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TRENDS

Prescription Drugs And The Changing Patterns Of Treatment For Mental Disorders, 1996–2001

Abstract

 
This paper uses detailed data on prescription drug and other services from the Medical Expenditure Panel Survey (MEPS) to examine recent trends in mental health and substance abuse (MH/SA) treatment between 1996 and 2001. While use of ambulatory services remained constant, prescription drug use increased rapidly, with the result that 5.5 million more Americans received treatment in 2001. Prescription drug spending increased at a real rate of almost 20 percent a year. About one-third of this increase came from more MH/SA medication users and two-thirds from higher costs per user.

There also are concerns that gaining access to MH/SA treatment providers has become more difficult with the spread of MBHOs and other forms of managed care. David Mechanic and Scott Bilder find that overall use of both specialty and primary care providers to treat MH/SA disorders declined between 1997 and 2001, although access appears to have improved among those with the most serious mental illnesses.³ In contrast, use of both prescription drugs and ambulatory services in MH/SA treatment greatly increased between 1987 and 1996/97.⁴

This paper examines in detail the recent changes in use and spending patterns for prescription drugs and other MH/SA treatments. It builds on previous analyses of data from the Medical Expenditure Panel Survey (MEPS) and its predecessors to describe national trends between 1996 and 2001. In particular, I address the implications of these changes for different population subgroups in terms of access to and out-of-pocket costs for MH/SA treatment, and for payers in terms of their costs.

Study Data And Methods

Top Study Data And Methods Study Results Discussion Editor's Notes NOTES

 
This study combines detailed information on prescription drug, ambulatory, and inpatient treatment use and spending with comprehensive personal and household characteristics from MEPS for 1996–2001. MEPS is a large, ongoing U.S. household survey of the civilian, noninstitutionalized population. Sample sizes are 21,571 for 1996; 32,636 for 1997; 22,953 for 1998; 23,565 for 1999; 23,839 for 2000; and 32,122 for 2001.⁵ The survey asked households to report detailed information about each prescription drug used and each of their physician and other provider visits, emergency department (ED) visits, and hospital stays. Follow-back surveys of physicians and hospitals in the MEPS Medical Provider Component (MEPS-MPC) and pharmacies in the Pharmacy Component (MEPS-PC) obtained more complete information on spending and payment sources; for prescription drugs, National Drug Code (NDC) codes, dosages, strengths, and quantities filled were obtained.⁶

Because of its study population, MEPS excludes a sizable fraction of total MH/SA use and spending in the United States. These exclusions include all stays at long-term psychiatric facilities, residential treatment facilities, nursing homes, and other assisted-living facilities; acute care MH/SA services for institutionalized populations, including for incarcerated people; and MH/SA services for homeless people, who tend to have high rates of severe mental and addictive disorders.⁷

MH/SA treatment includes services for the treatment of disorders covered by codes 291, 292, and 295–314 from the International Classification of Diseases, Ninth Revision/Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (ICD-9/DSM-IV).⁸ Alzheimer’s disease and other dementias, mental retardation, and developmental disabilities are specifically excluded, as are physical problems that are the direct result of MH/SA disorders, such as cirrhosis of the liver. Ambulatory visits include all office-based, outpatient hospital, or ED visits reported by households to be MH/SA related. The small number of MEPS respondents reporting MH/SA-related inpatient stays (about 0.3 percent) greatly limits analyses of this treatment component. Therefore, this paper focuses primarily on ambulatory treatment.

MH/SA-related drugs include all prescriptions filled that appear on a list of commonly prescribed MH/SA medications and where the household reported taking medications for an MH/SA condition.⁹ The MEPS drug spending data, like many other sources of such data, are not adjusted for rebates between manufacturers and insurers and pharmacy benefit managers (PBMs) and therefore overstate actual spending. The Medicaid Drug Rebate program is estimated to reduce the amount that states pay for drugs for their fee-for-service Medicaid enrollees by 20 percent, but no reliable estimates exist for private health plans.¹⁰

The analyses compare distributions of use, spending, payers, and patterns of MH/SA treatment between 1996 and 2001, both in aggregate and for population subgroups.¹¹ Spending dollar amounts for 1996 through 2000 were converted to constant 2001 dollars using the general gross domestic product (GDP) deflator. All differences between years and between groups reported in the text are significant at the .05 level unless otherwise noted. All of the statistical tests correct for the complex survey design of MEPS.

Study Results

Top Study Data And Methods Study Results Discussion Editor's Notes NOTES

 
Aggregate trends, 1996–2001. The number of Americans using MH/SA treatment continues to rise. Approximately 5.5 million more Americans received treatment in 2001 than in 1996 (Exhibit 1). The percentage of the population with ambulatory visits remained relatively flat during the study period, while the percentage using MH/SA drugs increased. Clearly, the increase in the number of people receiving MH/SA treatment is explained by the use of prescription drugs.

