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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.
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.
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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