*Direct health care costs were estimated using a retrospective matched cohort design. Patients with a documented diagnosis of schizophrenia matched to those without schizophrenia with the same age, gender, residence region (except Medicaid), health care plan type, race (Medicaid only), and index date year. Patients were classified into 3 samples: commercially insured, Medicare, or Medicaid. Data sources included Truven Health Analytics MarketScan Commercial Claims and Encounters (Q1 2010 to Q2 2013), Medicare Supplemental (Q1 2010 to Q2 2013), and Medicaid Multistate databases (Q1 2010 to Q4 2013).1
Cost of Prior Authorization (PA) vs. no PA
PA requirements have been shown to increase the probability of drug access problems by 20%.3
Abouzaid et al developed a decision-analytic model to compare the economic impact of a PA for AAPs in the treatment of schizophrenia versus no PA over a 1-year time horizon. Only a modest potential cost savings was recognized, without considering the potential increase in hospitalizations (ie, best-case scenario). Cost savings equated to $29 per patient per year when including increased costs of outpatient care and administrative costs associated with the PA program (2008 US dollars). The model was sensitive to the rate of hospitalizations; an increase in the subsequent hospitalization rate of only 0.5% would make the PA arm the more costly option.4
Fung et al evaluated Medicare Advantage Part D cost sharing on antipsychotic drug spending, adherence and clinical outcomes from 2006 to 2007 for beneficiaries with schizophrenia, bipolar disorder, or no mental health diagnosis. Among beneficiaries with a coverage gap, greater patient cost sharing during the gap decreased Medicare antipsychotic drug expenditures while increasing patient out-of-pocket costs. However, hospitalizations and ED visits increased during the gap, and adherence rates (as measured by proportion of days covered) decreased during the gap.
[schizophrenia: -20.6%; bipolar disorder: -18.1%]5
It is estimated that half of patients with schizophrenia are nonadherent to therapy, with poor adherence linked to worse functional outcomes and increased risk of hospitalization.5
Medication adherence poses significant challenges in schizophrenia6
- 40% of all hospital readmissions were attributed to non-adherence
The economic burden of schizophrenia in the United States in 2013
- History of relapse showed 3X higher health care cost than those without prior relapse
- Cloutier M, et al. The economic burden of schizophrenia in the United States in 2013. J Clin Psychiatry. 2016;77:764-771.
- Fitch K, et al. Resource utilization and cost in a commercially insured population with schizophrenia. Am Health Drug Benefits. 2014;7:18-26.
- Cunningham PJ. Medicaid cost containment and access to prescription drugs. Health Aff (Millwood). 2005;24(3):780-789.
- Abouzaid S, Jutkowitz E, Foley KA, Pizzi LT, Kim E, Bates J. Economic impact of prior authorization policies for atypical antipsychotics in the treatment of schizophrenia. Popul Health Manag. 2010;13(5):247-254.
- Rajagopalan K, et al. Review of outcomes associated with restricted access to atypical antibiotics. AJMC. 2016.
- National Committee for Quality Assurance (NCQA). The State of Healthcare Quality Report. Adherence to antipsychotic medications for people with schizophrenia. 2014.