Context
Treatment Selection
for Depression:
The Impact of Caseload
Characteristics
The tools of managed care are pervasive
in general health as well as behavioral
health
„ These tools have been shown to have
externalities at the macro level
„
Marisa Elena Domino, Ph.D.
The University of North Carolina
David S. Salkever, Ph.D.
The Johns Hopkins University
We would like to thank the APA for providing data for this project and
gratefully acknowledge support from NIMH.
Price sensitivity and managed care
„
2
Price sensitivity and managed care
Pre-managed care:
„
Physicians
have little knowledge of and
reaction to price
Consumers are somewhat price sensitive
RAND: drug prices matter, but only to
quantity, not to switching
managed care:
May
increase physicians’ response to price
through information or incentives
This response may spillover to non-managed
care patients
3
Setting: patients with
depression
Objectives:
„
„
„
to determine the price sensitivity of psychiatrists
when prescribing drugs for their depressed
patients
to determine the impact that various tools of
managed care have on price sensitivity
to investigate the existence of managed care
“spillovers” where psychiatrists with a greater
degree of managed care involvement
demonstrate increased/decreased price
sensitivity to their non-managed care patients
4
„
Why?
Highly
prevalent
range in price of treatments
Little difference in efficacy across all products
Wide
5
6
1
Dual Agency Model
„
Insurers want
physicians to chose
treatments that
minimize the
expenses of
treatment
„
Theoretical model
Consumers want
physicians to chose
treatments that
improve their health
and minimize their
out-of-pocket
expenses
„
Constrained utility maximization
Physician
maximizes own utility with
arguments: patient utility, income (possibly a
function of treatment), and effort (also a
function of treatment)
Patient utility a function of health, composite
good, constrained by income
7
8
Theoretical model
„
Empirical Methods
Drug price enters model through agency
relationship with consumers and through
own income
„
Nested multinomial logit model on
antidepressant drug choice
„
Standard errors were adjusted for
clustering on providers
9
10
Nesting Structure for
Logit Models
Methods
„
„
No Antidepressant
Drug Prescribed
TCAs
SSRIs
Others
(MAOIs, Heterocyclics)
Choice among
10 TCAs
Choice among
4 SSRIs
Choice among
7 Others
„
„
11
the variable of interest is the price variable
price alone determines price sensitivity
price interacted with patient managed care
variables determines additional influence
on price sensitivity from managed care
price interacted with managed care
caseload variables determines managed
care spillovers
12
2
Data:
Sample Selection
The American Psychiatric
Association Practice Research
Network
„
Persons with a clinical diagnosis of
depression (DSM codes 296.2, 296.3, or
311)
„ age 18 or over
„ seen on an outpatient basis
„ not receiving multiple concurrent
antidepressant therapy
„
The 1997 Study of Psychiatric Patients and
Treatments
linked by provider to:
„
The 1996 National Survey of Psychiatric
Practice
13
14
Physician and Patient
Characteristics
Variable
Description (n)
