Tseng Chien-Wen, Brook Robert H, Keeler Emmett, Steers W Neil, Mangione Carol M
University of Hawaii Department of Family Practice and Community Health, Honolulu, and UCLA Department of Medicine, Los Angeles, Calif.
JAMA. 2004 Aug 25;292(8):952-60. doi: 10.1001/jama.292.8.952.
The majority of Medicare drug benefits in managed care (Medicare + Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year. In the new national Medicare drug benefit, beneficiaries with high medication expenditures will also face a period without drug coverage when their total drug costs exceed annual caps but are not high enough to qualify for catastrophic coverage.
To describe strategies adopted by beneficiaries exceeding annual drug benefit caps to lower prescription costs, the type of medications involved, and their financial burden.
DESIGN, SETTING, AND PARTICIPANTS: A survey (completed in 2002) of Medicare + Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs (65% response rate). The different caps offered in different counties were used as a natural experiment. Study participants (n = 665) exceeded a 750 dollars or 1200 dollars yearly cap in 2001 and had coverage gaps of 75 to 180 days. Control participants (n = 643) had 2000 dollars caps, which they did not exceed. Study and control participants were matched by average total drug expenditures per month.
Proportion of beneficiaries reporting specific strategies to decrease medication costs, medications affected, and difficulty paying for prescriptions.
In multivariate analyses adjusting for demographic and health characteristics, a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18% vs 10%, respectively; P<.001), but similar proportions reported stopping medications completely (8% for both, P =.86) and of not starting prescribed medications (6% vs 5%, P =.39). Patients exceeding caps more often called pharmacies to find the best price (46% vs 29%, P<.001), switched medications (15% vs 9%, P =.002), used samples (34% vs 27%, P =.006), and had difficulty paying for prescriptions (62% vs 37%, P<.001). Twelve of the 20 therapeutic classes most often affected by decreases in use of medication were for chronic health problems such as hypertension, hyperlipidemia, and emphysema or asthma.
Medicare beneficiaries often decreased use of essential medications and experienced difficulty paying for prescriptions during gaps in coverage. Health professionals need to explore how they can lessen the impact of caps on patients' health and financial burden.
管理式医疗（“医疗保险 + 选择”计划）中的大多数医疗保险药品福利都设有年度金额限制或上限，许多受益人在年底前超过上限后会面临暂时但可能很大的保险覆盖缺口。在新的全国医疗保险药品福利计划中，药物支出高的受益人在其总药费超过年度上限但又未高到符合灾难性保险覆盖标准时，也会面临一段时间无药品保险的情况。
描述超过年度药品福利上限的受益人所采取的降低处方成本的策略、所涉及的药物类型及其经济负担。
设计、地点和参与者：一项于2002年完成的对65岁及以上、药物成本高且该计划的药品费用份额设有上限的“医疗保险 + 选择”受益人的调查（回复率为65%）。不同县提供的不同上限被用作一项自然实验。研究参与者（n = 665）在2001年超过了750美元或1200美元的年度上限，且有75至180天的保险覆盖缺口。对照参与者（n = 643）有2000美元的上限，且未超过该上限。研究参与者和对照参与者按每月平均总药费进行匹配。
报告采取特定策略降低药费的受益人比例、受影响的药物以及支付处方费用的困难程度。
在对人口统计学和健康特征进行调整的多变量分析中，超过上限的患者中报告减少处方药使用的比例高于对照组（分别为18%和10%；P <.001），但报告完全停药的比例相似（均为8%，P =.
86），未开始服用处方药的比例也相似（6%对5%，P =.39）。超过上限的患者更常打电话给药店以找到最优惠价格（46%对29%，P <.001）、更换药物（15%对9%，P =.002）、使用样品（34%对27%，P =.006），并且支付处方费用有困难（62%对37%，P <.001）。在因用药减少而受影响最频繁的20个治疗类别中，有12个是针对高血压、高脂血症、肺气肿或哮喘等慢性健康问题的。
医疗保险受益人在保险覆盖缺口期间经常减少基本药物的使用，并在支付处方费用方面遇到困难。卫生专业人员需要探索如何减轻上限对患者健康和经济负担的影响。
