Explaining drug spending trends: does perception match reality?

Several recent studies have made clear that drug expenditures are rising more rapidly than other health care spending. What has not been clear, however, is how much drug spending is driven by price rather than volume and whether volume increases are appropriate. This DataWatch takes a closer look at the components and drivers of drug spending using large claims databases from managed care and employer-sponsored health benefit plans. In both environments this study found volume, not price, to be the largest driver of drug spending for seven diseases studied. For four of the diseases, we review the clinical issues that may have influenced volume growth.

Absenteeism among employees treated for depression.

Depression-related costs include a relatively large share of indirect costs. We describe the impact of antidepressant treatment on absenteeism among workers diagnosed and treated for depression. Monthly absenteeism counts from employers were summed in the 6 months before and after the initiation of antidepressant therapy in 630 workers treated for depression with a tricyclic antidepressant or a selective serotonin reuptake inhibitor (fluoxetine, sertraline, paroxetine). Monthly mean absenteeism was compared using pairwise t tests. Absenteeism increased before antidepressant initiation and decreased after the treatment began for all antidepressant cohorts. Absenteeism in the selective serotonin reuptake inhibitor cohorts decreased at similar rates for 4 months but was higher in the paroxetine cohort in months five and six after the treatment initiation. Our data suggest that alternative treatments for depression may have differential impact on indirect costs, but further research is warranted.

The effects of adherence to antidepressant treatment guidelines on relapse and recurrence of depression.

BACKGROUND: Depression is associated with high rates of relapse and recurrence during a patient's lifetime. Current guidelines regarding treatment recommend 4 to 9 months of continuation antidepressant therapy following remission of acute symptoms to allow more complete resolution of the episode. In this article, we test whether adherence to these recommendations reduces the likelihood of relapse or recurrence in a Medicaid population. METHODS: We used a Medicaid database covering 1989 through 1994. The sample consists of the 4052 adult patients who filled an antidepressant prescription at the time of an initial diagnosis of depression. These patients were followed up for up to 2 years. Timing and counts of antidepressant prescription claims are used to construct a proxy measure for adherence to guidelines. Relapse or recurrence is defined by evidence of a new episode requiring antidepressant treatment, hospital admission for depression, electroconvulsive therapy, emergency department visit for mental health, or attempted suicide. We used survival analysis to predict relapse or recurrence for each patient and to examine the effect of following treatment guidelines on relapse and recurrence. RESULTS: Approximately one fourth of the patients had a relapse or recurrence during their follow-up period. Factors that affect relapse and recurrence include comorbidities, race, and guideline adherence. Those who continued therapy with their initial antidepressant were least likely to experience relapse or recurrence; those who discontinued their antidepressant early were most likely to experience relapse or recurrence. CONCLUSION: Adherence to depression treatment guidelines with an antidepressant that is likely to have continuous use by patients reduces the probability of relapse or recurrence.

The use of EPSDT and other health care services by children enrolled in Medicaid: the impact of OBRA'89.

To increase the participation of Medicaid children in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and to improve their health, Congress included several provisions in the Omnibus Budget Reconciliation Act of 1989 (OBRA'89) that addressed problematic program features. The impact of these provisions on children's health service use was investigated in a study funded by the Health Care Financing Administration. After conducting site visits to four states, the authors analyzed claims data for the children residing there and found evidence that, in 1992, these states placed a higher priority on improving the effectiveness of EPSDT than they did before 1989. The states' efforts to expand the EPSDT provider base and to enhance outreach and service provision were either directly or indirectly inspired by OBRA'89. The authors also found evidence of a significant impact on provider participation and caseloads and on children's use of both preventive care and diagnostic and treatment services. However, the effects were modest in comparison to the size of the progress that is required.