Getting to the Heart of the Matter

A quick word:

A report just published in Circulation: Cardiovascular  Quality and Outcomesa journal of the American Heart Association, came to some thought-provoking conclusions: patients who paid for their heart medications entirely through Medicare were 57 percent more likely not to take them during coverage gaps.  This is in contrast to those what had a Part D low-income subsidy or additional health insurance.

Heart and blood vessel, or cardiovascular disease, is the leading cause of death in this country.  The risk of disease increases with age.  The complications of heart disease can often be prevented, with a combination of lifestyle changes and appropriate medications.

Part D is the Medicare prescription drug benefit.  The coverage gap, or ‘doughnut hole’ is designed into the program.  Once certain spending limits are  reached, Medicare payments for medicine stop entirely.  These payments resume when a patient’s out-of-pocket expenses reach qualifying levels or the benefit is restarted in the next calendar year.  Part D subsidy programs or supplemental health insurance will help cover the expenses during the gap phase, but only if a patient purchased such coverage separately,  prior to need.

Lead study author and instructor in medicine at Harvard Medical School in Boston, Mass.,  Jennifer M. Polinski, Sc.D, M.P.H., commented that

Rather than prompting patients to switch to lower-cost alternatives, we found that sudden exposure to 100 percent of drug costs in the Part D coverage gap led to abrupt discontinuation of essential cardiovascular medications.

Any drug insurance policy that negatively influences essential cardiovascular drug use needs to be changed.

The initial study group included 122,255 heart disease patients who reached the Medicare Part D coverage gap in either 2006 or 2007.  They were predominantly white and about half were 65 yo 74 years old and female.  Most had high blood pressure and about one-third had heart failure — both conditions that can be fatal without appropriate medical care and prescription drug treatment.

It should be noted that patients who did not receive financial assistance during the coverage gap were no more likely to die, or be hospitalized for cardiovascular-related conditions, than those who did have financial assistance. This difference could be due to the short follow-up of 119 days in the current study’s design.  The 119 days is the typical amount of time spent in the coverage gap.  The coverage gap’s impact on cardiovascular health outcomes over the long term remain unclear.

Here’s the main thing: recent reforms include provisions in the Affordable Care Act (ACA) that close the coverage gap over time.  For example, as of 1 January 2011, Medicare beneficiaries receive a 50% discount on brand name drugs and a 7% discount on generic drugs while in the gap period.  This discount increases over time until the gap is totally eliminated by 2020.  However – and this is key – efforts to strike down or repeal the ACA, if ultimately successful, will take away these discounts for Medicare beneficiaries.  The notorious gap will be reinstated.  The unfortunate beneficiaries will again have to pay all their drug costs, costs they have no real control over, during coverage gaps.  The study indicated that patients are not likely to switch to other drugs during this time.  They just stop taking them altogether – never a good plan.

If you have a loved one or older friend or family member facing this situation, stay in the loop.  Consider consulting a reputable and experienced health insurance agent to go over their options.  Again, cardiovascular disease is this country’s leading cause of death.  It doesn’t make much sense to penalize those patients doing their best to follow doctors’ orders by making it too costly or complicated to comply.


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