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

(lsimoniw@rx.umaryland.edu)(lsimoniw@rx.umaryland.edu)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?