Access and Utilization of New Antidepressant and Antipsychotic Medications. The Use of Atypical Antipsychotics In Medicaid Has Grown Dramatically Since 1995

01/01/2000

Exhibit VI-5 depicts national trends in prescriptions for antipsychotics in Medicaid between 1995 and 1998. Overall, antipsychotic prescriptions rose from 9.2 million in 1995 to 11 million in 1998, an increase of nearly 20%. At the same time, total expenditures increased from $484 million in 1995, to $894 million in 1997 and $1.3 billion in 1998, an overall increase of 160% (Exhibit VI-6).

This disproportionate growth in expenditures as compared to prescriptions has been driven by the rapid uptake of newer agents. The data in Exhibit VI-7 also show that since the introduction of risperidone in 1994 and olanzapine in 4th quarter of 1996, there have been steady increases in the number of prescriptions for these agents. These occurred alongside a concomitant decrease in the number of prescriptions for oral haloperidol and phenothiazines both in terms of total prescriptions and in terms of market share. Thus, it appears that the introduction of atypical antipsychotics did not merely replace older therapies, but instead expanded the market for use of these agents as a category.

Exhibit VI-5. Antipsychotic Prescription Trends in Medicaid, 1995-1998

Exhibit VI-5. Antipsychotic Prescription Trends in Medicaid, 1995-1998

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1998. 46 States reporting, 1995-1998, 45 States Reporting, 1998.

Exhibit VI-6. Antipsychotic Prescription Trends in Medicaid, Total Expenditures, 1995-1998

Exhibit VI-6. Antipsychotic Prescription Trends in Medicaid, Total Expenditures, 1995-1998

 

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1997. 46 States reporting, 1995-1998, 45 States Reporting, 1998.

As shown in Exhibit VI-7, Medicaid prescriptions for risperidone increased from just over 1 million in 1995 (12% of total) to nearly 2.8 million in 1997 (25% of total). Similarly, the diffusion of olanzapine has also been rapid: 43,000 prescriptions were paid for by Medicaid in 1996 (0.5%), while just over 2.1 million prescriptions were covered in 1998 (20%). In contrast, prescriptions for oral haloperidol decreased from 2.1 million in 1995 (23%) to 1.6 million in 1998 (18%), and prescriptions for phenothiazines decreased from 4.2 million in 1995 (47%) to just under 3 million in 1997 (27%).

Clozapine prescriptions also increased between 1995 and 1997, but the rate of growth did not match that of risperidone and olanzapine. Medicaid paid for 506,000 prescriptions of clozapine in 1995 and 590,000 prescriptions in 1997, an increase of nearly 25%. Clozapine prescriptions as a percent of total, however, remained virtually constant at approximately 5.5% during this time period. Clozapine prescriptions dropped in 1998 to 442,000 (4%). This result is not surprising given that clozapine is used almost exclusively for treatment-refractory schizophrenia. The introduction of olanzapine in 1996 likely resulted in physicians moving clozapine to third-line therapy (after both risperidone and olanzapine) in difficult-to-treat patients, resulting in a reduction in the number of clozapine prescriptions. Similarly, use in injectable haloperidol prescriptions remained steady.

Exhibit VI-7. Antipsychotic Prescription Trends in Medicaid by Class, 1995-1998

Exhibit VI-7. Antipsychotic Prescription Trends in Medicaid by Class, 1995-1998

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1998. 45 States reporting, 1995-1998, 46 States Reporting, 1998.

In 1995, reimbursements for clozapine and risperidone each accounted for 33% of total antipsychotic expenditures (approximately $165 million each, see Exhibit VI-8). Reimbursements for phenothiazines accounted for an additional $101 million, or 20%. In 1996, Medicaid expenditures for risperidone reached $269 million (42%), while expenditures for clozapine increased only slightly to $198 million (31%). Phenothiazines accounted for an additional $103 million, or 16%. In 1998, risperidone expenditures reached $395 million (31%), while olanzapine reached $536 million in Medicaid reimbursements (42%). Spending for clozapine remained nearly constant in the range between $170 million and $192 million. By 1998, the $172 million spent on clozapine by these 45 programs represented only 14% of total expenditures for antipsychotics. This amount represents a smaller share of total spending than in previous years (e.g., in 1995, 21% of antipsychotic expenditures were for clozapine). Phenothiazines accounted for $76 million in 1998, or 6% of total spending.

Exhibit VI-8. Antipsychotic Prescription Trends in Medicaid, Total Expenditures by Class, 1995-1998

Exhibit VI-8. Antipsychotic Prescription Trends in Medicaid, Total Expenditures by Class, 1995-1998

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1997. 46 States reporting, 1995-1998, 45 States Reporting, 1998.