Medicare patients with serious illnesses incur extraordinary costs for their prescription drugs, according to a recent report study by the Kaiser Family Foundation.
Consider patients with hepatitis C who take Zepatier. They pay a median annual price of $ 2,622 for this drug. And it's the low end. People with prostate cancer pay $ 8,181 for Zytiga. And patients with leukemia treated with Idhifa earn $ 16,551 a year for their share of the price of this drug.
"Such prices are simply unaffordable for most Medicare beneficiaries," said Juliette Cubanski, associate director of the Medicare Policy Program of the Kaiser Family Foundation and co-author of the study.
The prices of drugs, which are already high, continue to rise. The KFF analysis revealed that Medicare Part D co-insurance costs for specialty-level drugs – expensive branded drugs prescribed for critical illness – are 12% higher in 2019 than in 2016 .
More "donut hole"
This is the case even though the so-called donut hole was eliminated this year. (The hole in the donut is the time when Part D Medicare beneficiaries had to pay the full cost of the drugs until certain spending limits were met and coverage was reinstated. )
Specialty drugs now account for more than 20% of total Part D spending, up from about 7% before 2010.
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The Kaiser study also looked at patient costs for 14 specialty drugs not covered by all or part of the Medicare Part-D plans. In these cases, patients were often responsible for the full price of the drug, which left them astronomical annual costs ranging from $ 26,209 to $ 145,769, according to the study.
What is going on?
Nobody thought drugs would become so expensive
The number of drugs whose annual price tags reach tens of thousands of dollars or more has increased dramatically since the introduction of Medicare Part D in 2006, explained Cubanski.
At the time, asking for modest coinsurance payments seemed reasonable. "We did not even know we would have these drugs when creating Part D," Cubanski said. "And we had not expected the prices to be as high as they are." She explained that her team had analyzed 30 expensive drugs, which was by no means an exhaustive list.
Determining how much Medicare Part D beneficiaries are paying for their own medication is not an easy task. This involves deciphering a complicated formula put in place by the government and the private insurers who manage the Part D plans. First, there is a deductible and then various coinsurance payments ranging from 25% to 30% for the drugs of origin. Then, once the beneficiaries have disbursed $ 5,100, they reach what is called the catastrophic threshold. From then on, they pay 5% co-insurance for all drugs.
"At first, 5% seem reasonable," Cubanski said. "And for many drugs, that's the case, but 5% of the thousands of dollars become unaffordable very quickly."
In addition, there is no limit to personal expenses when Medicare beneficiaries enter a catastrophic phase. In fact, for many of the specialty drugs included in the study, the majority of the costs borne will likely be incurred during the catastrophic phase, Cubanski said, noting that half of Medicare beneficiaries have an average annual income of 26,000 USD. or less.
How Trump plans to lower the price of drugs
The Kaiser study was released at a time when the Trump administration was announcing a proposal that would ban rebates paid to insurers and drug benefit managers by the drug industry for Medicare, Medicaid and perhaps even sponsored drug coverage. by the employer. The aim is to pass these rebates directly to consumers, theoretically lowering the list price of brand-name drugs and the costs incurred.
Patients have few options
Would the new approach offer substantial relief to patients in need of specialized drugs? Is not clear. Most of these drugs have few competitors and manufacturers offer little or no discount, explained Cubanski. And if they did, she pointed out that even a 20% or 30% break on a $ 50,000 or $ 100,000 drug would not reduce the price to an affordable level.
For the moment, Medicare patients who need specialty medicines can not do anything to reduce their direct costs. Very rarely, alternative medicines exist, and if they exist, they are also expensive, explained Cubanski. She advises patients to talk to their doctors about the price of drugs. "Doctors do not always know what the cost is for patients," she said. "But when they are informed, they can sometimes help patients find ways to reduce their costs."