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

Slide Presentation from the AHRQ 2009 Annual Conferenc

Slide presentation from the AHRQ 2009 conference.

Slide Presentation from the AHRQ 2009 Annual Conference


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


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)

8.513.3b36214436

Antipsychotics (all)

1.35.5b23155146

Anticonvulsants

2.75.5b29233307

ALL PRESCRIPTION DRUGS

63.1213b39314377
2006       

Antidepressants (all)

8.413.2b3516*8*36*5

Antipsychotics (all)

1.3

5.7b

2621*26*207

Anticonvulsants

2.85.7b3416*19*265

ALL PRESCRIPTION DRUGS

62.6224b35*20*7*33*6*
SOURCE: Medical Expenditure Panel Survey 2005-2006

 

Slide 4


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)

16.03.8b418182310

Antipsychotics (all)

3.32.1b2546443

Anticonvulsants

7.02.1b29435229

ALL PRESCRIPTION DRUGS

91.088.5b437162311
2006       

Antidepressants (all)

18.1*4.1b32*52*1*10*5

Antipsychotics (all)

3.61.9b2261*6*47

Anticonvulsants

7.21.9b3148*2*127

ALL PRESCRIPTION DRUGS

91.296.3b31*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)

18.80.9b2057032

Antipsychotics (all)

8.51.5b1228401

Anticonvulsants

13.00.9b1538210

ALL PRESCRIPTION DRUGS

88.018.7b1957312
2006       

Antidepressants (all)

20.81.0b9*84*5*03

Antipsychotics (all)

8.41.0b683*11*00

Anticonvulsants

11.50.6b*1278*7*12

ALL PRESCRIPTION DRUGS

87.017.7b1777*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/A83%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/A16%18%N/A5%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.
Current as of December 2009
Internet Citation: Dual Eligibles with Mental Disorders and Medicare Part D: How are They: Slide Presentation from the AHRQ 2009 Annual Conferenc. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/zuvekas/index.html