Dual Eligibles with Mental Disorders and Medicare Part D (Text Version)

On September 16, 2009, Sam Zuvekas made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (851 KB).

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Slide 1

 

Dual Eligibles with Mental Disorders and Medicare Part D: How are They Faring?

Julie Donohue
University of Pittsburgh

Haiden Huskamp
Harvard Medical School

Sam Zuvekas
Agency for Healthcare Research and Quality

 

Slide 2

 

Context

• 6 million Medicare beneficiaries dually eligible for Medicaid moved to Medicare Part D drug plans.
• Random assignment to one of multiple benchmark plans, can switch
• Estimated 60% of disabled and 20% of elderly dual-eligibles have mental disorders
• Protections
  • "All or substantially all" rule for antidepressants, antipsychotics, and anticonvulsants
  • Fixed copay for generics, slightly higher for branded drugs, can't use cost-sharing tiers
  • Risk adjusted payments to PDPs

 

Slide 3

 

Medication Use and Spending: U.S. Community Population

	% With Use	Total Spending $	Percent Distribution of Spending by Source
			OOP	Medicare	Medicaid	Private	Other
2005
Antidepressants (all)	8.5	13.3b	36	2	14	43	6
Antipsychotics (all)	1.3	5.5b	23	1	55	14	6
Anticonvulsants	2.7	5.5b	29	2	33	30	7
ALL PRESCRIPTION DRUGS	63.1	213b	39	3	14	37	7
2006
Antidepressants (all)	8.4	13.2b	35	16*	8*	36*	5
Antipsychotics (all)	1.3	5.7b	26	21*	26*	20	7
Anticonvulsants	2.8	5.7b	34	16*	19*	26	5
ALL PRESCRIPTION DRUGS	62.6	224b	35*	20*	7*	33*	6*

SOURCE: Medical Expenditure Panel Survey 2005-2006
 

 

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Medication Use and Spending: Medicare Community Population

	% With Use	Total Spending $	Percent Distribution of Spending by Source
			OOP	Medicare	Medicaid	Private	Other
2005
Antidepressants (all)	16.0	3.8b	41	8	18	23	10
Antipsychotics (all)	3.3	2.1b	25	4	64	4	3
Anticonvulsants	7.0	2.1b	29	4	35	22	9
ALL PRESCRIPTION DRUGS	91.0	88.5b	43	7	16	23	11
2006
Antidepressants (all)	18.1*	4.1b	32*	52*	1*	10*	5
Antipsychotics (all)	3.6	1.9b	22	61*	6*	4	7
Anticonvulsants	7.2	1.9b	31	48*	2*	12	7
ALL PRESCRIPTION DRUGS	91.2	96.3b	31*	45*	7*	14*	8*

SOURCE: Medical Expenditure Panel Survey 2005-2006
 

 

Slide 5

 

Medication Use and Spending: Dual Eligible Community Population

	% With Use	Total Spending $	Percent Distribution of Spending by Source
			OOP	Medicare	Medicaid	Private	Other
2005
Antidepressants (all)	18.8	0.9b	20	5	70	3	2
Antipsychotics (all)	8.5	1.5b	12	2	84	0	1
Anticonvulsants	13.0	0.9b	15	3	82	1	0
ALL PRESCRIPTION DRUGS	88.0	18.7b	19	5	73	1	2
2006
Antidepressants (all)	20.8	1.0b	9*	84*	5*	0	3
Antipsychotics (all)	8.4	1.0b	6	83*	11*	0	0
Anticonvulsants	11.5	0.6b*	12	78*	7*	1	2
ALL PRESCRIPTION DRUGS	87.0	17.7b	17	77*	5*	0*	1

SOURCE: Medical Expenditure Panel Survey 2005-2006

 

Slide 6

 

Formulary Coverage of Selected Atypical Antipsychotics

Drug Product	% Covered (Yes/No)
	'06	'07	'08
Abilify	100%	100%	100%
Abilify Discmelt	N/A	83%	100%
Risperdal	100%	100%	100%
Risperdal Consta (IM)	93%	100%	100%
Risperdal M-TAB ODT	93%	100%	100%
Zyprexa	100%	100%	100%
Zyprexa IM	74%	90%	100%
Zyprexa Zydis	84%	100%	100%

SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

 

