Cost control measures limit patient, physician choice in psychotropic medications

A new Brandeis University study published online in Clinical Therapeutics suggests that private health plans increasingly rely on escalating copayments to manage drug costs, as opposed to administrative controls. This makes treatment more expensive in many cases for patients, and may affect adherence to treatment, said lead author Dominic Hodgkin, associate professor at the Schneider Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University.

In the past decade, health insurers have increasingly turned to cost controls to manage prescription drug use, but little is known about how such policies affect the use of psychotropic drugs, said Hodgkin. Between 1996 and 2001, psychotropic drug use to treat psychiatric disorders climbed from 5.9 percent to 8.1 percent of the U.S. population. Newer, better tolerated drugs account for some of the growth; however, because they are often more expensive than more established treatments, psychotropic drug spending has skyrocketed, from an estimated $3.7 billion in 1991 to $18 billion in 2001.

"This growth has raised concern among public and private health care payers, who have responded with cost-containment policies that affect the choices of patients and physicians," explained Hodgkin. The study evaluated brand antidepressants, antipsychotics and drugs used to treat attention-deficit hyperactivity disorder (ADHD).

Medicaid programs, by contrast, rely on administrative controls to manage psychotropic drug costs. These controls include prior authorization by a physician before a patient can switch to a non-preferred drug at the same copayment level. Further complicating the picture, patient non-compliance rates are high for psychotropic drugs such as antidepressants and treatments for schizophrenia.

The study evaluated a nationally representative survey of private health plans regarding mental health and substance abuse services. Most plans covered at least 2 antidepressants and at least 2 antipsychotic drugs at a medium copayment (averaging $21) that gave the physician some leeway in choosing the initial medication. However, in many plans patients who did not respond to one of those drugs faced a substantial hike in copayment (to an average of $38) in order to try a potentially more effective drug. Coverage of drugs for ADHD was more restrictive.