Access and Utilization of New Antidepressant and Antipsychotic Medications

By:
The Lewin Group
January 2000

Submitted to:
The Office of the Assistant Secretary for Planning and Evaluation and
The National Institute of Mental Health,
U.S. Department of Health and Human Services

This report was prepared by Catherine Harrington, Razmic Gregorian, Eric Gemmen, Christina Hughes, Katharine Golden, Gail Robinson, and Leslie Scallet of The Lewin Group. This report was prepared under contract for the Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation, and The National Institute for Mental health, Department of Health and Human Services. The content of this report is solely the responsibility of The Lewin Group. For more information, please contact Catherine Harrington at 703-269 5730.

Table of Contents

Chapter I.   Introduction

  1. Understanding of the Problem
  2. Purpose of Study
  3. Scope of the Study
    1. Newer Antidepressant and Antipsychotic Medications
    2. Barriers to Access and Utilization of Newer Antidepressants and Antipsychotics: Starting Points for the Study
  4. Methodology
    1. Published Literature
    2. Medicaid Drug Rebate Data
    3. Expert Interviews
  5. Organization of the Report

Chapter II.   Principal Findings

  1. Access to Newer Antidepressant and Antipsychotic Medications
    1. Pharmaceutical Benefits
    2. Formularies
    3. Prior Authorization
    4. Step care
  2. Utilization of Antidepressant and Antipsychotic Medications
    1. Treatment Guidelines and Preferred Medications
    2. Clinical Development and Marketing
    3. Utilization Management
    4. Provider and Patient Compliance
  3. Utilization of Newer Antidepressant and Antipsychotic Medications by State Medicaid Programs 1995-1998
    1. Utilization of Antipsychotics
    2. Utilization of Antidepressants
    3. Comparison of Psychotherapeutic Utilization with Utilization of Other Drug Classes
  4. Cost-Effectiveness of Newer Antidepressant and Antipsychotic Medications
    1. Cost-Effectiveness of Newer Antidepressants
    2. Cost-Effectiveness of Newer Antipsychotics

Chapter III.   Defining Access and Utilization

  1. Defining Access
    1. Pharmaceutical Benefit Design
    2. Formularies
    3. Prior Authorization
    4. Step Care Protocols
  2. Defining Utilization
    1. Physician Habits and Treatment Guidelines
    2. Clinical Development and Pharmaceutical Marketing
    3. Utilization Review
    4. Patient Compliance and Disease Management

Chapter IV.   The Current State of Access to Newer Antidepressant and Antipsychotic Medications

  1. Benefit Design
    1. Coverage of Pharmaceuticals and Financing Arrangements
    2. Limits on Prescription Coverage and Cost Sharing Requirements
    3. Continuity of Care and Coordination of Benefits
    4. Access to Specialty Care and Prescriber Credentialling
  2. Formularies
    1. Formulary Status And Approach To Management
    2. Factors Influencing The Formulary Decision
    3. The Formulary Status Of Newer Antidepressant And Antipsychotic Medications
  3. Prior Authorization
    1. Public Programs
    2. Private Payers
    3. Special Populations
  4. Step care

Chapter V.   The Current State of Antidepressant and Antipsychotic Utilization

  1. Treatment Guidelines and Preferred Medications
    1. National Guidelines
    2. Public Program Guidelines
    3. Private Sector Guidelines
    4. Special Population Guidelines
  2. Clinical Development and Marketing
    1. Clinical Development and Trial Design
    2. Marketing
  3. Utilization Management
    1. Public Programs
    2. Private Payers
    3. Special Populations
  4. Compliance
    1. Provider Compliance
    2. Patient Compliance/Disease Management

Chapter VI.   Patterns of Antipsychotic and Antidepressant Utilization in Medicaid, 1995-1998

  1. Methodology
  2. Trends in Medicaid Pharmaceutical Coverage
  3. Utilization of Antipsychotics in Medicaid, 1995-1998
    1. In 1998, 51% of All Medicaid Prescriptions for Antipsychotics were for Atypical Antipsychotics. Expenditures on Atypicals Accounted for 89% of Total Spending on Antipsychotics
    2. The Use of Atypical Antipsychotics In Medicaid Has Grown Dramatically Since 1995
    3. Patterns of Antipsychotic Utilization in High-Volume States
    4. The Uptake of Newer Antipsychotic Agents into Medicaid Immediately Post-Launch has been Rapid
  4. Utilization of Antidepressants in Medicaid, 1995-1998
    1. In 1998, 62% of the 19 Million Medicaid Antidepressant Prescriptions were for New-Generation, Branded Antidepressants
    2. The Use of New-Generation Antidepressants in Medicaid Grew Dramatically Between 1995 and 1998
    3. Patterns of Antidepressant Utilization in High-Volume States
  5. Comparison of Psychotherapeutic Utilization with Utilization of Other Drug Classes

Chapter VII.   Pharmacoeconomics of Newer Antidepressant and Antipsychotic Medications

