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Gaps in Drug Benefits: Impact on Gaps in Drug Benefits: Impact on Utilization and Spending for Drugs Used Utilization and Spending for Drugs Used by Medicare Beneficiaries with Serious by Medicare Beneficiaries with Serious
Mental IllnessMental IllnessLinda Simoni-Wastila, PhDLinda Simoni-Wastila, PhD
([email protected])([email protected])Christopher Blanchette, MAChristopher Blanchette, MA
Xiaoqang Ren, MSXiaoqang Ren, MSBruce Stuart, PhDBruce Stuart, PhD
Peter Lamy Center on Drug Therapy and AgingPeter Lamy Center on Drug Therapy and AgingUniversity of Maryland BaltimoreUniversity of Maryland Baltimore
School of PharmacySchool of Pharmacy
AcademyHealth AcademyHealth Boston, MA Boston, MA
June 28, 2005June 28, 2005
Funded by the Robert Wood Johnson Foundation/Health Care and Financing Organization
BackgroundBackground
There are growing concerns that the MMA There are growing concerns that the MMA Part D benefit’s “donut hole” design may Part D benefit’s “donut hole” design may result in discontinuities in access to result in discontinuities in access to prescribed medicinesprescribed medicines
Such coverage gaps may be particularly Such coverage gaps may be particularly detrimental to older and disabled detrimental to older and disabled individuals with chronic conditions for individuals with chronic conditions for whom prescription drugs represent a whom prescription drugs represent a necessary treatment modalitynecessary treatment modality
BackgroundBackgroundPrior work found that drug coverage gaps Prior work found that drug coverage gaps reduced prescription drug use by Medicare reduced prescription drug use by Medicare beneficiaries. Using a simulation model, we beneficiaries. Using a simulation model, we projected total drug spending under Medicare projected total drug spending under Medicare Part D relative to those with continuous Part D relative to those with continuous coverage:coverage:– All MC Beneficiaries: 92.1%All MC Beneficiaries: 92.1%– COPD: 79.6%COPD: 79.6%– Diabetes: 83.2%Diabetes: 83.2%– Mental Illness: 76.0%Mental Illness: 76.0%
(Stuart, Simoni-Wastila and Chauncey Health Affairs web exclusive 2005)
PurposePurpose
To delve into greater detail on how drug To delve into greater detail on how drug coverage gaps impact drug use and coverage gaps impact drug use and spending by Medicare beneficiaries with spending by Medicare beneficiaries with serious mental illness (SMI)serious mental illness (SMI)Objectives:Objectives:– 1) To describe extent of drug coverage gaps 1) To describe extent of drug coverage gaps
experienced by SMI Medicare beneficiaries; andexperienced by SMI Medicare beneficiaries; and– 2) To determine impact of coverage gaps on use of 2) To determine impact of coverage gaps on use of
and spending for prescription drugs used to treat and spending for prescription drugs used to treat mental disordersmental disorders
Methods - DataMethods - Data
1997 – 2001 Medicare Current Beneficiary Survey 1997 – 2001 Medicare Current Beneficiary Survey (MCBS) linked to Medicare Part A and Part B claims(MCBS) linked to Medicare Part A and Part B claimsMCBS is longitudinal, nationally-representative sample of MCBS is longitudinal, nationally-representative sample of Medicare beneficiariesMedicare beneficiariesMCBS (linked to Part A and B claims) contains:MCBS (linked to Part A and B claims) contains:– DemographicsDemographics– Income and health insurance coverage, including drug benefits Income and health insurance coverage, including drug benefits
(with begin and end dates of coverage)(with begin and end dates of coverage)– Health and functional status Health and functional status – Utilization and expenditures for all health services, including Utilization and expenditures for all health services, including
