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

Dual Eligibles with Mental Disorders and Dual Eligibles with Mental Disorders and Medicare Part D: Medicare Part D:

How are They Faring?How are They Faring?

Julie DonohueJulie DonohueUniversity of PittsburghUniversity of Pittsburgh

Haiden HuskampHaiden HuskampHarvard Medical SchoolHarvard Medical School

Sam ZuvekasSam ZuvekasAgency for Healthcare Research and QualityAgency for Healthcare Research and Quality

ContextContext

6 million Medicare beneficiaries dually eligible for 6 million Medicare beneficiaries dually eligible for Medicaid moved to Medicare Part D drug plans.Medicaid moved to Medicare Part D drug plans.

Random assignment to one of multiple benchmark Random assignment to one of multiple benchmark plans, can switchplans, can switch

Estimated 60% of disabled and 20% of elderly dual-Estimated 60% of disabled and 20% of elderly dual-eligibles have mental disorderseligibles have mental disorders

ProtectionsProtections– ““All or substantially all” rule for antidepressants, All or substantially all” rule for antidepressants,

antipsychotics, and anticonvulsantsantipsychotics, and anticonvulsants

– Fixed copay for generics, slightly higher for branded Fixed copay for generics, slightly higher for branded drugs, can’t use cost-sharing tiersdrugs, can’t use cost-sharing tiers

– Risk adjusted payments to PDPsRisk adjusted payments to PDPs

Medication Use and Spending:Medication Use and Spending: U.S. Community Population 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

Medication Use and Spending:Medication Use and Spending: Medicare Community Population Medicare Community Population

% With Use

Total Spending

$



2005




ALL PRESCRIPTION DRUGS 91.0 88.5b 43 7 16 23 11

2006

Antidepressants (all) 18.1* 4.1b 32* 52* 1* 10* 5


Anticonvulsants 7.2 1.9b 31 48* 2* 12 7

ALL PRESCRIPTION DRUGS 91.2 96.3b 31* 45* 7* 14* 8*


Medication Use and Spending:Medication Use and Spending: Dual Eligible Community Population Dual Eligible Community Population

% With Use

Total Spending

$



2005




ALL PRESCRIPTION DRUGS 88.0 18.7b 19 5 73 1 2

2006

Antidepressants (all) 20.8 1.0b 9* 84* 5* 0 3


Anticonvulsants 11.5 0.6b* 12 78* 7* 1 2

ALL PRESCRIPTION DRUGS 87.0 17.7b 17 77* 5* 0* 1


Formulary Coverage of Selected Formulary Coverage of Selected Atypical AntipsychoticsAtypical 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

Formulary Coverage of Selected Formulary Coverage of Selected AntidepressantsAntidepressants

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%


Use of Utilization Management Tools Use of Utilization Management Tools for Selected Atypical Antipsychoticsfor 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%


Use of Utilization Management Tools Use of Utilization Management Tools for Selected Antidepressantsfor Selected Antidepressants

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

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%


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

31.8

52.0

62.2

25.4

41.43

50.1

39.1 37.7

43.8

2006 2007 2008

anticonvulsants

antidepressants

antipsychotics


Other Findings from the LiteratureOther Findings from the Literature

Medication DiscontinuitiesMedication Discontinuities– Some evidence of problems accessing particular Some evidence of problems accessing particular

medications (Hall et al 2007; West 2007, 2009)medications (Hall et al 2007; West 2007, 2009)

Psychotropic Drug PricesPsychotropic Drug Prices– Frank and Newhouse (2008) some evidence that Frank and Newhouse (2008) some evidence that

prices for antipsychotics increased under Part Dprices for antipsychotics increased under Part D

Plan ChoicePlan Choice– Most Dual Eligibles assigned randomly, few switch Most Dual Eligibles assigned randomly, few switch

plans (11% in 2006, Neuman et al. 2007)plans (11% in 2006, Neuman et al. 2007)– Reduction in the Number of Benchmark PlansReduction in the Number of Benchmark Plans

409 plans in 2006 => 308 in 2009409 plans in 2006 => 308 in 2009 2009 Six states have <=5 plans, Nevada has 12009 Six states have <=5 plans, Nevada has 1

Summary and Implications: Summary and Implications: Out-of-Pocket CostsOut-of-Pocket Costs

Major Change in Financing of Psychotropic Major Change in Financing of Psychotropic Medications:Medications:– Out of pocket costs decreased for non dual-Out of pocket costs decreased for non dual-

eligibleseligibles– Out of pocket costs flat for dual-eligiblesOut of pocket costs flat for dual-eligibles– Some indirect evidence of medication Some indirect evidence of medication

discontinuitiesdiscontinuities

Summary and Implications: Summary and Implications: Formulary CoverageFormulary Coverage

Formulary coverage relatively generousFormulary coverage relatively generous– But gaps for some formulationsBut gaps for some formulations

– Increasing use of utilization managementIncreasing use of utilization management Consider monitoring prior authorization Consider monitoring prior authorization

approval rates, include in plan performanceapproval rates, include in plan performance Consider alternatives to random assignmentConsider alternatives to random assignment

Summary and Implications: Summary and Implications: PDP MarketPDP Market

PDPs exiting from marketPDPs exiting from market– Limits choiceLimits choice

– Reassignment may lead to medication discontinuitiesReassignment may lead to medication discontinuities

– Doubling of PDP risk corridors in 2008 exposes plans Doubling of PDP risk corridors in 2008 exposes plans to greater risk and may lead to further plan exits if risk to greater risk and may lead to further plan exits if risk adjustment doesn’t accurately reflect dual eligibles adjustment doesn’t accurately reflect dual eligibles expected costsexpected costs Consider changes in risk adjustment systems to Consider changes in risk adjustment systems to

include drug utilizationinclude drug utilization Consider exposing PDPs to less risk for dual-Consider exposing PDPs to less risk for dual-

eligibleseligibles

More InformationMore Information

Donohue, Julie M, Haiden A. Huskamp and Donohue, Julie M, Haiden A. Huskamp and Samuel H. Zuvekas. 2009. “Dual Eligibles Samuel H. Zuvekas. 2009. “Dual Eligibles with Mental Disorders and Medicare Part with Mental Disorders and Medicare Part D: How Are They Faring?” D: How Are They Faring?” Health AffairsHealth Affairs 28(May/June): 746-759.28(May/June): 746-759.

Documents

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