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Beware the Doughnut Hole

Judy Zerzan, MD, MPH, was at a loss. A Health and Aging Policy Fellow and hospitalist at the University of Colorado Denver, Dr. Zerzan was examining a Medicare patient who was admitted to the hospital with an apparent urinary tract infection. But the same patient had been released from the hospital only five days earlier with an antibiotic prescription to treat an oddly similar infection.

The confusion only increased when lab cultures revealed an E. coli infection. It should have been sensitive to most antibiotics, especially to the brand-name moxifloxacin the patient said she had been taking since her last hospital stay.

Several days into the patient’s rehospitalization, a medical student finally cracked the case. “The medical student went in and started talking to her some more and learned that she didn’t fill the prescription because under her [insurance] plan, it was going to be something like $50, and she felt like she couldn’t afford it,” Dr. Zerzan recalls. “She felt really embarrassed about it, so she didn’t want to tell us that she didn’t fill it.”

The medical team sent the woman home with a $4 generic prescription. “She was much relieved,” Dr. Zerzan says. More importantly, the patient did not return to the hospital for a third stay.

Hospitalists might not see a $46 difference in drug pricing as a core consideration of patient care. But with many seniors enrolled in Medicare Part D’s prescription drug plan falling through holes in the partially privatized safety net, many agree that far more must be done to ensure that financial stress doesn’t lead to medical misfortune.

“It is an ethical issue,” says Stephen Soumerai, ScD, director of the Drug Policy Research Program and a professor in the Department of Ambulatory Care and Prevention at Harvard University. “ … It’s easy to target those people who are the most vulnerable in our society and, therefore, it is an opportunity to try to find ways for them to lower their problems of economic access to medicine.”

Soumerai calls cost-related medication nonadherence a matter of distributive justice. In a study published last year in the Journal of the American Medical Association, he and 10 co-authors found that even after enrolling in Medicare Part D, the sickest beneficiaries were just as likely to skip medications they couldn’t afford.1

Medicare Part D:

The Basics

Medicare Part D took effect in January 2006 as a partially privatized system for providing prescription drug coverage to Medicare beneficiaries. Most plans include a gap in coverage, or “doughnut hole,” that begins after the insurer and beneficiary have spent a specified amount for covered drugs (no more than $2,700 in 2009). While in the gap, the beneficiary must pay all drug costs—as much as $4,350—before “catastrophic” insurance coverage begins. Those expenses are in addition to the plan’s monthly premium; initial insurance copays can vary based on a cost “tier” assigned to each drug.—BN

Identify the Coverage Gap

Medicare’s prescription drug plan, initiated in 2006, has provided coverage for many beneficiaries who previously went without. But it has been widely criticized as unnecessarily confusing by both doctors and patients—and particularly expensive for beneficiaries unlucky enough to fall into its notorious gap in coverage, dubbed the “doughnut hole” (see “Medicare Part D: The Basics,” right).

That economic burden can be exacerbated by medical illiteracy, ignorance, and misinformation. Recent Consumer Reports polls suggest as few as 4% of patients discuss drug prices with their doctors; almost half of Americans have reservations or misgivings about lower-cost generic drugs.

As focal points in the coordination of patient care, hospitalists are better positioned than most to help steer the most vulnerable away from the douhgnut hole while helping hospitals equitably distribute limited resources. But hospitalists often are completely unaware of a patient’s plight. “My research interest is prescription drug coverage, so I think I’m more keyed into it, but certainly even I don’t generally think about, when discharging a patient, if something is going to be on their Part D formulary or not, or what sort of prior-authorization hoops their primary-care doc may have to go through,” Dr. Zerzan says. “And I think that’s generally true of my colleagues as well.”

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