Seniors at High Risk from Medicare Donut Hole Identified in Study

Kathleen Blanchard's picture

Researchers from UCLA studied groups of seniors at high risk for falling into the Medicare “donut hole” – the period of time when there is no Medicare part D prescription drug coverage. The “donut hole” is the stage 2 prescription coverage gap that occurs for some Medicare recipients who are on high cost medications.

Dr. Susan Ettner from UCLA in the US, and her colleagues examined the records of over 287,000 Medicare beneficiaries likely to fall into the donut hole, finding that older women with dementia and diabetes are at highest risk for not adhering to their drug regimens because of unsubsidized prescriptions from the Medicare part D donut hole.

The researchers say the findings are important for physicians who should counsel patients about which medications are most important to continue and which can be discontinued to help seniors through the Medicare coverage gap versus the risk of non compliance with taking essential medications.


The study identified women with high cholesterol, hypertension, heart disease, and depression at high risk for falling into the donut hole, leading to $3,600 total out-of-pocket drug expenses. Three percent of Medicare part D recipients were likely to fall into the coverage gap within the first 180, with only 7 percent receiving catastrophic drug coverage under Medicare before the year end. A total of 16 percent of seniors were likely to reach the donut hole, and with no prescription drug coverage.

The authors conclude: “Our findings suggest that medication cost-counseling interventions focusing on these clinically vulnerable subpopulations may be warranted. Physician-patient discussions about the expense and undesirable side effects of particular medications are one approach to managing outpatient drug therapy and controlling costs.”

Once Medicare part D recipients reach a spending threshold, prescription drug coverage is resumed. Only 7 percent of Medicare recipients identified in the study reached the threshold when prescription drug coverage is resumed, placing them at high risk for non compliance with medical therapy.

The study shows that physicians should counsel patients about which medications are essential when Medicare recipients fall into the donut hole prescription drug coverage gap. Medicare recipients who are in the donut hole can visit for prescription drug assistance from pharmaceutical manufacturers. Patients with diabetes, chronic pain, and cancer might also find help by visiting the Patient Advocate Foundation, a non-profit organization set up to help patients with co-payments associated with the high cost of medications.