Patient Level Characteristics
GAF
Global Assessment of Functioning scale (n=301)
Female
Patient is Female(n=289)
Educ
Years of Education for Patient (n=300)
Age
Age of Patient(n=305)
Inpatyr
Patient has been admitted to a psychiatric facility for the
treatment of a psychiatric disorder in the past 12 months
(n=299)
Subabu
Patient has ever had substance abuse or dependence disorder,
including alcohol or nicotine (n=281)
Primdep
Primary diagnosis of depression (n=305)
Yearstx
Number of years since first treatm ent (not necessarily for
depression) (n=304)
Provider Level Characteristics (weighted by number of patients in sample)
Doc_age
Age of provider (n=303)
Doc_fem
Provider is female (n=302)
Ppatmon
Number of patients in last month (asked in 1997 patient
survey) (n=301)
Managed Care Variables
M ean/
Percent
Standard
Deviation
49.4
63.3%
14.4
44.9
14.7%
12.0
M anaged C are
V ariable
P atient-level description and
percent
3.1
13.8
M anaged C are
P atient belongs to any type of
m anaged care plan (43.1% ; n= 295)
C arve-out
P atient belongs to a behavioral
health carve-out plan (12.9% ;
n= 295)
NA
44.4%
77.7%
2.7
49.2
31.5%
137.6
M anaged C are Panels
4.0
D iscounted F ee-ForService (patients)
9.9
93.2
P hysician is com pensated for
treatm ent provided to this patient at
this visit on a discounted fee-forservice basis (35.1% ; n= 305)
Provider-level descriptio n, m ean,
and standard deviation (w eighted
by num ber of patients)
Percentage of patients covered
through a m anaged care plan (34.4
(27.8); n= 294)
Percentage of patients covered
through a behavioral health carveout plan (19.8(23.1); n= 294)
N um ber of M anaged C are P anels to
w hich a Physician belongs
(5.3(6.9); n= 280)
Percentage of patients for w hich fees
are discounted. (40.8(34.4); n= 291)
15
Distribution of Treatments
16
Explanatory Variable of Interest:
Price
100%
90%
„
80%
70%
60%
Other
50%
SSRI
40%
TCA
30%
No Antidepressant
20%
Calculated as the median (of average)
price per prescription by chemical entity
(“drug”) for the first quarter of 1997 from
CMS data on Medicaid Drug Utilization
nationwide
10%
0%
All Persons
No
Managed
Care
Managed
Care
17
18
3
Model 1:
Any type of Managed Care
Expectations of “Price”
„
What we want to
happen:
»
What could confound
the results:
„
“price” picks up true
price effects
»
Lower Level
Variable
Price (*.01)
“price” picks up other
effects which are
correlated with the true
price
„
„
Tricyclic Branch
SSRI Branch
Other Branch
-0.684
(2.054)
-1.088
(2.393)
0.778
(1.554)
2.411
(3.040)
0.495
(0.218)
-0.097
(0.230)
-0.735
(2.282)
-0.014
(0.087)
0.290
(0.815)
-0.498
(1.333)
-0.179
(0.019)
3.753
(0.517)
0.599
(2.693)
0.021
(0.067)
-0.415
(2.284)
0.494
(0.946)
2.505
(2.949)
-0.705
(3.404)
Price*Patient MC
Price*Physician MC
(*.01)
Price*Patient MC*
Physician MC (*.01)
Market Age (*.01)
side effects
episode costs
Market Age
Squared (*.0001)
19
20
Model 1:
Any type of Managed Care
T r ic y c lic B r a n c h
S S R I B ra n c h
O th e r B ra n c h
- 1 .0 8 2
(0 .1 3 0 )
5 .4 2 3
(2 .2 7 7 )
0 .9 7 6
(1 .5 0 9 )
1 .0 8 6
(1 .6 4 2 )
0 .5 1 5
(0 .9 2 5 )
0 .5 4 0
(0 .5 5 6 )
- 4 .1 8 1
(0 .3 3 9 )
9 .9 7 8
(0 .7 8 0 )
0 .5 5 4
(0 .9 0 1 )