prescription drugsprescription drugs– Diagnostic information (ICD-9 diagnoses from claims; self-report Diagnostic information (ICD-9 diagnoses from claims; self-report
from MCBS survey)from MCBS survey)
Methods – Study SampleMethods – Study Sample
Pooled sample of three 3-year cohorts Pooled sample of three 3-year cohorts (1997-1999, 1998-2000, and 1999-2001) (1997-1999, 1998-2000, and 1999-2001) of community-dwelling MCBS respondentsof community-dwelling MCBS respondents
Excluded from analysis: M + C plan Excluded from analysis: M + C plan members, LTC residents, and those lost to members, LTC residents, and those lost to follow-up follow-up Sample = 9,219 Sample = 9,219
Methods – Study SampleMethods – Study Sample
SMI defined as: 1 or more SMI diagnoses in baseline SMI defined as: 1 or more SMI diagnoses in baseline year + at least one other of same diagnosis during any of year + at least one other of same diagnosis during any of study yearsstudy yearsSMI diagnoses include:SMI diagnoses include:– Schizophrenia/psychotic disorders (ICD-9 = 294.xx, 295.xx, Schizophrenia/psychotic disorders (ICD-9 = 294.xx, 295.xx,
297.xx, 298.xx, and 299.xx)297.xx, 298.xx, and 299.xx)– Manic/Bipolar disorders (ICD-9 = 296.0, 296.1, 296.4-296.9)Manic/Bipolar disorders (ICD-9 = 296.0, 296.1, 296.4-296.9)– Major depression (ICD- 9 = 296.2, 296.3)Major depression (ICD- 9 = 296.2, 296.3)
Application of these criteria resulted in an analytic Application of these criteria resulted in an analytic sample of 901 seriously mentally-ill Medicare sample of 901 seriously mentally-ill Medicare beneficiaries followed for up to 3 yearsbeneficiaries followed for up to 3 years
Methods – Dependent VariablesMethods – Dependent Variables
Mental health drug use and spendingMental health drug use and spendingUse defined as all Prescription Medication Events (PME) per Use defined as all Prescription Medication Events (PME) per respondent over three year periodrespondent over three year period– % use, annual mean PMEs% use, annual mean PMEs
Expenditures defined as all mental health drug spending per Expenditures defined as all mental health drug spending per respondent over three period, expressed in constant 2001 respondent over three period, expressed in constant 2001 dollars (and annualized)dollars (and annualized)Total mental health drug use and spending, as well as by Total mental health drug use and spending, as well as by therapeutic class:therapeutic class:– Antipsychotics (atypicals, typicals)Antipsychotics (atypicals, typicals)– Antidepressants (newer, traditional)Antidepressants (newer, traditional)– Anxiolytics/Sedative-hypnoticsAnxiolytics/Sedative-hypnotics– Anti-mania drugsAnti-mania drugs– Anticonvulsants (“mood-stabilizers”)Anticonvulsants (“mood-stabilizers”)
Methods – Independent VariablesMethods – Independent Variables
Prescription gap months = summed Prescription gap months = summed number of months over the three-year number of months over the three-year period during which the beneficiary had no period during which the beneficiary had no evidence of prescription drug coverageevidence of prescription drug coverage– 0 Gap Months (Full drug coverage) [ref]0 Gap Months (Full drug coverage) [ref]– 1-18 Gap Months1-18 Gap Months– 19-35 Gap Months19-35 Gap Months– 36 Gap Months (No drug coverage) 36 Gap Months (No drug coverage)
Methods - CovariatesMethods - Covariates
Age (<65, 65-74, 75-84, 85+ [ref])Age (<65, 65-74, 75-84, 85+ [ref])Gender [Female is ref]Gender [Female is ref]Race/ethnicity [Non-white is ref]Race/ethnicity [Non-white is ref]Education [<HS is ref]Education [<HS is ref]Income [FPL > 300 is ref]Income [FPL > 300 is ref]Non-drug supplemental insurance (0/1)Non-drug supplemental insurance (0/1)Geographic region [West is ref]Geographic region [West is ref]Urbanicity [Rural is ref]Urbanicity [Rural is ref]Health Status [Poor is ref]Health Status [Poor is ref]Death status (0/1 indicator of died in year 1, 2 or 3)Death status (0/1 indicator of died in year 1, 2 or 3)Psychosis or depression (0/1 indicator of condition)Psychosis or depression (0/1 indicator of condition)Comorbidity Index (DCG/HCC)Comorbidity Index (DCG/HCC)
