Dual Eligibles with Mental Disorders and Medicare Part D: How are They Faring? Julie Donohue University of Pittsburgh Haiden Huskamp Harvard Medical School.

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Presentation transcript:

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

Context 6 million Medicare beneficiaries dually eligible for Medicaid moved to Medicare Part D drug plans. 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 Random assignment to one of multiple benchmark plans, can switch Estimated 60% of disabled and 20% of elderly dual- eligibles have mental disorders Estimated 60% of disabled and 20% of elderly dual- eligibles have mental disorders Protections 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

Medication Use and Spending: U.S. Community Population % With Use Total Spending $ Percent Distribution of Spending by Source OOPMedicareMedicaidPrivateOther 2005 Antidepressants (all) b Antipsychotics (all)1.35.5b Anticonvulsants2.75.5b ALL PRESCRIPTION DRUGS b Antidepressants (all) b3516*8*36*5 Antipsychotics (all)1.35.7b2621*26*207 Anticonvulsants2.85.7b3416*19*265 ALL PRESCRIPTION DRUGS b 35* 20* 7* 33*6* SOURCE: Medical Expenditure Panel Survey

Medication Use and Spending: Medicare Community Population % With Use Total Spending $ Percent Distribution of Spending by Source OOPMedicareMedicaidPrivateOther 2005 Antidepressants (all) b Antipsychotics (all)3.32.1b Anticonvulsants7.02.1b ALL PRESCRIPTION DRUGS b Antidepressants (all)18.1*4.1b32*52*1*10*5 Antipsychotics (all)3.61.9b2261*6*47 Anticonvulsants7.21.9b3148*2*127 ALL PRESCRIPTION DRUGS b 31* 45* 7* 14*8* SOURCE: Medical Expenditure Panel Survey

Medication Use and Spending: Dual Eligible Community Population % With Use Total Spending $ Percent Distribution of Spending by Source OOPMedicareMedicaidPrivateOther 2005 Antidepressants (all) b Antipsychotics (all)8.51.5b Anticonvulsants b ALL PRESCRIPTION DRUGS b Antidepressants (all) b9*84*5*03 Antipsychotics (all)8.41.0b683*11*00 Anticonvulsants b*1278*7*12 ALL PRESCRIPTION DRUGS b 17 77* 5* 0*1 SOURCE: Medical Expenditure Panel Survey

Formulary Coverage of Selected Atypical Antipsychotics Drug Product % Covered (Yes/No) ‘06‘07‘08 Abilify100% Abilify DiscmeltN/A83%100% Risperdal100% Risperdal Consta (IM)93%100% Risperdal M-TAB ODT93%100% Zyprexa100% Zyprexa IM74%90%100% Zyprexa Zydis84%100% SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

Formulary Coverage of Selected Antidepressants Drug Product % Covered (Yes/No) ‘06‘07‘08 Celexa17%29%28% Citalopram100% Lexapro71%83%88% Cymbalta100% Paroxetine100% Paxil17%29%28% Paxil CR64%59%52% SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

Use of Utilization Management Tools for Selected Atypical Antipsychotics Of Plans that Cover Drug, % that Require Each Utilization Management Tool Drug ProductPrior AuthorizationStep Therapy ‘06‘07‘08‘06‘07‘08 Abilify14% 12%0%5%7% Abilify DiscmeltN/A16%18%N/A5%7% Risperdal11%0% 0.5%0% Risperdal Consta (IM)26%17%15%0.5%0% Risperdal M-TAB ODT11%6% 0.5%0% Zyprexa11%10%7%0.5%3%7% Zyprexa IM23%16%7%0.5%4%7% Zyprexa Zydis7%19%18%0.5%0.2%2% SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

Use of Utilization Management Tools for Selected Antidepressants Of Plans that Cover Drug, % that Require Each Utilization Management Tool Drug ProductPrior AuthorizationStep Therapy ‘06‘07‘08‘06‘07‘08 Celexa0%2% 0%3%51% Citalopram0% 1%0% Lexapro0% 14%26% Cymbalta15%1%2%0%24%33% Paroxetine0% 4%0% Paxil0%2% 0%3%51% Paxil CR5%0%1%5%7%39% SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

Percentage of Benchmark PDPs Requiring Either Step Therapy or Prior Authorization for Any Drug SOURCE: January 2006, 2007, and 2008 CMS Prescription Drug Formulary and Pharmacy Network Files

Other Findings from the Literature Medication Discontinuities Medication Discontinuities – Some evidence of problems accessing particular medications (Hall et al 2007; West 2007, 2009) Psychotropic Drug Prices Psychotropic Drug Prices – Frank and Newhouse (2008) some evidence that prices for antipsychotics increased under Part D Plan Choice 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 plans in 2006 => 308 in Six states have <=5 plans, Nevada has Six states have <=5 plans, Nevada has 1

Summary and Implications: Out-of-Pocket Costs Major Change in Financing of Psychotropic Medications: 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

Summary and Implications: Formulary Coverage Formulary coverage relatively generous 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

Summary and Implications: PDP Market PDPs exiting from 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

More Information Donohue, Julie M, Haiden A. Huskamp and Samuel H. Zuvekas “Dual Eligibles with Mental Disorders and Medicare Part D: How Are They Faring?” Health Affairs 28(May/June):