Drivers of spending increases. The rapid increases in MH/SA prescription drug spending are driven not only by more people using the drugs, but also by increases in the mean spending per user (Exhibit 1). Of the total increase, 37 percent was accounted for by new users, and 63 percent, by higher spending per user. How much of this increase is the result of substitution of newer medications for older generic drugs, longer duration of drug treatment, or price increases are important questions for future research.

Treatment patterns. The increasing importance of prescription drugs in the treatment of MH/SA disorders is also seen in changes in the pattern of treatment over time (Exhibit 2).¹² Among MH/SA treatment users, 36 percent reported ambulatory visits without prescription drug purchases in 1996, but only 25 percent did so in 2001. In contrast, 34 percent of MH/SA treatment users reported only drug purchases in 2001, up from 26 percent in 1996. Future analyses using the panel data from MEPS or other sources to construct treatment episodes may provide a clearer picture of the true change in treatment patterns.

The number of people using SSRIs and other newer antidepressants increased from 7.9 million in 1996 to 15.4 million in 2001, while the number using the older tricyclic antidepressants decreased from 2.3 million to 1.2 million (Exhibit 3). This suggests both that the newer antidepressants are replacing older drugs and that many more people are receiving antidepressant treatment. Spending on the newer antidepressants rose from $3.4 billion in 1996 to $7.9 billion in 2001, or at an annual rate of 18.5 percent.

Insurance coverage. The relative importance of different types of MH/SA drugs varies across the population by insurance coverage (Exhibit 4). By 2001 SSRIs and other newer antidepressants were the most commonly prescribed MH/SA drugs, regardless of insurance coverage. However, atypical antipsychotics ranked first in spending in 2001 for the Medicare population under age sixty-five and for those covered by Medicaid. Among the Medicare population age sixty-five and older, the newer antidepressants accounted for 60 percent of the MH/SA drug spending growth in 1996–2001, while atypical antipsychotics accounted for 17 percent. In contrast, among the Medicare population under age sixty-five and those covered by Medicaid, atypical antipsychotics accounted for 50 percent and 61 percent, respectively. For those covered by private health plans, the newer antidepressants were by far the largest contributor, at 66 percent, to rising MH/SA drug spending and accounted for nearly two-thirds of drug spending in 2001.

Treatment use. Adults age sixty-five and older had the lowest rates of ambulatory MH/SA use but the highest rates of MH/SA prescription drug use during 1996–2001 (Exhibits 6 and 7). However, average drug spending for this group was much lower than for younger adults because of the relatively greater use of older psychotropic medications such as sedatives, hypnotics, and benzodiazepines. Those under age sixty-five with Medicare, Medicaid, or other public coverage were more likely than the privately insured to use both ambulatory MH/SA services and prescription drugs and to use them more intensively. Although prescription drug use among the uninsured rose between 1996 and 2001, the uninsured still had the lowest rates of MH/SA drug and ambulatory services use.

People with family incomes below the federal poverty level were much more likely than people with family incomes above 125 percent of poverty to use both ambulatory MH/SA services and prescription drugs. The poor paid relatively little out of pocket for ambulatory MH/SA services but paid large amounts for their MH/SA drugs.

Comparisons with trends in total health spending and use. Total spending for MH/SA treatment increased by 27 percent in real terms between 1996 and 2001, but this increase was not statistically different from the increase for all non-MH/SA treatment for the noninstitutionalized population. However, MH/SA-related drug spending grew at a faster rate (19.8 percent annually) than for all non-MH/SA prescription drugs (12.4 percent). The share of total drug spending accounted for by MH/SA-related drug use rose from 8 percent in 1996 to 11 percent in 2001.

Discussion

Top Study Data And Methods Study Results Discussion Editor's Notes NOTES

 
Limitations. The data used in this analysis have two important limitations. First, as mentioned earlier, MEPS excludes a number of policy-relevant populations, including homeless people and those residing in state psychiatric institutions, nursing homes, residential treatment centers, and many group homes. Thus, a substantial portion of use of and spending on MH/SA services is excluded here. Second, MEPS relies on household reports of health services use, which could result in the underreporting of all health care services, but particularly MH/SA treatment because of the associated stigma.