  1. Overview of Pharmacoeconomics
  2. The Cost-Effectiveness of Newer Antidepressant Medications
    1. The Cost Of Depressive Illness In The United States
    2. Pharmacoeconomic Analyses Of Specific Pharmaceutical Agents
  3. The Cost-Effectiveness of Newer Antipsychotic Medications
    1. The Cost Of Schizophrenia And Related Illness In The United States
    2. Pharmacoeconomic Analyses Of Specific Antipsychotic Agents

Chapter VIII.   Future Directions in the Benefits Status of Psychotherapeutic Pharmaceuticals

  1. New Chemical Entities and Generic Competition
  2. The Changing Meaning of the Formulary
  3. Three-Tiered Copayment Requirements: Placing Greater Choice in the Hands of Consumers at a Cost
  4. Mental Health Parity Legislation: Promise and Threat
  5. The Changing Role of Managed Care

Appendix A.   Interview Protocol

Appendix B.   Interview Strategy

Appendix C.   Interview Respondents

REFERENCES

Exhibits

CHAPTER I. INTRODUCTION
Exhibit I-1. Representative Antidepressants Marketed in the United States, 1999
Exhibit I-2. Representative Antipsychotics Marketed in the United States, 1999
Exhibit I-3. List of Key Informants
CHAPTER IV. THE CURRENT STATE OF ACCESS TO NEWER ANTIDEPRESSANT AND ANTIPSYCHOTIC MEDICATIONS
Exhibit IV-1. Reimbursement Mechanisms for Pharmacy Benefit under Medicaid and State Mental Health System Programs
Exhibit IV-2. Relative Importance of Issues Affecting Formulary Decisions
Exhibit IV-3. Formulary Status of Antidepressants in 41 Managed Care Plans
Exhibit IV-4. Formulary Status of Antipsychotics in 41 Managed Care Plans
Exhibit IV-5. Formulary Status of Lipid Lowering Agents (Statins) in 40 Managed Care Plans
CHAPTER VI. PATTERNS OF ANTIPSYCHOTIC AND ANTIDEPRESSANT UTILIZATION IN MEDICAID, 1995-1998
Exhibit VI-1. Antipsychotic Categories
Exhibit VI-2. Market Share of Antipsychotic Classes in 45 Medicaid States, 1998.
Exhibit VI-3. Market Share of Antipsychotic Classes in 45 Medicaid States, 1998.
Exhibit VI-4. Share of Medicaid Antipsychotic Prescriptions and Expenditures by Class, 1998
Exhibit VI-5. Antipsychotic Prescription Trends in Medicaid, 1995-1998
Exhibit VI-6. Antipsychotic Prescription Trends in Medicaid, Total Expenditures, 1995-1998
Exhibit VI-7. Antipsychotic Prescription Trends in Medicaid by Class, 1995-1998
Exhibit VI-8. Antipsychotic Prescription Trends in Medicaid, Total Expenditures by Class, 1995-1998
Exhibit VI-9. Number of Antipsychotic Prescriptions and Total Amount of Medicaid Reimbursement 12 High-Volume Prescription States, 1998
Exhibit VI-10. Market Share of Antipsychotics in 12 High-Volume Medicaid States as a Percent of Total Antipsychotic Prescriptions, 1998
Exhibit VI-11. Uptake of Newer Antipsychotic Medications in Medicaid and Growth of Prescription Volume 1996-1998
Exhibit VI-12. Antidepressant Classes
Exhibit VI-13. Market Share of Antidepressant Classes in 45 Medicaid States, 1998.
Exhibit VI-14. Market Share of Antidepressant Classes in 45 State Medicaid Programs, 1998.
Exhibit VI-15. Share of Medicaid Antidepressant Prescriptions and Expenditures by Class, 1998
Exhibit VI-16. Antidepressant Prescription Trends in Medicaid, 1995-1998. Total Prescriptions in Thousands
Exhibit VI-17. Antidepressant Prescription Trends in Medicaid, 1995-1998. Expenditures in Millions
Exhibit VI-18. Antidepressant Class Prescription Trends in Medicaid, 1995-1998. Total Prescriptions inThousands
Exhibit VI-19. Antidepressant Class Prescription Trends in Medicaid, 1995-1998. Total Expenditures in Millions
Exhibit VI-20. Number of Antidepressant Prescriptions and Total Amount of Medicaid Reimbursement for 12 High Volume States, 1995-1998
Exhibit VI-21. Market Share of Antidepressants in 12 High-Volume Medicaid States as Percent of Total Prescriptions, 1998
Exhibit VI-22. Oral Antidiabetic Categories
Exhibit VI-23. Comparison of Increase in Prescriptions and Expenditures for 3 Pharmaceutical Classes in Medicaid, 1995-1998
CHAPTER VII. PHARMACOECONOMICS OF NEWER ANTIDEPRESSANT AND ANTIPSYCHOTIC MEDICATIONS
Exhibit VII-1. Comparison of Pharmacoeconomic Methodologies
Exhibit VII-2. Studies Using Hospitalization as a Proxy for Costs in Treatment with Risperidone or Clozapine
Exhibit VII-3. Historical Comparison Studies with Clozapine

 

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Last updated August 20, 2000