Methods – Analytic ApproachMethods – Analytic Approach
Descriptive:Descriptive: Mental health drug use and Mental health drug use and spending, overall and by gap statusspending, overall and by gap status
Multivariate:Multivariate: Ordinary least squares regression Ordinary least squares regression to estimate the impact of gap status on mental to estimate the impact of gap status on mental health drug use and spendinghealth drug use and spending– Tested for endogeneity of the coverage variables and Tested for endogeneity of the coverage variables and
found that controlling for comorbidity (HCC/DCG) found that controlling for comorbidity (HCC/DCG) eliminated all endogeneity eliminated all endogeneity
All analyses weighted All analyses weighted nationally nationally representative estimatesrepresentative estimates
Results – Baseline CharacteristicsResults – Baseline CharacteristicsPercent of SMI BeneficiariesPercent of SMI Beneficiaries
Age < 65Age < 65 34.1%34.1%
FemaleFemale 61.761.7
WhiteWhite 82.082.0
≤ ≤ 100% FPL100% FPL 31.031.0
Fair/Poor HealthFair/Poor Health 44.844.8
Mental Health ProblemsMental Health Problems Major DepressionMajor Depression Psychotic Disorders/BipolarPsychotic Disorders/Bipolar Non-SMI MH conditionsNon-SMI MH conditions
52.852.855.055.067.367.3
DiedDied Year 1Year 1 Year 2Year 2 Year 3 Year 3
4.34.35.25.26.26.2
Annual Mean Total and MH Drug Annual Mean Total and MH Drug Spending by MC Beneficiaries Spending by MC Beneficiaries (unadjusted)(unadjusted)
$2,421
$824
$1,550
$166
$0
$500
$1,000
$1,500
$2,000
$2,500
SMI MC Beneficiaries All MC Beneficiaries
Annual Mean Total Drug Spending Annual Mean MMH Spending
34.0%
10.7%
Drug Coverage Gaps Among MC Drug Coverage Gaps Among MC Beneficiaries with SMI Beneficiaries with SMI (unadjusted)(unadjusted)
Prescription Prescription Coverage Gaps Coverage Gaps in Monthsin Months
% of MC % of MC Beneficiaries Beneficiaries
with SMIwith SMI
Mean Annual Mean Annual PME Fills by SMI PME Fills by SMI MC BeneficiariesMC Beneficiaries
0 (Full drug 0 (Full drug coverage)coverage)
51.4%51.4% 11.211.2
1-18 Months1-18 Months 18.7%18.7% 9.69.6
19-35 Months19-35 Months 11.5%11.5% 6.36.3
36 Months (No 36 Months (No coverage)coverage)
18.4%18.4% 6.06.0
Proportion of SMI MC Beneficiaries Using Any Proportion of SMI MC Beneficiaries Using Any MH Drugs, Antidepressants and Antipsychotics MH Drugs, Antidepressants and Antipsychotics
by Coverage Gap Status by Coverage Gap Status (unadjusted)(unadjusted)
77.0
56.7
27.2
83.2
61.5
32.6
79.1
61.1
27.9
66.0
50.8
15.2
66.5
43.1
19.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
All SMI FullCoverage
1-18 GapMonths
19-35 GapMonths
NoCoverage
All MH Drugs Antidepressants Antipsychotics
Regression ResultsRegression Results
The next several slides illustrate the The next several slides illustrate the impact of having coverage gaps on impact of having coverage gaps on utilization of and spending onutilization of and spending on
All mental health drugsAll mental health drugs
AntidepressantsAntidepressants
AntipsychoticsAntipsychotics
ceteris paribusceteris paribus
All findings are presented as mean annual All findings are presented as mean annual prescriptions or expendituresprescriptions or expenditures
Annual Mean PMEs (Fills) by Coverage Gap Annual Mean PMEs (Fills) by Coverage Gap StatusStatus (adjusted)(adjusted)
10.1
3.6
2.5
7.9
2.31.8
6.9
2.2
1.4
7.0
2.5
1.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Full Coverage 1-18 Gap Months 19-35 GapMonths
No Coverage
All MH Drugs Antidepressants Antipsychotics
Annual Mean Drug Spending by Coverage Gap Annual Mean Drug Spending by Coverage Gap Status Status (adjusted)(adjusted)
