U.S. Physician and Payer Forum

September 2013

Healthcare Reform: Impact of Health Exchanges and Medicaid Expansion on Prescribing of Schizophrenia, Unipolar Depression, and Bipolar Disorder Drugs

Introduction:

As the Affordable Care Act takes full effect in 2014, the addition of millions of U.S. patients newly insured by Medicaid and exchange-based commercial plans will significantly enlarge the total demand for mental health therapies. However, prescribing of most branded drugs will drop in these cost-conscious plans compared with that in traditional commercial plans. Currently, commercial plans themselves derive cost savings by favoring generics over brands through formulary rules and other mechanisms. The mainstay class of SSRI antidepressants such as Prozac is fully genericized, and patent expirations in recent years have also opened up broad generic choices within the costly class of atypical antipsychotics, such as Seroquel and Zyprexa. Nevertheless, some branded drugs have preserved substantial shares of prescribing in commercial plans, most notably Bristol-Myers Squibb's atypical antipsychotic Abilify (aripiprazole), which is widely covered and reimbursed in schizophrenia, unipolar depression, and bipolar disorder. In Medicaid and exchange-based plans, prescribing will be reduced for Abilify and other brands that have competed well with generics in commercial plans, including AstraZeneca's atypical antipsychotic Seroquel XR (quetiapine XR) and Eli Lilly's antidepressant Cymbalta (duloxetine) in the SNRI class. Even so, these well-established brands will still retain a significant percentage of use in Medicaid and exchange-based plans, particularly Abilify. The added patient volume under the ACA will augment total revenues. However, other brands such as Sunovion's newer atypical antipsychotic Latuda (lurasidone), which has gained ground as a later line option for psychiatrists treating schizophrenia, will be barred from some formularies in Medicaid and exchange-based plans, or shifted out to less favorable tiers. Emerging therapies will struggle under similar restrictions. Prescribing in all plans, and for many drugs, will be reconfigured with the advent in 2015 of generic forms of Abilify, when demand will no longer be constrained by the brand's premium price.

Key products in the mental health market include the following:

- Bristol-Myers Squibb's atypical antipsychotic Abilify (aripiprazole), which is approved for schizophrenia, unipolar depression, and bipolar disorder and perceived as an effective drug with relatively low side effects.

- AstraZeneca's atypical antipsychotic Seroquel (quetiapine) and its branded, long-acting injectable form Seroquel XR (quetiapine XR), which together vie with Abilify as the most-prescribed of the studied therapies for mental health disorders.

- Eli Lilly’s Cymbalta (duloxetine), a selective serotonin and norepinephrine reuptake inhibitor and the second SNRI antidepressant introduced after the 1997 launch of Pfizer’s Effexor (venlafaxine). This dual action drug class was designed to have broader efficacy and to avoid the emotional blunting associated with SSRIs.

- Pfizer's Pristiq (desvenlafaxine), a metabolite of venlafaxine, was approved for the treatment of MDD in the United States in February 2008. This relatively high-cost SNRI is differentiated from venlafaxine by its once-daily dosing and improved tolerability. 

In this report, we explore the current and projected use of key established mental health therapies, and more recently launched brands, in the expanding U.S. population of patients insured by Medicaid and commercial plans to be accessed through healthcare exchanges. In a survey of 74 psychiatrists, 70 PCPs, and 40 MCO directors, we also gauge the potential reception of emerging mental health drugs, including Lundbeck's vortioxetine (Brintellix) and Forest Laboratories' cariprazine, in commercial, Medicaid, and exchange-based plans. By evaluating the attitudes and expectations of prescribers and payers, stakeholders can gain an understanding of the strategies needed to navigate an historic expansion of the U.S. healthcare market.

Questions Answered in This Report:

  *   How will the demand for mental health therapies increase under the ACA compared with other disorders? How will the millions of newly insured patients be distributed between PCPs and psychiatrists, and among state-administered Medicaid plans, Medicaid MCOs, and exchange-based commercial plans?

  *   How different will formulary rules and other restrictions be in Medicaid and exchange-based  plans compared with traditional commercial plans? Which plans will be the most restrictive: state-administered Medicaid plans, Medicaid MCOs, or exchange-based plans?

  *   How have/will physicians incorporate Abilify, Seroquel XR, Cymbalta, and newer brands into their mental health practices, despite the growing availability of generic alternatives in most drug classes?  How can brands establish or maintain market share in spite of the cost-cutting imperatives of the Medicaid and exchange-based plans expanding under the ACA?

  *   What metrics will commercial plans use to determine coverage for emerging mental health therapies such as Lundbeck's vortioxetine (Brintellix) and Forest Laboratories' cariprazine? How will those standards change in the new plans created under the ACA?

Scope:

Markets covered: United States.

Primary research: 74 psychiatrists, 70 PCPs, 40 MCO pharmacy/medical directors.

Epidemiology: The following populations with mental health disorders are represented: schizophrenia, unipolar depression, major depression, treatment-resistant depression, bipolar disorder, bipolar depression.

Population segments: Where appropriate, our data and analyses are segmented by the following  populations with mental health disorders: schizophrenia, unipolar depression, bipolar disorder.


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