1 .6 5 8
(1 .2 9 5 )
-2 3 .6 6 1
( 2 .2 1 9 )
4 .2 3 0
(0 .7 1 0 )
0 .4 2 3
(0 .4 5 7 )
- 6 .6 3 8
(0 .2 3 5 )
- 1 7 .5 0 6
(0 .6 1 6 )
3 .5 7 9
(0 .5 7 0 )
- 0 .4 9 9
(0 .2 1 8 )
- 2 .3 0 5
(1 .2 4 7 )
- 0 .0 2 9
(0 .0 4 0 )
- 7 0 .6 2 5
( 0 .2 5 4 )
- 0 .8 1 1
( 0 .4 0 2 )
0 .1 4 8
( 0 .3 0 1 )
1 .1 0 2
( 2 .2 5 8 )
-1 .1 6 6
(1 .9 3 3 )
0 .7 4 4
( 1 .0 5 2 )
- 1 0 .1 5 0
( 1 .1 6 1 )
8 .4 2 9
( 0 .8 7 3 )
0 .5 6 4
( 1 .1 3 5 )
- 1 .1 0 4
( 1 .0 9 0 )
- 2 .7 0 6
( 0 .3 4 8 )
6 .2 9 2
( 1 .1 4 8 )
1 .3 0 3
( 2 .3 6 8 )
1 9 .3 4 0
( 1 .0 8 9 )
- 2 1 .2 8 8
( 1 .2 8 7 )
- 1 0 9 .8 0 5
( 0 .4 2 5 )
- 2 .9 4 3
( 0 .0 7 6 )
6 6 .4 3 0
( 0 .5 3 9 )
- 2 9 .6 5 9
( 0 .3 6 0 )
- 5 1 5 .4 9
- 1 3 9 .2 5 0
(1 .4 2 0 )
0 .9 7 3
(0 .4 5 0 )
0 .8 7 6
(1 .5 9 0 )
1 .0 4 4
( 2 .0 2 7 )
- 0 .4 3 7
(0 .7 3 8 )
0 .5 2 5
(0 .6 4 6 )
- 7 .3 6 9
(0 .7 0 9 )
7 .4 1 6
(0 .6 6 8 )
0 .3 2 7
(0 .5 7 5 )
- 1 .3 6 9
(0 .9 8 1 )
5 .0 1 2
(0 .6 5 6 )
1 0 .5 5 6
( 2 .0 6 4 )
1 .3 4 5
( 2 .1 8 9 )
1 .8 7 2
(0 .1 0 3 )
- 6 .4 0 8
(0 .3 8 7 )
- 5 3 .2 1 5
(0 .9 0 9 )
- 2 .9 8 0
(0 .0 7 2 )
4 5 .5 8 9
(1 .4 2 5 )
2 4 .1 9 8
(1 .3 1 1 )
G A F ( * .0 1 )
S u b ab u
P r im d e p
Y e a r s tx (* .1 )
In p a ty r
A g e ( * .0 1 )
A g e 2 ( * .0 0 0 1 )
F e m a le
P a tie n t G e n d e r
M is s in g
E d u c a t io n
P p a t m o n ( * .0 0 1 )
D o c _ fem
D o c _ a g e ( * .0 1 )
D o c _ a g e 2 (* .0 0 0 1 )
P a tie n t M C *
P h y s ic ia n M C
P a tie n t M C
P h y s ic ia n M C
I n c lu s iv e V a lu e
lo g - L ik e lih o o d
6.000
4.000
2.000
Patient not in Managed Care
Elasticity
U p p e r le v e l
c o e ffic ie n ts
In te rc e p t
Figure 2: Estim ated Price Elasticity of TCAs
With 90% Confidence Interval, based on Results from Model 1
Patient in Managed Care
0.000
0
0.1
0.2
0.3
0.5
0.6
0.7
0.8
0.9
CI-Upper around no MC
1
CI-Low er around no MC
-2.000
CI-Upper around MC
CI-Low er around MC
-4.000
-6.000
-8.000
Percent of Physician Caseload in Managed Care
21
22
Figure 3: Estim ated Price Elasticity of SSRIs
With 90% Confidence Interval, Based on Results from Model 1
Figure 4: Estim ated Elasticity of SSRIs
With 90% Confidence Interval, Based on Results from Model 2
1.000
2.000
0.000
0.000
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
-1.000
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
-2.000
-2.000
Patient not in Managed Care
Patient in Managed Care
-3.000
CI-Upper no MC
CI-Low er no MC
-4.000
CI-Upper MC
CI-Low er MC
-5.000
Estimated Elasticity
Estimated Elasticity
0.4
Patient not in Carve-out
-4.000
Patient in Carve-out
CI-Upper no CO
-6.000
CI-Low er no CO
CI-Upper CO
-8.000
CI-Low er CO
-10.000
-6.000
-12.000
-7.000
-8.000
-14.000
Percent of Physician Caseload in Managed Care
Percent of Physician Caseload in Carve-outs
23
24
4
Conclusions:
Conclusions:
Price effects vary strongly among the
three classes of antidepressants
„ Psychiatrists do demonstrate price
sensitivity when choosing among
antidepressants
„ Price elasticity estimates range from
-0.4 to -4.2
„
Higher price elasticities for managed care
patients
„ Significant evidence of spillovers
„
Not
always in the expected direction
only to other managed care
patients
Generally
25
26
5