications, or stop taking them altogether. Since the Kaiser survey was conducted, an increasing number of older adults with Medicare drug coverage are likely to have confronted such unexpected costs—due to the benefit’s coverage gap, widely known as the “donut hole.”

As a result of the gap, beneficiaries are responsible for 100% of drug costs between $2250 and $5100. In July, newspapers nationwide were reporting that older adults enrolled in the Medicare plan were beginning to encounter the donut hole. Odds are many didn’t anticipate this. Consider another Kaiser survey finding: Roughly 36% of older adults said their plan didn’t include a coverage gap—even though nearly all plans have such a gap.

The Medicare drug plan is complex and, clearly, many older adults need more help understanding it. Among other things, they need help understanding and planning for the donut hole, and, it appears, help finding financial assistance when necessary. Another eye-opening Kaiser survey finding: Nearly two in three older adults were unaware that a program administered by Social Security helps low-income beneficiaries with drug benefit premiums and cost-sharing requirements. What’s more, seniors who qualify for this extra help don’t experience the “donut hole” coverage gap, thanks to additional government subsidies.

To help healthcare providers help older adults and their caregivers better understand the Medicare drug benefit, the American Geriatrics Society (AGS) provides ongoing updates, alerts, and resources concerning the plan. The Medicare drug benefit section of the AGS website, www.americangeriatrics.org, is continually updated and includes authoritative information from leading experts, including AGS members, and sources such as the Centers for Medicare & Medicaid Services, the Kaiser Family Foundation, and the nonprofit Access to Benefits Coalition. A subsection specifically for providers covers a wide array of issues, including issues unique to drug plan enrollees in long-term care. The patient subsection provides an easy-to-understand and comprehensive listing of answers to frequently asked questions concerning the drug benefit.

A number of legislators have proposed changes in the benefit that would eliminate the donut hole, but the fate of these measures remains unclear. Look to the Medicare drug plan section of AGS’ website and AGS News Week in Review for updates on these and other proposed changes to the benefit, and information you and your patients can use now to make the most of it.