Out-of-Pocket Prescription Drug Costs Remain a Burden for Medicare Beneficiaries

Most older adults in the U.S. have been diagnosed with one or more chronic illnesses, and managing these conditions presents a significant cost burden, according to a January study in JAMA Internal Medicine. The authors studied eight of the most common chronic conditions, both as single disease states and in clusters, and determined hypothetical annual out-of-pocket (OOP) costs for individual seniors enrolled in Medicare Advantage-Prescription Drug plans and Standalone Part D plans in 2009 and 2019. While annual costs for many of the conditions dropped, likely due to the availability of new generic drugs, OOP costs for atrial fibrillation, type 2 diabetes and heart failure skyrocketed. This was attributed to the introduction of brand-name therapies without generic alternatives that received clinical guideline recommendations. To remedy this, study authors urged Congress to act on drug pricing reforms, including allowing Medicare to negotiate list prices and cap annual OOP costs for seniors.

NOTES: COPD=chronic obstructive pulmonary disease; HFrEF=heart failure with reduced ejection fraction. Out-of-pocket costs were inflation adjusted to 2019 dollars. HFrEF Approach 1 assumed the patient was prescribed an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, an evidence-based beta blocker, and an aldosterone antagonist in 2019. HFrEF Approach 2 assumed the patient was prescribed an angiotensin receptor neprilysin inhibitor (sacubitril-valsartan), an evidence-based beta blocker, and an aldosterone antagonist in 2019. Cluster A conditions include COPD, type 2 diabetes, hypertension, osteoarthritis and osteoporosis. Cluster B conditions include atrial fibrillation, COPD, type 2 diabetes, HFrEF (approach 1), high cholesterol, hypertension, osteoarthritis and osteoporosis.

SOURCE: “Assessment of Hypothetical Out-of-Pocket Costs of Guideline-Recommended Medications for the Treatment of Older Adults With Multiple Chronic Conditions, 2009 and 2019,” JAMA, Jan. 4, 2022.

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