Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

Dual Eligibles with Mental Disorders and Medicare Part D (Text Version)

Slide presentation from the AHRQ 2009 conference.

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


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) 8.5 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
 

 

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) 16.0 3.8b 41 8 18 23 10
Antipsychotics (all) 3.3 2.1b 25 4 64 4 3
Anticonvulsants 7.0 2.1b 29 4 35 22 9
ALL PRESCRIPTION DRUGS 91.0 88.5b 43 7 16 23 11
2006              
Antidepressants (all) 18.1* 4.1b 32* 52* 1* 10* 5
Antipsychotics (all) 3.6 1.9b 22 61* 6* 4 7
Anticonvulsants 7.2 1.9b 31 48* 2* 12 7
ALL PRESCRIPTION DRUGS 91.2 96.3b 31* 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) 18.8 0.9b 20 5 70 3 2
Antipsychotics (all) 8.5 1.5b 12 2 84 0 1
Anticonvulsants 13.0 0.9b 15 3 82 1 0
ALL PRESCRIPTION DRUGS 88.0 18.7b 19 5 73 1 2
2006              
Antidepressants (all) 20.8 1.0b 9* 84* 5* 0 3
Antipsychotics (all) 8.4 1.0b 6 83* 11* 0 0
Anticonvulsants 11.5 0.6b* 12 78* 7* 1 2
ALL PRESCRIPTION DRUGS 87.0 17.7b 17 77* 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/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

 

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/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%

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 (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2009/zuvekas/index.html

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care