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Better Planning For Medicare Part D’s Donut Hole

March 30, 2010

Managing certain chronic conditions makes you more likely to fall into the donut hole of Medicare Part D, according to new research done by a team including Susan Ettner, professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA and the study's lead author. Published online in the Journal of General Internal Medicine, the study looked at records from more than 287,000 Medicare recipients in eight US states, primarily in the West. Researchers investigated which beneficiaries were most likely to fall into the donut hole gap, as well as which medical conditions could put them there. They also examined which medications contributed most to pre-gap spending. They found that 16 percent of enrollees entered the gap, with nearly 3 percent entering the gap very early, within the first 180 days of the year. Of those who entered the gap, only 7 percent exited again. Women and patients with dementia and diabetes were the most likely to enter the gap. Other conditions also predisposed beneficiaries to gap entry, including end-stage renal disease, coronary artery disease, chronic obstructive pulmonary disease, mental health conditions and congestive heart failure. The donut hole, which starts after beneficiaries reach their annual coverage limit and before catastrophic coverage kicks in, leaves these patients exposed to unsubsidized medication costs. The researchers point to the need for patients to work with their healthcare providers on how to best manage costs through either drug substitution or discontinuation of specific non-essential medications. "Physician-patient discussions about the expense and undesirable side effects of particular medications are one approach to managing outpatient drug therapy and controlling costs...This is important so that more essential medication is not discontinued, with adverse effects on patients' health due to cost reasons only," said Ettner. "These patients need to continue adhering to their medication regimen."