Slide 7

 

Formulary Coverage of Selected Antidepressants

Drug Product	% Covered (Yes/No)
	'06	'07	'08
Celexa	17%	29%	28%
Citalopram	100%	100%	100%
Lexapro	71%	83%	88%
Cymbalta	100%	100%	100%
Paroxetine	100%	100%	100%
Paxil	17%	29%	28%
Paxil CR	64%	59%	52%

SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

 

Slide 8

 

Use of Utilization Management Tools for Selected Atypical Antipsychotics

Of Plans that Cover Drug, % that Require Each Utilization Management Tool

Drug Product	Prior Authorization			Step Therapy
	'06	'07	'08	'06	'07	'08
Abilify	14%	14%	12%	0%	5%	7%
Abilify Discmelt	N/A	16%	18%	N/A	5%	7%
Risperdal	11%	0%	0%	0.5%	0%	0%
Risperdal Consta (IM)	26%	17%	15%	0.5%	0%	0%
Risperdal M-TAB ODT	11%	6%	6%	0.5%	0%	0%
Zyprexa	11%	10%	7%	0.5%	3%	7%
Zyprexa IM	23%	16%	7%	0.5%	4%	7%
Zyprexa Zydis	7%	19%	18%	0.5%	0.2%	2%

SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

 

Slide 9

 

Use of Utilization Management Tools for Selected Antidepressants

Drug Product	Prior Authorization			Step Therapy
	'06	'07	'08	'06	'07	'08
Celexa	0%	2%	2%	0%	3%	51%
Citalopram	0%	0%	0%	1%	0%	0%
Lexapro	0%	0%	0%	0%	14%	26%
Cymbalta	15%	1%	2%	0%	24%	33%
Paroxetine	0%	0%	0%	4%	0%	0%
Paxil	0%	2%	2%	0%	3%	51%
Paxil CR	5%	0%	1%	5%	7%	39%

SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

 

Slide 10

 

Percentage of Benchmark PDPs Requiring Either Step Therapy or Prior Authorization for Any Drug

2006

• Anticonvulsants: 31.8%
• Antidepressants: 25.4%
• Antipsychotics: 39.1%

2007

• Anticonvulsants: 52.0%
• Antidepressants: 41.43%
• Antipsychotics: 37.7%

2008

• Anticonvulsants: 62.2%
• Antidepressants: 50.1%
• Antipsychotics: 43.8%

SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

 

Slide 11

 

Other Findings from the Literature

• Medication Discontinuities
  • Some evidence of problems accessing particular medications (Hall et al 2007; West 2007, 2009)
• Psychotropic Drug Prices
  • Frank and Newhouse (2008) some evidence that prices for antipsychotics increased under Part D
• Plan Choice
  • Most Dual Eligibles assigned randomly, few switch plans (11% in 2006, Neuman et al. 2007)
  • Reduction in the Number of Benchmark Plans
    • 409 plans in 2006 ≥308 in 2009
    • 2009 Six states have ≤5 plans, Nevada has 1

 

Slide 12

 

Summary and Implications: Out-of-Pocket Costs

• Major Change in Financing of Psychotropic Medications:
  • Out of pocket costs decreased for non dual-eligibles
  • Out of pocket costs flat for dual-eligibles
  • Some indirect evidence of medication discontinuities

 

Slide 13

 

Summary and Implications: Formulary Coverage

• Formulary coverage relatively generous
  • But gaps for some formulations
  • Increasing use of utilization management
    • Consider monitoring prior authorization approval rates, include in plan performance
    • Consider alternatives to random assignment
      

 

Slide 14

 

Summary and Implications:
PDP Market

• PDPs exiting from market
  • Limits choice
  • Reassignment may lead to medication discontinuities
  • Doubling of PDP risk corridors in 2008 exposes plans to greater risk and may lead to further plan exits if risk adjustment doesn't accurately reflect dual eligibles expected costs
    • Consider changes in risk adjustment systems to include drug utilization
    • Consider exposing PDPs to less risk for dual-eligibles

 

Slide 15

 

More Information

• Donohue, Julie M, Haiden A. Huskamp and Samuel H. Zuvekas. 2009. "Dual Eligibles with Mental Disorders and Medicare Part D: How Are They Faring?" Health Affairs 28(May/June): 746-759.