$893
$297$330
$742
$174
$308
$572
$151
$210
$612
$175
$238
$0
$100
$200
$300
$400
$500
$600
$700
$800
$900
Full Coverage 1-18 Gap Months 19-35 GapMonths
No Coverage
All Mental Health Antidepressant Antipsychotics
Other Multivariate FindingsOther Multivariate Findings
Age is important – individuals aged <65 (i.e., the Age is important – individuals aged <65 (i.e., the disabled) had significantly increased use and disabled) had significantly increased use and spending of all MH drugs and drug classes spending of all MH drugs and drug classes relative to those aged 85+relative to those aged 85+Sex, race/ethnicity, income, health status, and Sex, race/ethnicity, income, health status, and other covariates varied by therapeutic classother covariates varied by therapeutic classComorbidity, as assessed using the DCG/HCC, Comorbidity, as assessed using the DCG/HCC, was not a significant predictor of MH drug use or was not a significant predictor of MH drug use or spending; however, the individual diagnoses of spending; however, the individual diagnoses of depression and psychotic disorders were depression and psychotic disorders were significant positive predictors of drug use and significant positive predictors of drug use and spendingspending
Other Multivariate FindingsOther Multivariate Findings
In within therapeutic class analyses (not shown In within therapeutic class analyses (not shown here), we found that coverage gaps did not here), we found that coverage gaps did not influence use of and spending on the newer influence use of and spending on the newer mental health drugs, such as the atypical mental health drugs, such as the atypical antipsychotics or SSRI/SNRIs, suggesting that antipsychotics or SSRI/SNRIs, suggesting that coverage status may not influence type of drug coverage status may not influence type of drug one receivesone receives– However, when we examined the probability of However, when we examined the probability of
receiving any “newer” MH drug (ie, any SSRI/SRNI or receiving any “newer” MH drug (ie, any SSRI/SRNI or atypical), we found that among any antidepressant/ atypical), we found that among any antidepressant/ antipsychotic users, “newer” drug use and spending antipsychotic users, “newer” drug use and spending was less likely among those with gaps or no coverage was less likely among those with gaps or no coverage relative to those with full coveragerelative to those with full coverage
Conclusions and Next StepsConclusions and Next Steps
It is clear that coverage gaps make a difference in terms It is clear that coverage gaps make a difference in terms of access to medications used to treat Medicare of access to medications used to treat Medicare beneficiaries with serious mental illness, controlling for beneficiaries with serious mental illness, controlling for comorbidity and other important covariatescomorbidity and other important covariatesNext StepsNext Steps– Examine variation in use of and spending for other MH Examine variation in use of and spending for other MH
therapeutic categories (e.g., mood stabilizers; anxiolytics; therapeutic categories (e.g., mood stabilizers; anxiolytics; “newer” MH drugs) “newer” MH drugs)
– Examine how use and spending differ by age (i.e., eligibility Examine how use and spending differ by age (i.e., eligibility based on disability versus age) based on disability versus age)
– Answer the question: Do differences in mental health drug use Answer the question: Do differences in mental health drug use due to coverage gaps impact the use of and spending on other due to coverage gaps impact the use of and spending on other medical services, including hospitalization, emergency medical services, including hospitalization, emergency department visits, and psychiatric treatment? department visits, and psychiatric treatment?