No Limit: Medicare Part D Enrollees Exposed to High Out-of-Pocket Drug Costs Without a Hard Cap on Spending
| Table 1: Characteristics of Medicare Part D Enrollees with Spending Above the Catastrophic Coverage Threshold, by Low-Income Subsidy Enrollment, 2015 | ||||||||
| All Part D enrollees | Enrollees with spending above the catastrophic coverage threshold | |||||||
| Total | Enrollees with the low-income subsidy | Enrollees without the low-income subsidy | ||||||
| Number | Percent of total | Number | Percent of total | Number | Percent of total | Number | Percent of total | |
| Total | 41,278,580 | 100% | 3,619,640 | 100% | 2,616,940 | 100% | 1,002,700 | 100% |
| Gender | ||||||||
| Female | 23,652,440 | 57% | 2,109,320 | 58% | 1,596,300 | 61% | 513,020 | 51% |
| Male | 17,626,140 | 43% | 1,510,320 | 42% | 1,020,640 | 39% | 489,680 | 49% |
| Age | ||||||||
| <65 | 7,090,980 | 17% | 1,463,680 | 40% | 1,331,620 | 51% | 132,060 | 13% |
| 65-69 | 10,162,920 | 25% | 606,880 | 17% | 365,340 | 14% | 241,540 | 24% |
| 70-74 | 8,461,240 | 20% | 545,880 | 15% | 304,440 | 12% | 241,440 | 24% |
| 75-79 | 6,192,700 | 15% | 415,120 | 11% | 242,460 | 9% | 172,660 | 17% |
| 80-84 | 4,393,760 | 11% | 295,000 | 8% | 181,040 | 7% | 113,960 | 11% |
| 85+ | 4,976,980 | 12% | 293,080 | 8% | 192,040 | 7% | 101,040 | 10% |
| Race/ethnicity | ||||||||
| White non-Hispanic | 30,932,840 | 75% | 2,450,240 | 68% | 1,581,740 | 60% | 868,500 | 87% |
| Black non-Hispanic | 4,593,300 | 11% | 558,440 | 15% | 495,860 | 19% | 62,580 | 6% |
| Hispanic | 3,463,640 | 8% | 385,820 | 11% | 353,040 | 13% | 32,780 | 3% |
| Asian/Pacific Islander | 1,362,340 | 3% | 146,840 | 4% | 131,380 | 5% | 15,460 | 2% |
| Other/unknown | 926,460 | 2% | 78,300 | 2% | 54,920 | 2% | 23,380 | 2% |
| Residence | ||||||||
| Nursing home/ facility resident | 2,567,880 | 6% | 578,420 | 16% | 516,940 | 20% | 61,480 | 6% |
| Non-facility resident | 38,710,700 | 94% | 3,041,220 | 84% | 2,100,000 | 80% | 941,220 | 94% |
| NOTE: Analysis includes enrollees in stand-alone prescription drug plans and Medicare Advantage drug plans. Out-of-pocket costs include Part D drug costs, but not Part D premiums or costs for Part B-covered drugs. Numbers may not sum to totals due to rounding. SOURCE: Kaiser Family Foundation analysis of a five percent sample of 2015 Medicare prescription drug event claims from the CMS Chronic Conditions Data Warehouse. |
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| Table 2: Top 20 Most Prevalent Chronic Conditions among Medicare Part D Enrollees in Stand-alone Prescription Drug Plans with High Out-of-Pocket Drug Costs, 2015 | ||||||
| All Medicare Part D enrollees in PDPs without the low-income subsidy | Part D enrollees in PDPs with high out-of-pocket drug costs | |||||
| Number | Percent of total | Number | Among PDP enrollees with high out-of-pocket drug costs, % with this disease | Among PDP enrollees with this disease, % with high out-of-pocket drug costs | Average out-of-pocket spending | |
| Total PDP enrollees | 16,710,620 | 100.0% | 708,680 | 100.0% | 4.2% | $2,995 |
| Hypertension | 9,163,440 | 54.8% | 498,120 | 70.3% | 5.4% | $2,991 |
| Hyperlipidemia | 7,900,800 | 47.3% | 428,660 | 60.5% | 5.4% | $2,925 |
| Diabetes | 4,014,700 | 24.0% | 341,700 | 48.2% | 8.5% | $2,827 |
| Ischemic heart disease | 4,364,120 | 26.1% | 298,080 | 42.1% | 6.8% | $2,940 |
| Rheumatoid arthritis/osteoarthritis | 4,979,740 | 29.8% | 286,580 | 40.4% | 5.8% | $3,017 |
| Anemia | 3,281,360 | 19.6% | 255,800 | 36.1% | 7.8% | $3,158 |
| Chronic kidney disease | 2,714,380 | 16.2% | 244,500 | 34.5% | 9.0% | $2,989 |
| Alzheimer’s disease, related disorders, or senile dementia & depression | 3,012,980 | 18.0% | 216,480 | 30.5% | 7.2% | $3,067 |
| Heart failure | 1,963,400 | 11.7% | 171,220 | 24.2% | 8.7% | $2,971 |
| Depression | 2,218,100 | 13.3% | 168,500 | 23.8% | 7.6% | $3,127 |
| Depressive disorders | 2,077,900 | 12.4% | 164,900 | 23.3% | 7.9% | $3,116 |
| Acquired hypothyroidism | 2,540,920 | 15.2% | 156,580 | 22.1% | 6.2% | $3,036 |
| Obesity | 1,742,780 | 10.4% | 152,580 | 21.5% | 8.8% | $2,849 |
| Fibromyalgia, chronic pain & chronic fatigue | 1,727,700 | 10.3% | 144,900 | 20.4% | 8.4% | $3,160 |
| Chronic obstructive pulmonary disease & bronchiectasis | 1,560,860 | 9.3% | 144,400 | 20.4% | 9.3% | $2,935 |
| Cataract | 3,305,420 | 19.8% | 143,140 | 20.2% | 4.3% | $3,100 |
| Peripheral vascular disease | 1,647,880 | 9.9% | 130,080 | 18.4% | 7.9% | $2,887 |
