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 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

Slide 4

Medication Use and Spending: Medicare Community Population

Slide 5

Medication Use and Spending: Dual Eligible Community Population

SOURCE: Medical Expenditure Panel Survey 2005-2006

Slide 6

Formulary Coverage of Selected Atypical Antipsychotics

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

Slide 7

Formulary Coverage of Selected Antidepressants

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

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

Slide 9

Use of Utilization Management Tools for Selected Antidepressants

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.