The spending figures derived here for the community population from MEPS are, in fact, much lower than aggregate spending estimates for MH/SA treatment previously reported by Tami Mark and colleagues, which are based on a National Health Accounts (NHA) model.¹³ However, a previously published detailed analysis suggests that the differences are primarily attributable to the differences in the scope of the populations and services included.¹⁴ Moreover, the MEPS-derived estimate of total spending for psychotropic drugs (regardless of whether it was reported as MH/SA related) was actually higher ($9.8 billion) than the $9.1 billion retail drug spending estimate for 1997 reported by Mark and colleagues.¹⁵ However, household under-reporting may still lead to underestimates of MH/SA treatment use and spending in MEPS. Unfortunately, the extent of this and whether it has systematically changed over time, thus affecting trend analyses, are not known.

Policy implications. The continued rapid rise in prescription drug use during the study period meant that about 5.5 million more Americans, or a total of 30.5 million, reported receiving MH/SA treatment in 2001 than in 1996. MH/SA disorders have historically been greatly undertreated—epidemiologic studies from the 1980s and 1990s established that less a third of those with severe mental disorders received treatment—so this rise suggests that much progress has been made in reducing the gap between treatment need and use.¹⁶ At the same time, the surgeon general’s report on mental health raised questions about the overuse of antidepressants and other medications.¹⁷ Thus, while there have been gains in the number of people accessing MH/SA treatment, it is not clear that these gains have been distributed optimally, on the basis of medical or other societal judgments.

The largest increases in MH/SA treatment use between 1996 and 2001 occurred among women and whites. Women are disproportionately more likely to have two of the most common types of mental disorders, depression and anxiety, so it is not surprising that innovations in drug treatments for these disorders would lead to greater increases in treatment for women. Many more whites received treatment in 2001 than in 1996, but gains among Hispanics were much smaller, and there was little change for blacks. As a result, disparities increased over this five-year period for blacks and Hispanics, who still have relatively low rates of treatment use.

Surprisingly, the increased use of prescription drugs did not translate into increased use of ambulatory MH/SA services. It may be that MH/SA medications are substituting for services or that there are longer periods between visits for management of them.

This pattern was true even for those covered by private health insurance, where mental health parity mandates passed in thirty-three states would be expected to reduce out-of-pocket spending and to increase access to and use of ambulatory MH/SA services.¹⁸ However, these mandates did not apply to large portions of the privately insured populations working for either firms that self-insured or smaller firms that were often exempted in the state legislation. The increased use of carve-outs to MBHOs may also have offset the increased demand for ambulatory treatment resulting from better coverage for at least some employees, as well as increased demand for MH/SA prescriptions. Future work will examine the potential impact of the parity mandates in more detail using these MEPS data and multivariate regression difference-in-difference techniques.

Spending for psychotropic drugs rose almost 20 percent a year during the study period, even faster than the annual 13.1 percent increases in overall prescription drug spending. Private insurers have been seeking to restrain these increases through formularies and tiered consumer cost sharing, but it is unclear how much of an impact these will have on the long-term growth in consumer demand, especially as the uses of the newer antidepressants have been expanding into the treatment of anxiety disorders and even non–mental health problems. Similarly, the explosive growth in spending on atypical antipsychotics has had a major impact on Medicaid and other public programs’ drug spending, although the net impact on total MH/SA spending is unclear. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 will mean that a sizable proportion of these expenditures for atypical antipsychotics will shift from Medicaid to Medicare, because many of those receiving these drugs are disabled Medicare enrollees who are also eligible for Medicaid. In addition, the Medicare program will have to contend with the increasing use of these costly atypical antipsychotics for the treatment of Alzheimer’s and other dementias, when prescription drug coverage begins in 2006.

Editor's Notes

Top Study Data And Methods Study Results Discussion Editor's Notes NOTES

 
Sam Zuvekas (szuvekas{at}ahrq.gov) is a senior economist at the Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, in Rockville, Maryland.

The author especially thanks Grayson Norquist, Darrel Regier, and William Narrow for their help in developing algorithms to identify and classify mental health–related prescription drug use. An earlier version of this paper was presented at the conference "How MEPS Informs Policy on Insurance Coverage and Health Care Costs," in Washington, D.C., 13 May 2004. The views expressed are those of the author, and no official endorsement by the Agency for Healthcare Research and Quality or the Department of Health and Human Services is intended or should be inferred.