| Anxiety disorders | 1,831,880 | 11.0% | 127,540 | 18.0% | 7.0% | $3,108 |
| Asthma | 1,139,820 | 6.8% | 115,140 | 16.2% | 10.1% | $2,933 |
| Cancer: Colorectal; endometrial; female or male breast; lung; prostate | 1,485,380 | 8.9% | 95,780 | 13.5% | 6.4% | $3,413 |
| NOTE: PDP is stand-alone prescription drug plan. Analysis by chronic conditions excludes Medicare Advantage enrollees. Analysis includes the top 20 conditions among those chronic conditions included in the Chronic Conditions and Other Chronic or Potentially Disabling Conditions segments of the Medicare Master Beneficiary Summary file. “High out-of-pocket drug costs” refers to Part D enrollees without low-income subsidies who incurred drug spending above the catastrophic coverage threshold. Analysis includes enrollees in stand-alone prescription drug plans. Out-of-pocket costs include Part D drug costs, but not Part D premiums or costs for Part B-covered drugs. Numbers may not sum to totals due to rounding. SOURCE: Kaiser Family Foundation analysis of a five percent sample of 2015 Medicare prescription drug event claims from the CMS Chronic Conditions Data Warehouse. |
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| Table 3: Top 20 Chronic Conditions with the Largest Percent of Medicare Part D Enrollees in Stand-alone Prescription Drug Plans (PDPs) with High Out-of-Pocket Drug Costs, 2015 | ||||||
| All Medicare Part D enrollees in PDPs without the low-income subsidy | Part D enrollees in PDPs with high out-of-pocket drug costs | |||||
| Number | Percent of total | Number | Among PDP enrollees with high out-of-pocket drug costs, % with this disease | Among PDP enrollees with this disease, % with high out-of-pocket drug costs | Average out-of-pocket spending | |
| Total PDP enrollees | 16,710,620 | 100.0% | 708,680 | 100.0% | 4.2% | $2,995 |
| HIV/AIDS | 20,580 | 0.1% | 16,240 | 2.3% | 78.9% | $2,354 |
| Multiple sclerosis & transverse myelitis | 64,480 | 0.4% | 22,320 | 3.1% | 34.6% | $4,389 |
| Viral hepatitis | 90,620 | 0.5% | 21,660 | 3.1% | 23.9% | $5,200 |
| Leukemia & lymphoma | 269,440 | 1.6% | 30,000 | 4.2% | 11.1% | $4,269 |
| Schizophrenia | 55,980 | 0.3% | 5,980 | 0.8% | 10.7% | $2,827 |
| Liver disease, cirrhosis, & other liver conditions (excluding hepatitis) | 516,100 | 3.1% | 54,040 | 7.6% | 10.5% | $3,651 |
| Pressure ulcers & chronic ulcer | 596,680 | 3.6% | 61,400 | 8.7% | 10.3% | $2,991 |
| Asthma | 1,139,820 | 6.8% | 115,140 | 16.2% | 10.1% | $2,933 |
| Cystic fibrosis & other metabolic developmental disorders | 88,980 | 0.5% | 8,460 | 1.2% | 9.5% | $3,635 |
| Bipolar disorder | 248,740 | 1.5% | 23,480 | 3.3% | 9.4% | $3,020 |
| Epilepsy | 219,560 | 1.3% | 20,480 | 2.9% | 9.3% | $3,152 |
| Traumatic brain injury & nonpsychotic mental disorders due to brain damage | 51,080 | 0.3% | 4,760 | 0.7% | 9.3% | $3,125 |
| Chronic obstructive pulmonary disease & bronchiectasis | 1,560,860 | 9.3% | 144,400 | 20.4% | 9.3% | $2,935 |
| Conduct disorders & hyperkinetic syndrome | 63,620 | 0.4% | 5,820 | 0.8% | 9.1% | $3,164 |
| Chronic kidney disease | 2,714,380 | 16.2% | 244,500 | 34.5% | 9.0% | $2,989 |
| Schizophrenia & other psychotic disorders | 277,880 | 1.7% | 24,440 | 3.4% | 8.8% | $3,078 |
| Obesity | 1,742,780 | 10.4% | 152,580 | 21.5% | 8.8% | $2,849 |
| Heart failure | 1,963,400 | 11.7% | 171,220 | 24.2% | 8.7% | $2,971 |
| Spinal cord injury | 43,920 | 0.3% | 3,820 | 0.5% | 8.7% | $3,134 |
| Personality disorders | 58,620 | 0.4% | 5,000 | 0.7% | 8.5% | $3,088 |
| NOTE: PDP is stand-alone prescription drug plan. Analysis by chronic conditions excludes Medicare Advantage enrollees. Analysis includes the top 20 conditions among those chronic conditions included in the Chronic Conditions and Other Chronic or Potentially Disabling Conditions segments of the Medicare Master Beneficiary Summary file. “High out-of-pocket drug costs” refers to Part D enrollees without low-income subsidies who incurred drug spending above the catastrophic coverage threshold. Analysis includes enrollees in stand-alone prescription drug plans. Out-of-pocket costs include Part D drug costs, but not Part D premiums or costs for Part B-covered drugs. Numbers may not sum to totals due to rounding.
SOURCE: Kaiser Family Foundation analysis of a five percent sample of 2015 Medicare prescription drug event claims from the CMS Chronic Conditions Data Warehouse. |
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