OAKLAND, Calif. (MCT) — More than one-third of Medicare recipients in a Kaiser Permanente plan reported that they changed their drug-taking or purchasing behaviors to save costs, according to a study published Tuesday in the Journal of the American Medical Association.

The behavior changes were particularly pronounced as recipients neared or entered the controversial "doughnut hole" coverage gap, the study indicated.

The gap refers to a Medicare policy requiring members to pay all their drug costs once they purchase more than $2,510 in medications in a year, according to 2008 figures. This year, coverage then resumes after $4,050 in annual prescription medication purchases.

And the figure is likely higher for Medicare beneficiaries not within Kaiser, said Dr. John Hsu, lead author of the study and director of Kaiser's Center for Health Policy Studies in Oakland.

"We think it's probably a best-case scenario," he said, explaining that Kaiser members are steered toward cost-saving generic drugs when suitable, and get a "great deal of physician and pharmacist involvement" in their prescription drug regimen.

In contrast, Medicare beneficiaries in other plans often face more "fragmented" care, he said. Doctors, for example, may not know what drugs other physicians their patient visited have prescribed, Hsu said. Nor do they generally have access to a shared electronic medical record system, such as those in Kaiser medical centers, which provides instant access to patient records.

While the study does not set out to critique the Medicare drug plan, called Medicare Part D, it shows there is ample room for improving educational programs for patients to ensure they don't make decisions that could adversely affect their health.

"While there was a fair amount of educational effort in this particular plan, our findings suggest it's not enough," Hsu said.

The study's researchers conducted telephone surveys of more than 1,000 Kaiser members in Northern California enrolled in the HMO's Medicare Advantage prescription drug plan, assessing their knowledge of the plan's benefits.

Patients were also asked if they engaged in specific behaviors to save costs on drugs to avoid co-payments or reaching the coverage gap, such as splitting or skipping pills, switching to lower-cost or over-the-counter drugs, stopping medications, or foregoing other essentials, like food or gas.

The most frequently cited cost-saving behavior by study participants was switching to a cheaper drug — 15 percent reported making that change in 2006, during the first year they were enrolled in the plan. As for altering adherence patterns, the most frequent change, at 8 percent, was not refilling a prescription. And 5 percent reported going without necessities like food to pay for drugs.

"What we're finding is that most people don't understand Part D, and they're paying a pretty high price for poor knowledge," Hsu said.

The Medicare prescription drug plan, which took effect Jan. 1, 2006, offers all Medicare recipients subsidized prescription drugs coverage. The drug plan is regarded as the most significant improvement in benefits since Medicare's inception. It is projected to provide $724 billion in drug benefits between 2006 and 2015.

Hsu agreed that without the Medicare drug plan, many patients wouldn't have access to subsidized prescription medications. But he added that prior to the launch of the new plan, many Medicare enrollees had drug coverage through other means such as employer pension plans, extra coverage they purchased and joining a Medicare managed care plan that offers prescription drug coverage.

"The question is if the average person is better off. Yes, they probably are," he said. "Does that mean everyone is better off? Not necessarily."

Most Medicare patients are pleased with the new drug plan, said Jeff Nelligan, a spokesman for the Centers for Medicare and Medicaid Services, citing studies reporting satisfaction rates of 80 percent or higher. In addition, he said the program is exceeding cost-saving expectations.

Nelligan said the agency is continuing to enhance its education program for Medicare Part D.

"We have significantly improved and expanded our online tools to help beneficiaries understand plan differences and assess their potential out-of-pocket costs," he stated.

Hsu emphasized, however, that education alone won't end the angst some patients feel about the cost-sharing load of the plan. Instead, more sophisticated tools are needed to help determine which medicines are the best and most cost-effective for patients. He called it a "real-time tool," and said it ideally would consist of a shared electronic database for Medicare recipients.

"A real-time tool could help patients optimize the drugs they're on," Hsu said, noting that studies show many people take unneeded drugs.

In the meantime, he said, patients can help lower their costs and potentially improve their health by showing their doctors a list of drugs they use and asking questions about prescribed drugs.

"There are a lot of things patients can do," Hsu said, including asking why a certain drug is needed, how long it should be used, and if there are less expensive alternatives.