NOTES

Top Study Data And Methods Study Results Discussion Editor's Notes NOTES

 

1. National Institute for Health Care Management Research and Educational Foundation, Prescription Drug Expenditures in 2001: Another Year of Escalating Costs, May 2002, www.nihcm.org/spending2001.pdf (7 October 2004).
2. National Advisory Mental Health Council, Parity in Financing Mental Health Services: Managed Care Effects on Cost, Access, and Quality, An Interim Report to Congress by the National Advisory Mental Health Council (Bethesda, Md.: National Institute of Mental Health, 1998).
3. D. Mechanic and S. Bilder, "Treatment of People with Mental Illness: A Decade-Long Perspective," Health Affairs 23, no. 4 (2004): 84–95.[Abstract/Free Full Text]
4. M. Olfson et al., "National Trends in Outpatient Treatment of Depression," Journal of the American Medical Association 287, no. 2 (2002): 203–209[Abstract/Free Full Text]; M. Olfson et al., "National Trends in the Use of Out-patient Psychotherapy," American Journal of Psychiatry 159, no. 11 (2002): 1914–1920[Abstract/Free Full Text]; and S.H. Zuvekas, "Trends in Mental Health Services Use and Spending, 1987–1996," Health Affairs 20, no. 2 (2001) 214–224. The estimates for 1996 reported here are slightly higher than those reported in the 2001 Zuvekas study because of refinements in the algorithms identifying MH/SA ambulatory visits and prescription drugs, as well as the rerelease of the 1996 MEPS prescription drug file, MEPS PUF-010A. For additional details, contact the author at szuvekas{at}ahrq.gov.[Free Full Text]
5. J.W. Cohen et al., "The Medical Expenditure Panel Survey: A National Health Information Resource," Inquiry 33, no. 4 (1996): 373–389.
6. See S. Machlin and A.K. Taylor, Design, Methods, and Field Results of the 1996 Medical Expenditure Panel Survey Medical Provider Component, MEPS Methodology Report no. 9, Pub. no. 00-0028 (Rockville, Md.: Agency for Healthcare Research and Quality, 2000); and J.F. Moeller et al., Outpatient Prescription Drugs: Data Collection and Editing in the 1996 Medical Expenditure Panel Survey (HC-010A), MEPS Methodology Report no. 12, Pub. no. 01-0002 (Rockville, Md.: AHRQ, 2001).
7. P. Koegel, M.A. Burnam, and R.K. Farr, "The Prevalence of Specific Psychiatric Disorders among Homeless Men and Women," Archives of General Psychiatry 45, no. 12 (1988): 1085–1092[Abstract]; and C.S. North et al., "Correlates of Early Onset and Chronicity of Homelessness in Large Urban Homeless Population," Journal of Nervous and Mental Disorders 186, no. 7 (1998): 393–400.
8. Additional details are available from the author.
9. The list of potential MH/SA-related drugs is available from the author. Household reporting of conditions associated with these drugs follows a logical pattern. Lithium, atypical antipsychotics, and stimulants (amphetamines, methylphenidate) are almost always reported as being MH/SA related. SSRIs and other newer antidepressants are usually reported as such. A smaller proportion of older antidepressants and even fewer anti-anxiety medications and sedatives/hypnotics, which have a large number of other uses, are reported as being MH/SA related. The list also includes drugs in other therapeutic classes such as anticonvulsants (bipolar disorder) that are often used to treat MH/SA disorders.
10. C.D. Tepper and T.R. Lied, "Trends in Medicaid Prescribed Drug Expenditures and Utilization," Health Care Financing Review 25, no. 3 (2004): 69–78.[Medline]
11. Family income was measured in relationship to the federal poverty level, with poor (less than 100 percent of poverty), near-poor (100–124 percent), low-income (125–199 percent), middle-income (200–399 percent), and high-income (400 percent and above) categories. Health insurance status for those under age sixty-five is represented by four mutually exclusive, hierarchically defined categories: Medicare; private insurance, including TRICARE (formerly CHAMPUS/CHAMPVA) for civilian dependents; Medicaid or other public coverage; and uninsured all year.
12. Those reporting medication use without ambulatory MH/SA-related visits in a particular year may be on maintenance drugs and had not seen their provider recently, or had seen a provider recently but in a previous year.
13. T.L. Mark et al., "Spending on Mental Health and Substance Abuse Treatment, 1987–1997," Health Affairs 19, no. 4 (2000): 108–120.[Abstract]
14. T.M. Selden et al, "Reconciling Medical Expenditure Estimates from the Medical Expenditure Panel Survey and the National Health Accounts, 1996," Health Care Financing Review 23, no. 1 (2000): 161–178.
15. Mark et al., "Spending on Mental Health."
16. R.C. Kessler et al., "Lifetime and Twelve-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results of the National Comorbidity Survey," Archives of General Psychiatry 51, no. 1 (1994): 8–19[Abstract]; and W.E. Narrow et al., "Use of Services by Persons with Mental and Addictive Disorders: Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program," Archives of General Psychiatry 50, no. 2 (1993): 95–107.[Abstract]
17. U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, Md.: DHHS, 1999).
18. National Mental Health Association, "What Have States Done to Ensure Insurance Parity?" Summer 2004, www.nmha.org/state/parity/state_parity.pdf (16 November 2004).

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