Doctors brace for fallout as seniors hit gap in Medicare drug coverage

Virgilio Licona, MD, fears the tough choices many patients will encounter once they are forced to pay out of pocket for prescriptions previously covered by Medicare Part D.

"They are going to have to make the decision between food, gas, rent and their medications," said Dr. Licona, a family physician practicing at Salud Family Health Center in Brighton, Colo. "That's scary."

About 3 million seniors are expected to reach a gap in their Medicare Part D prescription coverage before the end of the year, estimates America's Health Insurance Plans. About 38 million Medicare beneficiaries have drug coverage through a variety of sources, including stand-alone Part D plans, Medicare managed care plans, their employers and other federal programs.

Dr. Licona and many other physicians across the country are bracing themselves for questions from patients who hit the coverage break and for the fallout from the difficult decisions seniors might have to make.

Although AHIP officials predict the number of affected beneficiaries is less than the 3.4 million to 6.9 million originally projected by various groups, many physicians say the underlying cost to the health care community and society, overall, will be significant.

Dr. Licona, for example, said many of his patients facing the gap are on fixed incomes with little wiggle room. Some, he knows, will choose to go without medications.

As their conditions worsen, many of them will wind up in the emergency department or make more frequent and lengthier visits to hospitals, Dr. Licona said. "This cost will be enormous, and it won't be identified as being connected to Part D."

Yul Ejnes, MD, a general internist practicing in Cranston, R.I., agrees. "If they are not taking medications when they should and they are not taking care of their health, that could cost more in the long run," he said.

Dr. Ejnes, who estimates that 30% to 35% of his patients are on Medicare, said about two dozen have already hit the coverage gap, sometimes called the "doughnut hole."

"It was one of those things that you knew was coming, but in the initial euphoria you got excited about any coverage, you forgot about the doughnut hole," he said. "It caught some people off guard."

AMA Trustee Edward Langston, MD, said he is pleased by the AHIP projections that fewer seniors are likely to reach the Medicare Part D coverage gap than expected.

"At the same time," he said, "we have serious concerns that patients who suddenly find themselves without coverage, and who know that their coverage will begin again Jan. 1, may try doing without their prescription medicines during the intervening weeks or months."

Policy criticized

The coverage gap occurs in most Medicare plans after the patient and Medicare have spent a total of $2,250 on prescriptions. Coverage is resumed only after the patient spends another $2,850 out of pocket.

"It's a concept that makes no sense," said Dr. Ejnes, chair of the American College of Physicians board of governors. "It was a stupid plan."

Dr. Licona, an American Academy of Family Physicians board member, said the coverage break could be seen as a cruel joke to play on seniors.

"Basically they're saying we're going to help you with your medications and then you will have to jump over this canyon, and it is such a wide canyon a lot of people are going to fall in the canyon, but if you get over, then we'll help you out again," he said.

Additionally, the plan's logistics are confusing. "It's hard for seniors, many of whom have trouble keeping track of this anyway," Dr. Ejnes said. "They have one set of rules for part of the year and then another set of rules the rest of the year."

Physicians are frustrated as well.

"It's not simple to me," Dr. Licona said. "That lack of understanding is pervasive."

The confusion, Dr. Ejnes predicts, may cause seniors to opt next year for drug plans that charge a higher premium up front but cover patients during the gap. In the interim, his patients are inquiring about sample drugs and alternative, cheaper medications such as generics. They also are considering taking partial doses or skipping days, Dr. Ejnes said.

"They will have to squeak through, the way they were before the benefit became available," he said.

About 10% of beneficiaries who have bought Part D coverage on their own have reached the coverage break to date, according to AHIP studies. About 10.4 million beneficiaries were enrolled in stand-alone drug plans as of June, according to the most recent data from the Centers for Medicare & Medicaid Services.

AHIP's estimate that about 3 million will hit the gap this year is in line with a PricewaterhouseCoopers study, which found that about 3.4 million people with Medicare would find themselves in that predicament.

Karen Ignagni, president and CEO of AHIP, said physicians and patients should not lose sight of the fact that, even with the lapse, many seniors enjoyed better coverage for most of the year than they had previously.

One resource for beneficiaries and their physicians looking for price information is the Web site "Consumer Reports Best Buy Drugs," which offers drug cost comparisons.

"Many Americans don't realize there are safe and effective alternatives to the high-priced prescriptions," said Gail Shearer, health policy director for Consumers Union, publisher of Consumer Reports. "Medicare beneficiaries especially need to know they have options that can save them significant amounts of money."

Dr. Licona encourages his patients to write and call their legislators to ask for a long-term solution.

"You can tell them, 'look at this Web site,' but many are not that fluid with computers and not everyone has a computer," he said.

Consumers Union and the AMA support legislation allowing Medicare to negotiate lower prices from the drug industry. That money could help close the gap in coverage, the consumer group said.

Dr. Licona also supports that idea and says Congress should negotiate better prices upfront. "People ask, 'Where's the money?' Well, we left it on the table. My solution is we take the money back off the table and have the marketplace pay for it."