How Has Part D Influenced Access to Medications?

Huskamp and associates¹ recently reported that in the year following the implementation of Part D, many patients dually eligible for Medicaid and Medicare benefits had difficulty gaining access to psychiatric medications.

They analyzed data obtained from randomly selected psychiatrists who were asked to report on the experiences of dually eligible patients during the 9 to 12 months after Part D was implemented. The results showed that of 908 patients, 35% were unable to gain access to clinically indicated refills or new prescriptions because the medications were not covered or approved, 19% had to switch to another medication because refills were not covered or approved, and 22% had problems gaining access to medications because of copayments. Overall, 44% of patients encountered one or more of these problems.

The study also found that patients who had experienced difficulty gaining access to medications were significantly more likely to visit a psychiatric emergency department. However, they were not more likely to require inpatient psychiatric care.

The authors acknowledge that some of the problems encountered may have been resolved, with little harm to the patient. However, disruptions in medication continuity should not be taken lightly, since such disruptions have been linked with increased risk of symptom exacerbation or relapse and hospitalization in psychiatric patients.

1. Huskamp HA, West JC, Rae DS, et al. Part D and dually eligible patients with mental illness: medication access problems and use of intensive services. Psychiatr Serv. 2009;60:1169-1174.

Assessing the Costs and Benefits of Telephone-Based Programs in Depression Management
For managing depression in the primary care setting, a structured telephone program that includes care management and cognitive- behavioral psychotherapy is beneficial and is associated with only modest increase in health services cost. This conclusion was reported by Simon and colleagues,¹ who conducted a randomized trial involving 600 patients who were depressed.

They compared the benefits and costs of 2 programs with continued usual care for depression management in 7 primary care clinics. The telephone care management intervention included up to 5 outreach calls for monitoring and support, feedback to treating physicians, and care coordination. The care management plus telephone psychotherapy intervention added an 8-session structured cognitive- behavioral therapy program with up to 4 additional calls for reinforcement.

During 2 years, telephone care management resulted in an increase of 29 depression-free days and a $676 increase in outpatient health care costs; the incremental net benefit was negative. Case management plus telephone psychotherapy resulted in an increase of 46 depression-free days and a $397 increase in outpatient costs. The incremental net benefit of this intervention was positive if one day free of depression was valued at $9 or more.

1. Simon GE, Ludman EJ, Rutter CM. Incremental benefit and cost of telephone care management and telephone psycho- therapy for depression in primary care. Arch Gen Psychiatry. 2009;66:1081-1089.

Comparing 2 Drugs in the Management of Acute Agitation in Psychiatric Patients
For the management of acute agitation in a psychiatric facility, intramuscular haloperidol appears to be as effective as intramuscular olanzapine, and it is significantly less expensive, according to a recent study.

Freeman and coworkers¹ retrospectively studied 53 patients who received either intramuscular haloperidol (27 patients, 47 episodes) or intramuscular olanzapine (26 patients, 38 episodes) for acute agitation in a state psychiatric facility. The mean cost of treating an episode of agitation with haloperidol was significantly lower than the cost of using olanzapine ($4.06 vs $27.84, respectively; P < .0001). Patients who received haloperidol were less likely to require additional pharmacotherapy to manage agitation than those who received olanzapine (41% vs 69%, respectively; P = .04).

The 2 groups did not differ in the mean number of repeat doses of psychotropic drugs required, the percentage of patients who required seclusion or restraints, or the time spent in seclusion or restraints.

1. Freeman DJ, DiPaula BA, Love RC. Intramuscular haloperidol versus intramuscular olanzapine for treatment of acute agitation: a cost-minimization study. Pharmacotherapy. 2009;29:930-936.