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Published on November 07, 2016

‘Donut Hole’ not so sweet for some seniors‘Donut Hole’ not so sweet for some seniors

Beverly CarmichaelPrimary care doctors who work with senior citizens, especially those with chronic conditions, are well aware of an aspect of health insurance that can potentially harm their patients – the “donut hole” gap in prescription coverage that is part of the Part D of Medicare.

The “donut hole” means that once a senior has spent a certain amount of money for prescriptions, they fall into a gap in their insurance where they have to pay more for their prescriptions until they reach a certain dollar amount of out of pocket expenses and then they qualify for catastrophic coverage.

Sheila Curtis, regional project manager of S.H.I.N.E. (Serving the Health Information Needs of Elders) for the Cape and Islands explained how this happens.

“The dollar amounts change every year, so for 2016, when the retail cost of the person’s medication reaches $3,310 for the year, they are in that donut hole gap,” Curtis said. “Once in that gap, they have to pay 45 percent for brand name medications and 58 percent for generics.”

“I think the donut hole is a huge, huge problem,” said Munir Ahmed, MD, an internist with Emerald Physicians in Sandwich and South Yarmouth.

“It’s hard for those folks because they don’t have the money to pay for their medications.”

Dr. Ahmed is referring to patients like Beverly Carmichael of Brewster. She also happens to be my mother.

“Usually sometime around the beginning of November, I go into the drug store one day and my prescription is $400 and all of a sudden I don’t have insurance to pay for it, because I have fallen into the ‘donut hole’ of my coverage,” Carmichael said. “This year it happened in July.”

The thing that frustrates Carmichael is that she pays a deductible of about $360 in the beginning of every year for her supplemental insurance, currently with Humana, and she has to pay insurance premiums even in the months she falls into the donut hole.

“So basically you are paying for health insurance for your medicines 12 months of the year, but only have coverage for eight,” she said. “I don’t understand why they do that to the old people. We’re the people who take the most prescriptions and we have the least amount of money to pay for them.”

Carmichael has rheumatoid arthritis, asthma, and chronic obstructive pulmonary disease among other conditions. She has had four joint replacement surgeries as well as other health issues that require her to take 11 different prescriptions.

Getting the care she needs is both difficult and expensive – so expensive that her 71-year-old husband Tom Carmichael cannot stop working, despite health issues of his own.

“These costs are the primary reason I’m still working,” he said. “I spend my entire pension on her medications after insurance. That means we’re basically living on social security and it’s not enough.”

S.H.I.N.E Can Help

Curtis and the volunteers at S.H.I.N.E. can help seniors who find themselves struggling with donut hole costs. They assist seniors in going over all of the Part D options to choose the best plan for their situation. The process is complicated because every year they need to re-visit the plans.

“Every fall during the open enrollment (October 15 through December 7) they need to relook because these plans change so much from year to year,” she said.

The first thing S.H.I.N.E. volunteers do is find out if the senior qualifies for Mass Health, because if they do they automatically get extra help with their Part D. They also refer people to Prescription Advantage, the state’s pharmacy plan to help people in the donut hole.

“It’s based on income and it goes up pretty high,” Curtis said. “For a single person you can make up to $35,640 and a couple its $48,060.”

Another category of Prescription Advantage helps people by capping their out-of-pocket expenses at $3,530. Once that number is reached, Prescription Advantage will pay the rest of the year for you.

“It’s a great program,” she said. “I don’t know whether people realize it’s out there.”

Curtis said Mass Health also has a program called Frail Elder Waiver that allows for frail people with higher incomes to qualify, but the asset limit is $2,000 excluding their house and car. Elder Services administers the clinical part and the cost is zero.

Another tactic S.H.I.N.E. representatives suggest is for people to join generic discount programs at pharmacies.

“A lot of people will use the discount programs for their generics and then they will use Part D for the brand names,” she said. “If they do that it takes them longer to hit that gap.”

Reform Is Needed

Primary care physician Anna Marie Espiritu, MD, of Bramblebush Primary Care in Falmouth believes the donut hole should be eliminated.

“A majority of the aged population is on fixed income yearly and have very limited retirement money,” she said. “Going through the donut hole brings a lot of emotional and mental stress to the seniors. Medically, it does not help them, especially if they decide to stop their meds if they are in the donut hole.”

In order to avoid having her patients fall into the donut hole, Dr. Espiritu prescribes generic medicines whenever possible. Keeping overall costs down is one way to avoid it. She said that medicine samples are becoming more scarce because of restrictions imposed by the drug representatives.

“Handing out med samples to help seniors in the donut hole is not a dependable solution,” she said.

Dr. Ahmed agreed.

“We need to have some kind of reform for these folks,” he said. “It is ridiculous what the insurance companies are charging them. As physicians we try to prescribe cheaper medications but sometimes the cheaper medication doesn’t work well. Every person has a different physiology, a different anatomy and therefore a different way their body works. Some people do well on the cheaper medications but for some people those medications doesn’t work on them. Some people need the expensive medication but the insurance doesn’t pay for it. As physicians our hands are pretty tied. It frustrates us.”

Even though it is harder for the elderly to shop around, Curtis referenced an article in the January 2016 issue of Consumer Reports as a good reason to consider it. The magazine had secret shoppers make more than 300 calls to over 200 pharmacies to check the prices of five common generic drugs. They found that drugs could cost as much as ten times more from one retailer to another – sometimes even in the same city.

These tactics are important because in the accompanying survey Consumer Reports did, about 40 percent of the people they talked to admitted to cutting corners with their medications because of the cost. Some skipped doses, others cut their pills in half, some just stopped taking the medication. Thankfully, a solution is on the way, even though it is slow in coming.

The good news is that the donut hole will be phased out in a few years.

“When Plan D first came out seniors had to pay 100 percent when they reached the donut hole,” Curtis said. “The Affordable Care Act has been closing that a little since 2010. In 2020, there will no longer be a donut hole.”

[Featured Image: L-R, Tom and Beverly Carmichael.]

Note: As of 5/1/2019, Emerald Physicians joined Medical Affiliates of Cape Cod (MACC), a division of primary and specialty care physicians from Cape Cod Healthcare.