Time to fill the doughnuts--health care reform and Medicare Part D.

10.1056/nejmp1011625 nejm.org 1 the Medicare Part D benefit.1 Several months ago, seniors who had reached the spending threshold that marked the beginning of their doughnut hole began to receive their $250 rebate checks. Incrementally between now and 2020, the coverage gap will be filled with subsidies from manufacturers of brandname drugs and from the federal government. Thus, the ACA, like Part D itself, has expanded coverage for prescription medications — but it has done so in a complex manner that owes more to political wrangling than to any straightforward effort to promote health and cost-effective medication use. The plan for filling in the doughnut hole will most likely confuse many beneficiaries and, at least temporarily, work against cost consciousness, and providers and payers will need to assist patients in navigating the benefit and identifying affordable medications in the years leading up to 2020. Medicare Part D was the largest expansion of Medicare benefits since the program’s inception and is widely considered to be successful. With the standard Part D benefit, patients are responsible for all their medication costs up to the dollar amount of an initial deductible. Having paid the deductible, they become responsible for only 25% of additional medication costs up to a preset spending limit. Then they enter a coverage gap, or doughnut hole, in which they must again pay the entire cost of their medications. Once their drug spending has passed the upper end of the doughnut hole, patients receive catastrophic coverage that pays for 95% of any further medication costs. Although few plans strictly follow the outlines of the defined benefit, the majority offer little or no gap coverage. The implementation of Part D has meaningfully increased drug utilization overall, improved adherence to essential medications for chronic conditions, and reduced patients’ out-of-pocket costs.2 Early reports evaluating the effect of Part D on health outcomes have also been encouraging.3 However, the inconsistent coverage patterns have proved Time to Fill the Doughnuts — Health Care Reform and Medicare Part D