Senior citizens with chronic illness were more likely to receive
prescription drug coverage through the Medicare Part D program, which began at
the start of 2006, than through other options, but that program was likely to
cost them significantly more than other coverage, according to a recent
The results of the survey, conducted in fall 2006 by the Kaiser Family
Foundation, Commonwealth Fund, and Tufts-New England Medical Center, were
published in the August Health Affairs.
The survey included a national, random sample of more than 16,000 seniors
and looked at their out-of-pocket spending and cost-related experiences,
broken out by type of drug coverage, with a more in-depth look at the
experiences of seniors with low incomes.
The survey found that a larger share of seniors in Part D than those in
employer-sponsored or VA insurance programs spent more than $300 monthly,
despite taking a similar or smaller number of medications. Part D enrollees
were twice as likely to spend at least $300 monthly as seniors with
employer-sponsored coverage, and they were three times as likely to do so as
were VA beneficiaries.
The differing impact of drug costs on chronically ill enrollees was even
more pronounced than among Medicare beneficiaries in general. Among seniors
with multiple chronic illnesses, Part D enrollees took the same number of
medications as others, on average, but spent "significantly more out of
pocket" with significantly higher rates of cost-related nonadherence.
The survey found that 11 percent of chronically ill Part D enrollees, 8
percent in employer plans, and 7 percent in the VA spent more than $300
monthly on prescriptions.
The survey results also indicated that older Americans enrolled in a
Medicare Part D plan had more medication-access problems than those who relied
on other sources of drug coverage, such as employer-sponsored coverage or
benefits from the VA.
Part D enrollees decided against or delayed filling or refilling
prescriptions at twice the rate of seniors who got their prescription coverage
through employer plans or the VA. Part D enrollees were more than twice as
likely as seniors in employer plans to delay or avoid filling or refilling
prescriptions because of cost, which the researchers called"
The study authors said that more research is needed to clarify the reason
for the higher spending by Part D beneficiaries, but they said it was likely
attributable, in part, to the coverage gap that exposes Part D enrollees to
100 percent cost sharing after their total spending exceeds a certain
threshold. The so-called "donut hole" coverage gaps are rare in
employer-sponsored plans and are not a feature of VA benefits.
"We still have a lot of work to do to make sure that Medicare
beneficiaries—particularly those who are most vulnerable because of low
incomes or chronic illness—can get the drugs they need and are not
subject to burdensome out-of-pocket costs," said Karen Davis, president
of the Commonwealth Fund, in a written
The survey reported that another notable change in Part D enrollees'
prescription-drug practices was a high level of medication switching.
One-fourth of Part D enrollees reported switching to a cheaper medication
than the one they were originally prescribed after they enrolled in a Part D
plan, with little variation by income. The change included moving from a
high-cost to a lower-cost brand-name drug or from a brand-name drug to a
"The relatively high rate of switching to cheaper medications might
be a function of beneficiaries moving into plans that use financial incentives
(such as tiered copayments) and cost-management tools (such as step therapy)
to steer enrollees toward lower-cost medications," the survey authors
The survey also identified aspects of the Part D program that had a
particular impact on the approximately 6 million low-income enrollees eligible
for both Medicare and Medicaid, known as dual eligibles. Dual eligibles
include many beneficiaries with psychiatric drug prescriptions. The survey
found that 1 in 5 dual eligibles said they needed to obtain "special
permission" from the Part D insurance plan that covered them to get a
prescription filled, which was double the rate of higher-income Part D
The researchers attributed the higher rate of special permission required
for dual eligibles to the nature of the medications they are prescribed or
their plan's use of tools such as prior authorization, which might restrict
access to "the high-cost medications used disproportionately by dual
Many of the findings on access difficulties and higher costs reflected
problems in the first year of the program identified in a study by the
American Psychiatric Institute for Research and Education (APIRE), of
psychiatric patients' experience with Part D. The study was the first to
compile clinically detailed, national data on the impact of drug-plan
management practices under Medicare Part D on dual-eligible psychiatric
patients' medication access, compliance, and clinical outcomes
(Psychiatric News, May 18 and July 20).
The APIRE survey of 1,183 psychiatrists in the first eight months of 2006
and another 1,600 in the last four months of that year reported clinically
detailed information on one systematically selected, dual-eligible Part D
patient under the care of each surveyed psychiatrist.
The study found that large numbers of patients had problems filling their
prescriptions and that many psychiatrists reported changing or discontinuing
their patients' clinically indicated medications rather than pursuing appeals
or exceptions. A growing number of psychiatrists also had to ask drug plans
for exemptions to their drug coverage rules so that patients could get needed
Other problems identified in the APIRE study were difficulty accessing
medication refills and insurance-plan requirements to switch to a different
medication because clinically preferred medication refills were not covered or
"Medicare Prescription Drug Benefit Progress Report: Findings
From a 2006 National Survey of Seniors" is posted at<http://content.healthaffairs.org/cgi/content/abstract/26/5/w630>.▪