Clinical Geriatrics

Before the new plan year starts on January 1, marking once again the beginning of the prescription drug benefit cycle, many Medicare beneficiaries will find themselves having a difficult time obtaining their medications because of the gap in coverage. This gap in coverage, commonly referred to as the “donut hole,” is the period in the Medicare Part D benefit when the beneficiaries are completely responsible for the cost of their medications.

While many long-term care (LTC) residents are not subject to the donut hole, a fair number of them unfortunately are. The Kaiser Family Foundation estimates that some 4 million Medicare beneficiaries are affected by this gap in coverage. Many are just now entering the donut hole, where a gap in coverage occurs during the period after a beneficiary reaches $2250 in total medication costs until coverage resumes at $5100 (ie, the Medicare beneficiary must pay $2850 out of pocket for medications). The dually eligible, those having Medicare and Medicaid, are fortunate enough to have complete coverage with zero out-of-pocket expenditures, so they never need to pay for their Medicare Part D–covered medications.

The obvious problem for those entering the donut hole is how this can affect medication adherence. The Kaiser Family Foundation demonstrated that adherence falls significantly when out-of-pocket expenditures rise.¹ For LTC facilities, failure of their residents to have adequate resources to pay for medications places the responsibility on the facility for making sure that all ordered medications are available to residents who are unable to pay. This creates an added financial burden for facilities, many of whom are already experiencing financial difficulties.

How can the donut hole be filled so that neither the Medicare beneficiary nor the LTC facility has to bear those expenses? The answer to that question lay in first making sure that the patient is prescribed the “right” medication, and then ensuring that it is covered in the “best” way possible.

THE RIGHT MEDICATION
The first step in providing donut hole coverage is making sure that patients don’t enter this gap in coverage unless they truly cannot avoid it. This avoidance of the donut hole can occur by ensuring that the most effective—as well as the most efficient—medications are prescribed. The “most effective” refers to those medications that deliver the highest results with the fewest side effects; the “most efficient” refers to those medications that are similar enough with regard to pharmacokinetics, but available at a lower cost. This includes suitable generic and combination medications.

All prescription plans are required to offer Medication Therapy Management Programs (MTMPs), which are aimed at optimizing medication therapy, including efficient and effective use. Unfortunately, an MTMP is limited to those Medicare beneficiaries who are taking multiple medications, suffering from multiple chronic diseases, and likely to incur medication expenditures of more than $4000 per year. The threshold of $4000 for 2006 will remain the same for 2007 as determined by the Secretary of Health and Human Services. While Medicare beneficiaries entering the donut hole by definition will have met at least one of these requirements, it is possible that many do not meet all three requirements. In addition, MTMPs are directed by each individual prescription drug plan (PDP), so each process will vary. Since PDPs are not at financial risk when Medicare beneficiaries fall within the donut hole, many plans may not see the benefit in aggressively managing the expenditures of these members. As a result, this responsibility is likely to fall upon other providers.

One of those providers who can play a critical role here is the consultant pharmacist in the skilled nursing facility.